The Stable Instability of Patients with Borderline Personality Disorder and the Difficulty Clinicians Face Trying to Treat Them

One of the most challenging psychological disorders for a therapist to treat and among the most resistant to therapy, Borderline Personality Disorder features a number of pathological symptoms including suicidal and parasuicidal ideation, impulsivity, aggression, dysphoria, sensitivity to abandonment, identity disturbance, instability, and angry affect (Grube, 2007). These symptoms present themselves with varying degrees of severity depending upon the patient’s type and level of BPD dysfunction. In a 1968 behavioral study of ego functions, clinical psychologists Roy Grinker, Beatrice Werble, and Robert Drye conducted cluster analysis research to identify four distinct types of patients afflicted with Borderline Personality Disorder. According to their findings, these four subgroups comprising BPD appear to occupy a continuum of decreasing severity on the border between psychotic and neurotic psychopathology. Among all four subgroups, leading features of BPD are “stable instability” (Schmideberg, 1959), “panneurosis”’ “pananxiety”, and “pansexuality” (Knight, 1953). Residing nearest the psychotic border, the BPD Type I subgroup displays features such as quasi-psychotic thought, manipulative suicide efforts, and countertransference difficulties (Zanarini et al., 1990). Type II is characterized by a pervasive pattern of instability within interpersonal relationships. Typically, these Type II patients display several dysfunctional behaviors such as self-mutilation, excessive demands/entitlement, and expressions of concern about abandonment/engulfment and annihilation (Zanarini et al., 1990), in their effort to avoid real or imagined abandonment, separation, loss, or rejection. Type III BPD sufferers show a generalized lack of personal identity, appearing to be immensely challenged at maintaining a stable or consistent sense of themselves as individuals, tending to borrow an identity from others. Chessick (1987) noted a “well-hidden poverty of genuine emotional relationships behind an attractive and personable social façade” (p.532). Type IV Borderline patients – exhibiting various traits indicating countertransference difficulties and treatment regressions (Zanarini et al., 1990) – make up the subgroup closest to the neurotic border (Gabbard, 2005). The borderline patient’s suffering is a relatively stable and enduring condition (Chessick, 1979). Often, a BPD sufferer’s emotional dysregulation leads to an uncontrollable outward volatile affect. Such a sudden shift in affect typically reflects disillusionment with a love object, and indicates the patient’s expectation of impending abandonment. Impulsivity is another characteristic signpost of the disorder. Paul, Schroeter, Dahme, and Nutzinger, 2002 found that typical expressions of impulsivity on the part of the BPD patient include binge eating, self-mutilation, substance abuse, unsafe sex and reckless driving (Zanarini et al., 2007). The patient with BPD often dramatically changes career goals, values, sexual identity, and friends (Gabbard, 2005). While in a crisis of instability a patient may inexplicably quit a job, withdraw socially, and isolate entirely. Such an impulsive and chaotic temperamental display leads to anxiety, guilt, and self-loathing for which the patient may choose to engage in high-risk or self-harming behavior in order to feel relief. These patients are known to have chronic suicidal ideation and often engage in self-harm through acts of cutting or burning (Blatt & Levy, 2003; Clarkin, et al., 2006). The BPD patient who uses cutting, burning, food, drugs, alcohol or other self-injurious behavior may obtain at least temporary pseudo-relief from feelings of self-hatred, lassitude, emptiness, and seemingly intolerable loneliness. All too often impulsive marriages and divorces, unexpected pregnancies and abortions, the perpetual starting and stopping of jobs and academic careers, spoiled successes, and blighted relationships coalesce and contribute to the failure of a promising life and even suicide (Blatt & Levy, 2003; Clarkin, et al., 2006; Lilienfeld, 2012; Linehan, et al., 2006; Wenzel, et al., 2006). Inappropriate or out of proportion expressions of anger are a distinguishing feature of BPD. Although the patient may be high functioning, efficient, and display socially acceptable conduct most of the time, the inevitable outbreak of a regressed or childlike state of helpless anger -- observed clinically by Knight (1953) and, later, Kernberg, (1975) -- devastates interpersonal interactions (Clarkin, Yeomans, & Kernberg, 2006; Gabbard, 2001, 2005; Grinker et al., 1968). At times, inappropriate anger can escalate into physical confrontations, explosive rages, and violence. BPD is widely known to interfere with interpersonal relationships. Patients’ unrealistic relational expectations with others lead to devaluation following initial