Borderline Therapy and Other Thoughts

by Patty Pheil M.S.W.

 Updated:  11/02

While researching information about the borderline personality disorder (BPD), we find that there are many different "orientations" to BPD including psychoanalytic, biological, eclectic, biosocial and cognitive. See page on "Major Orientations to BPD."

We read one book and say to ourselves that we finally have some answers, only to find that the next book about BPD may say something entirely different.  Some professionals even tell us we cannot get better. As a result, many of us are confused. All we know is that we are hurting and we want the pain to go away.

I would like to address these issues with you that coincide with current research.  So much still remains unknown about this disorder, yet we do know more now.

First of all, it is extremely important to know that no form of therapy will assist a person with the borderline personality disorder unless the person is properly medicated, reducing many of the symptoms. Paul Markovitz, M.D., Ph. D, states "Antidepressants do not change the hardwiring. They simply damp down the circuits to a point where many individuals can control their lives. Mood swings, somatic complaints, rage, irritability, binge eating, anxiety, and even black-white thinking are reduced significantly. The treatment now is crude compared to what we will do 10 to 15 years from now, but it works. I have seen virtually no data that therapy reverses the illness. While Cognitive Behavior Therapy helps a bit, it's impacts on life is limited. I have seen no data that it reduces any of the things medications reduce. I think therapy is a good thing, but in all fields of medicine we use it after we fix what is broken, e.g., rehab (therapy) following heart surgery and weight training after ligaments in a knee have been repaired. Current forms of therapy need to be continually upgraded and reevaluated, just like I do with medications.

I am always galled by the concept of therapy prior to medications. It supposes if an individual really tried, they could be better. BPD is a debilitating biological illness. Talking to it is like talking to diabetes. First insulin, then therapy."

LATEST RECOMMENDATIONS

The recommendations of treating people with borderline personality disorder according to the American Psychiatric Association (This practice guideline was approved in July 2001 and published in October 2001) is as follows:

"The primary treatment for borderline personality disorder is psychotherapy, complemented by symptom-targeted pharmacotherapy...

Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective in the treatment of borderline personality disorder [I]. Although it has not been empirically established that one approach is more effective than another, clinical experience suggests that most patients with borderline personality disorder will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning [II]. Pharmacotherapy often has an important adjunctive role, especially for diminution of symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior [I]. No studies have compared a combination of psychotherapy and pharmacotherapy to either treatment alone, but clinical experience indicates that many patients will benefit most from a combination of these treatments [II]...

Two psychotherapeutic approaches have been shown in randomized controlled trials to have efficacy: psychoanalytic/psychodynamic therapy and dialectical behavior therapy [I]. The treatment provided in these trials has three key features: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/supervision. No results are available from direct comparisons of these two approaches to suggest which patients may respond better to which type of treatment...

The literature on group therapy or group skills training for patients with borderline personality disorder is limited but indicates that this treatment may be helpful...The published literature on couples therapy is limited but suggests that it may be a useful and, at times, essential adjunctive treatment modality."

The clinician begins working with someone with borderline personality disorder by doing an assessment. The patient's safety needs to be evaluated since suicidal ideation is commonly experienced. The treatment setting needs to be evaluated - inpatient vs. outpatient.

Secondly a more intensive evaluation needs to be done on the client/patient with BPD. It "includes assessing the presence of comorbid disorders, degree and type of functional impairment, needs and goals, intrapsychic conflicts and defenses, developmental progress and arrests, adaptive and maladaptive coping styles, psychosocial stressors, and strengths in the face of stressors (see Part B, section V.B., "Assessment"). The psychiatrist should attempt to understand the biological, interpersonal, familial, social, and cultural factors that affect the patient."

Thirdly it is now time for the "treatment contract." This will include the goals of the client/patient as well as a plan for crisis management, the availability of the counselor/Dr. after hours, fees, etc.

What Else is New?

Psychodynamic therapy, according to the 3/02 Harvard Mental Health Letter is highly recommended along with DBT. The choice of therapy depends upon the person and the level of functioning. This form of therapy brings the unconscious to the conscious level and deals with transference issues. 

For example the therapist may point out that the client has misplaced anger. The client may be expressing angry feelings at the therapist and the therapist may suggest that the client is really angry with someone in their past. The client in this form of therapy tells their life story 

It is recommended that more than one therapist be involved in a person with BPD's treatment. Consulting co-workers and supervisors is highly recommended due to transference and countertransference.

It is extremely important to treat depression in borderline patients and to take all suicidal threats seriously. No suicide contracts are not enough. These patients may need to be hospitalized.

While waiting for medications like SSRI's or mood stabilizers to work, a benzodiazepine like Ativan can assist with anxiety.

Remember, how can you help someone with a biological problem with therapy? Remember Dr. Markovitz's statement? "Talking to it is like talking to diabetes. First insulin, then therapy."

Some therapists will say "It doesn't matter what your diagnosis is. I don't group people into categories. I treat everyone the same." If you hear this from a counselor, don't just walk to the exit, run! They simply don't have a clue of how to treat borderlines.

