The best treatments for Borderline Personality Disorder are deeply personal

It’s a diagnosis that ravages two percent of the general population and twenty percent of patients in psychiatric inpatient facilities. Characterized by frantic efforts to avoid abandonment, intense patterns of idealization and devaluation of interpersonal relationships, high levels of impulsivity in spending, sexuality, or eating-- all with deleterious effects—and this is only the beginning.

Welcome to the world of Borderline Personality Disorder (BPD).

The fragile realm of BPD is rapidly changing in treatment and diagnosis. Changes to the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are heralding the most prominent adjustments to psychiatric diagnosis in some thirty years. Personality disorders are taking the biggest hit – half of personality disorders in the current manual getting the “boot.” All these changes and more are preliminary and awaiting field trial.

While diagnosis is an important part of the mix of modern medical and mental healthcare, it does little to directly help treatment and recovery. For those effected by BPD – it’s ravaging. For those that treat it – taxing.

But advances in treatment have occurred:  you just won’t find them in the DSM.  Research-based humanistic person centered treatment methods provide a beacon of hope for those with BPD.

Research published in the Journal of Humanistic Psychology provides hope and help. Adam Quinn, a social worker and clinician whose work covers the gamut of trauma survivors, veterans, and seriously mentally ill clients tackles the treatment of Borderline Personality Disorder with the Person Centered Treatment Model (PCT).

Quinn tackles the diagnosis and treatment of BPD with rigor, practicality and eloquence. Examining the array of conventional approaches, Quinn highlights the empirical evidence for person centered treatment for individuals diagnosed with or possessing characteristics of Borderline Personality Disorder.

It’s Carl Rogers’ technique, twenty first century style.

The following six process mechanisms, resulting from Person Centered facilitative mechanisms demonstrate the effectiveness of such therapy:

Increased Accurate Awareness: Through the therapist’s facilitative embodiment of congruence, unconditional positive regard, and empathic understanding, a BPD client moves from a state of idealized interpretations of their environment to reality based interpretations; thus a lessening of interpersonal abandonment issues.

Internal Locus of Control: As the therapeutic alliance continues to authenticate and express congruence, a BPD client gradually moves from the external locus of control that causes many issues, to an internal locus of control.

Assimilate Previously Threatening Experience: In the process of gaining an internal locus of control, the interpretation of external experiences changes and assimilates into the realistic realm of expectations. As an increase in accurate awareness of inner and external realities occurs, the positive regard of the therapist becomes part of the “selfhood” of the client; thus promoting inherent elf-actualizing and self-growth tendencies.

Defensiveness to Acceptance: Based on the facilitative qualities present in the therapeutic relationship, the client gradually moves from their classic defensive state to a state of self-acceptance. The borderline tendencies of the client begin to substantially lessen as the internal locus of control recognizes its value as a person through the experience of the therapist’s genuinely expressed non-possessive unconditional positive regard. Issues of suicidality are common in this phase for the client as they test their “worthiness” in the face of the clinicians continued positive regard.

Increased Acceptance of Others: Through the testing and subsequent internalization of the therapeutic acceptance, the client begins to more fully accept themselves and in turn begins to accept others; without the previous fear of abandonment, and the elements of devaluation and idealization. Self-harm behaviors lessen as interpersonal unstable relationships decrease. The self-actualizing tendency further promotes congruency between self and experience; thus the client begins choosing healthier relationships.

Reliance on Self Evaluation: In this phase, internal evaluation of experience becomes paramount as increased reliance is placed on the client’s internal locus of control. Through the genuine person centered therapeutic relationship, the client moves toward an inner locus of control; where reactivity and affective instability cease to exist and self-evaluation predominates.

 

With Quinn’s research as a foundation, great work and hope remains to recognize the endless possibilities with treating borderline personality disorder with the person centered therapy model. As Carl Rogers once said, “This is the person-centered scenario of the future. We may choose it, but whether we choose it or not, it appears that to some degree it is inexorably moving to change our culture…”

-- Liz Schreiber

Comments

[John Bessa]

Hello Liz,

You write about the defensiveness to acceptance phase that "Issues of suicidality are common in this phase.."

How do you mean "issues." According to DBT therapists, there is a tendency for self-harming with open encounter sessions among BPD sufferers.

My understanding is that BPD sufferers can have valid structural thought (Synopsis of Psych, Saddock) and that it is their emotional thought that is distorted, or dysfunctional. My thought is that an objective view of Rogers' personality model, for instance, might appeal to this structural ability providing locus of control objectively rather than subjectively.

Below are two links of my writing with references, etc.

Rogers personality theory:
http://docs.google.com/View?id=ddk32zv4_1718htcdkcct

Dialectic BT:
http://docs.google.com/View?id=ddk32zv4_1340gj6424fr

[Marshall Bennett]

Interesting comment Liz but I think that you take for granted the claim the DBT is the best EBP treatment and/or understanding of BPD, and I think many Dynamically oriented clinicians would at least partially disagree. In my work with BPD patients I only use principles from DBT (and other CBT oriented therapies) and my central treatment mode is Transference Focused Psychotherapy (Otto Kernburg). Dr. Glenn Gabbard recently mentioned that there are actually 7 EBP treatment modalities for BPD, so I would think there is many more disagreements around suicidality, self-harming and other primitive defensive maneuvers as well...

[Liz Schreiber]

Marshall--

Thank you for your comment.

Some fairly recent research (August 2010) sheds some light on both of our perspectives. In the Journal of Consulting and Clinical Psychology, researchers Hopwood and Zanarini looked at predicting patient functioning utilizing the 5-factor model (FFM) as it applies to personality traits and BPD. (Emphasizing the constructs being proposed for the upcoming DSM-5)

While the research is long and involved, one of the understandings that emerged was the following--

"This finding might suggest the importance of social contexts to mediate disorder-functional relations. It may also highlight the importance of adaptive or positive features that are not fully captured by diagnostic variables."

The finding goes on to explain distinctions in BPD clients depending on their psychosocial contexts.

Here is the reference:
Hopwood, C. J., & Zanarini, M. C. (2010). Borderline personality traits and disorder: Predicting prospective patient functioning. Journal of Consulting and Clinical Psychology, 78(4), 585-589. doi:10.1037/a0019003

With the upcoming revisions to the DSM, personality disorder treatment will surely be interesting!

Thanks for the comment.

All the best,

[Liz Schreiber]

John--

Thank you for your comment.

Yes, absolutely BDP clients typically have valid structural thought and labile/dysfunctional emotional thought, experiences and processing.

It is of course important to distinguish if there is a dual diagnosis or not. In my understanding, it is not uncommon for suicidality and self-harm behaviors to be common phenomena throughout treatment for BDP sufferers; often leading to the necessity of inpatient care or similar programs. The degree of self-harm behaviors depends on the progression of therapy, substance abuse, dual-diagnosis and/or concurrent psychopharmacological treatment.

Important elements here are the client's support system, the constraints of treatment (insurance or financial) and the course that the BPD has taken on the client's life up to the point of treatment (suggesting repeatable patterns)

Thank you for sharing your work--it is phenomenal!

Overall, rather subjective or objective, it seems essentially that Rogers comes into the "treatment equation" with BDP clients.

Thanks for your comment!

All the best--

Liz Schreiber