idealization. The patient’s behavior often has a profoundly negative impact on family members (Hoffman et al., 2005). For example, the patient’s inability to exhibit self-control may lead him or her to take a vindictive and rageful reproach (Linehan, 1993) for perceived slights. Family members may be witness to out-of the-blue tantrums with pronounced volatility (Hoffman et al., 2005). Family and loved ones of the patient feel unable to stop or help the patient who appears to explode outwardly and implode inwardly. Commonly, such a patient struggles with a life descending into chaos and a desire to die resulting from feelings of ineptitude, subservience, and self-loathing for his or her perceived inability to self-actualize (van Reekum, et al., 1993; Wenzel, et al., 2006). Koenigsberg & Siever (2000) found evidence that BPD patients may enter a dissociative state and attempt to gain relief through self-harming behavior in order to expiate feelings of non-existence. This finding was consistent with Marsha Linehan’s research (1993). Although deeply unhappy, it is usually only during a time of crisis that the BPD patient is most likely to seek clinical intervention and treatment (Linehan, 1993). The patient with a BPD diagnosis who is in crisis is usually suffering from actual or perceived rejection or separation (Clarkin, et al., 2006). The patient’s intense dysphoria, irritability, and anxiety may vacillate in a noticeably reactive mood -- shifting in intensity, duration and frequency within hours, and on occasion can last for several days (Blatt & Levy, 2003). Depersonalization is known to occur (Zanarini and Frankenburg, 2008) during times of transient paranoid ideation and extreme stress. These feelings of depersonalization usually last from a few minutes to a few hours, and the real or imagined return of a caregiver’s affection and attention may allow the symptoms to spontaneously remit (Clarkin, Levy, et al., 2007; Hallquist & Pilkonis, 2012; Kreisman & Straus, 2010; Watson & Sinha, 1998; Westen, Gabbard, & Blagov, 2006). Patients diagnosed with BPD notoriously pose challenges to therapists seeing them in clinical practice (Adler, 1979; Gabbard, 2000; Levy, Clarkin, Yeomans, Scott, Wasserman, & Kernberg, 2006). Marsha Linehan (1993) reported that it is not uncommon for those with the disorder to storm out of sessions, make frequent calls to therapists between scheduled sessions, and blame therapists for hurting their feelings. Linehan further states that a patient’s fear of rejection by the therapist often leads to noncompliance, a decreased probability of establishing a sound therapeutic alliance, a negative outlook on the therapy process, premature discontinuation of treatment, and a poor prognosis. The rapid cycling of alternating moods and the tendency of BPD patients to inappropriately cross personal boundaries (Gabbard, 2005) can prove challenging and frustrating for a therapist. Patients entering into therapy at the height of crisis often awaken the therapist’s counter-transference response to protect and rescue. However, the patient’s characteristic tendency to idealize and, subsequently, despise others typically triggers some therapists’ intense feelings of disappointment and anger. The volatile dynamic that these patients create is likely to stem from increased sensitivity to criticism and perceived slights (Clarkin, Yeoman, & Kernberg, 2006), which heightens the patient’s instability in sense of self. Compounding these problems further is the sufferer’s chaotic use of medical and psychiatric services (Bateman & Fonagy, 2003), refusal to comply with taking prescribed medications (Gabbard, 2005), and overall noncompliance resulting in the reputation of the patient with BPD as being difficult to treat. The life threatening and debilitating effects of the disorder represent a serious public health and clinical concern (Bateman & Fonagy, 2003). That said, this group is not so much defined by therapists for their symptoms, but rather the characteristic problems underlying the symptoms, as well as the ramifications of their behavior upon others (Clarkin, Yeoman, & Kernberg, 2006). Although no single factor is known to cause the disorder, research conducted by Skodol et al. (2002) suggests contributing factors that may amalgamate, leading to the etiology and onset. Zanarini and Frankenburg (1997) propose that an inherited vulnerability (Masterson and Rinsley, 1975), a particular temperamental constellation (Cloniger et al., 1993), early childhood trauma (Paris, 1998), subtle changes in the patient’s neurobiology (Coccaro and Kavoussi, 1997; Coccaro et al., 1989; Siever and Davis, 1991), and disruptions to hormonal balance (Gabbard, 2005) may coalesce, resulting in BPD. Inconsistent and unstable patterns from caregivers during childhood (Zanarini and Frankenburg, 1997) may result in a “limited behavioral repertoire” and result in dysfunctional compensatory strategies aimed at affect regulation and emotional containment.