Anytime your therapy takes you to "the edge, feeling suicidal" it is time to STOP! The suicide rate for borderlines is 10% and this moves up to 25% if the person also has a diagnosis of panic disorder.

Yes, therapy is needed, but you need to live through it. You just need the right kind of therapy and therapists desperately need to be educated regarding this.

I hear constantly how borderlines go in and out of the hospital during therapy. On top of that, many counselors will "dump" their client while in the hospital as they don't want to take a "risky client." Many borderlines are dumped by counselors because they display BPD symptoms, when the  therapist knew initially that the client had the BPD. Imagine how this would feel to someone who already has tremendous issues with abandonment.

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STEPPS: a cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder--a preliminary report.

Blum N, Pfohl B, John DS, Monahan P, Black DW.

Department of Psychiatry, University of Iowa College of Medicine, and University of Iowa Health Care, Iowa City, IA 52242, USA.

We describe a new cognitive-behavioral systems-based group treatment for persons with borderline personality disorder (BPD). The program is called STEPPS, an acronym for Systems Training for Emotional Predictability and Problem Solving. Briefly, the program combines cognitive-behavioral techniques and skills training with a systems component. The latter involves patients with BPD and persons in their system (e.g., family members, significant others, health care professionals). The program involves 20 two-hour weekly group meetings with two facilitators, is manual-based, and has specific goals to accomplish each week. Here, we review the background and development of the program, and present preliminary efficacy data from a subset of patients which suggest that patients experience improvement in BPD and mood-related symptoms. Survey results suggest moderate to high levels of satisfaction for the treatment from patients and therapists. A new scale, the Borderline Evaluation of Severity Over Time (BEST), developed to measure severity and change in persons with BPD, is described. We propose to conduct additional research to further validate the efficacy of STEPPS. Copyright 2002, Elsevier Science (USA). All rights reserved.  

What Therapists Need to Know

Many people in the helping profession do not feel good about using labels on individuals from the "mental health bible" - the DSM IV which discusses diagnosis and criteria. So, many discard these labels, some to the extent that they will not read a client’s chart before counseling them. These therapists don't have a clue on how to treat someone with the borderline personality disorder. You do NOT treat someone with this disorder the same way you would treat someone without this disorder. DO read their chart. DO pay attention to their diagnoses which will help to give you a map on treatment. You may want to refer them to a medical Dr. for an assessment as well if they are not being seen medically.

Many therapists refuse to treat people with BPD for many reasons. One being my very point, that they can easily be triggered and become suicidal, wind up in the hospital etc. and many therapists don’t want to deal with that.

Becoming educated about the borderline disorder, knowing and accepting your limitations will help protect you "out there" in a world where borderlines are widely misunderstood and are, in my opinion, wide open to being hurt and damaged further by lack of education by professionals. 

You know you need therapy and that you need help and thus the process of shopping for a therapist must be done wisely.

Many of you however, don’t have the luxury of "shopping" due to your insurance, lack of finances, etc. You have to "take what you can get."

However, for those who *can* shop, look for someone who is  experienced in working with borderlines. Ask them to fill out a questionnaire that I have created.

I encourage you if possible to obtain this form of therapy created by Marsha Linehan, from the University of Seattle in Washington. It is therapy especially designed for borderlines. 

DBT has assisted many people who have the borderline personality disorder. However, DBT has not helped everyone with the BPD. It is not a "cure-all" in my opinion.

There is a workbook out that I recommend in my book section called "Skills Training Manual for Treating Borderline Personality Disorder." I encourage you to get that and begin working in it.

There is a DBT email support group on-line that I have posted in the "Resources" section.

I know in New York for example that Medicare will cover DBT and now in certain places in Oregon, the Oregon Health Plan will pay for it. Check it out where you live. See if you can afford it and if you can find someone who does DBT. I believe there is a severe shortage of people who are trained in DBT. Hopefully in the future this will not be a problem.

Remember that you are vitally important and an extremely precious human being. You deserve the best of care and the best out of life. You deserve good medical care and therapy as well.

I don’t know at what level you are functioning when you read this, but whatever level that is, you MUST find the strength to get the help you need. You are worth it. Your self-esteem may be in the bucket right now but you must know that these feelings are simply a part of your illness. They are not reality. You did not ask for your illness. You did not cause it and it is not your fault.

You are not alone, you are among many even though you do not see them, they suffer with you and like you. This should tell you that there is hope. There is a light, though it may appear dim, out there at the end of this long tunnel you are in now. In my opinion, medication will shorten this tunnel tremendously.

There is always light out there for you. There is love out there and peace. There is healing.

REFERENCES

American Psychiatric Association, Practice Guideline for the Treatment of Patients with Borderline Personality Disorder, Work GROUP ON BORDERLINE PERSONALITY DISORDER, John M. Oldham, M.D., Chair

Harvard Mental Health Letter
March 2002