Terrible Therapists: Bad Marriage Counseling Hurts People with Borderline Personality Disorder

I am an expert on Borderline Personality Disorder (BPD) and write extensively on the subject. I became familiar with it in the 1980’s, wrote a 175 page doctoral dissertation on it, presently blog about it on Patch, and have numerous clients affected by it (either themselves or through a friend or loved one). I gave up the practice of psychotherapy because I think it serves no good purpose to label, diagnose and talk to people year after year about their problems. Although I do not diagnose my clients with this, or any, disorder I do not dispute the fact that the term is widely used within the mental health field. It typically denotes a chronic and persistent pattern of maladaptive behavior that includes harmful “acting out” (suicide attempts, high-risk sex, etc.), and harmful “acting in” (alcohol and drug abuse, eating disorders, etc.). I do not approve of the pharmaceutical industries’ agenda to have doctors label, diagnose and prescribe dangerous and addictive pills to hook unsuspecting consumers. Also, I do not agree with how people are labeled and treated in therapy – especially women and minorities. It is all a scam, in my humble opinion. I became a certified life coach to avoid the pitfalls I see in the current, mental-health zeitgeist (read: DSM5). If you are unsure as to what BPD means exactly, I encourage you to read other posts I have written that describe it in depth. Also, there is no shortage of good literature about BPD in the DSM-IV-TR, DSM5, and various trusted websites. A recent client and I had the following exchange: Client: A therapist my wife and I were seeing diagnosed my wife with BPD and I want to know if I should leave my wife and get custody of the children? Dr. Jabin: Why would you do that? Client: The therapist said BPD is a severe mental illness that is not curable. I am starting to see signs of BPD in my toddler and nine-year old daughter. Dr Jabin: I disagree that BPD is a “non-curable disorder.” My personal experience with clients is tells me otherwise. I have coached people so successfully that they can no longer be considered BPD by therapists who diagnose. Aside from my success with my clients, there is new longitudinal research that suggests the most troubling symptoms remit by the fourth decade. I do not believe you are actually seeing BPD in your toddler, nor do I think you should contextualize your nine-year old’s behavior as occurring along a BPD continuum. What I found the most troubling was that this man was part of a “couple” who had gone to marriage therapy for help. Instead, the therapist aligned him or herself to my client and together they conspired to triangulate against the wife. So perverse is this, yet so common too, that I am moved to write about it. The therapist even had the audacity to suggest to my client that he leave this country and return to his country of origin where he could successfully wrestle away his wife’s parenting abilities due to a power and money imbalance. I was trained in graduate school that American psychologists should not rush to label foreigners with western diagnoses – especially a stigmatizing, “non-curable” diagnosis. Did this therapist understand that he or she was in a trusted position to point out resources? It does not appear to be the case. No wonder so many couples do not get the help they need and deserve when they go to marriage therapy. Despite the fact that couples go to counseling they do not get the tools, learn the skills, or find the resources that they need to repair the marriage. I believe this is because too many marriage counselors are horrible at their job. God help the unsuspecting clients who end up in the throes of a therapist with a secret agenda -- such as "acting out" his or her own traumas under the guise of "therapy." My client’s wife may have some valid reasons for her inappropriate behavior towards her husband that could be respectfully and competently looked at in a more empathic way. A good therapist could gently persuade her to try new and different things to get better results. This woman did nothing to deserve a therapist misusing her position of power to wrestle her husband and children away from her. She did deserve compassion, empathy, hope, and a chance to heal herself and her marriage. Why else would this woman leave the comfort of her home to attend marital therapy, put her children in the paid care of another and agree to attend counseling with her husband? Not for this trickery, I assure you. Therapists with unresolved personal problems that negatively color their therapeutic outlook pose a danger to society. Our society puts doctors and therapists on pedestals to be the gatekeepers of morality and virtue. Doctors get to decide what behavior is “normal” and what behavior gets labeled “disordered.” Judges depend on therapists’ input to help them rule in favor of leniency or harsh sentences. Therapists persuade judges and juries every day about which parents are more fit and which offenders are deserving of second chances. Being a doctor carries a lot of weight in society. Therapists who can’t manage their own healthy relationships should not be able to advise clients on what they should or should not do. Every therapist should be in therapy in order to be accountable and to know what it feels like to be the client. I advised my client to get his wife to a medical doctor for a complete physical that includes blood and urine work. I reminded him that as women age our hormone levels change and that all his wife may need are vitamins and whatever appropriate pharmacology would help her feel better . This may or may not mean antidepressant medication. One of my favorite sayings, and my mantra, is this: If you hear hooves approaching, expect to see horses and not zebras. This reminds me that the cause is usually something fairly more obvious (depleted hormone levels and specific life event stressors) rather than the exotic (an incurable, mental-disorder dreamed up by the gatekeepers of moral society). Another favorite saying of mine speaks about the Art of Detachment. It goes like this: "Detach with love, not with an axe." I seriously doubt the couple's first therapist is correct to advise my client that he should relocate his family to their far away country of origin, lawyer up and rip away the young children from their mother forever. Did I mention that this couple had an arranged marriage and their religion tells them they are married for life and eternity? Psychological Ethics 101 tells American therapists to respect other cultures, learn about client cultures that are markedly different from our own, seek out knowledgeable colleagues for help, and do not pathologize these people because they are not displaying typical American values and norms. Hopefully, my readers know better than to agree with the advice of a terrible therapist.

Can a Shrink Really Help Patients Who Have Borderline Personality Disorder?

Psychoanalysis as a Clinical Treatment for BPD Freud’s observation that individuals are often unaware of their own causal factors affecting emotions and behavior led to his development of psychoanalysis. According to Freud’s psychodynamic perspective, the intrapsychic drives influencing human behavior are primarily unconscious. His theory of personality focuses on unconscious forces, psychic determinism, anxieties, and internal conflicts which coalesce to manifest as intellectual and emotional difficulties (Brenner, 2001; Friedman, 1975; Gabbard, 2004; Gaston, et al., 1998; Greenberg & Mitchell, 1983; Ogden, 1986). Seven features distinguish psychodynamic therapy from other therapies (Shedler, 2010). These features are (1) focus on affect and expression of emotion; (2) exploration of attempts to void distressing thoughts and feelings; (3) identification of recurring themes and patterns; (4) discussion of past experience (developmental focus); (5) focus on interpersonal relations; (6) focus on the therapeutic relationship; and, (7) exploration of fantasy life (Blagys & Hilsenroth, 2002; Burum & Goldfried, 2007; Shedler, 2010). The determination of these distinguishing features was made through empirical examination of session recordings and from transcripts of therapy sessions (Shedler, 2010). Psychodynamic therapists explore reoccurring themes and disruptive thought patterns that negatively affect concepts of self, interpersonal relationships, and the ability to enjoy life. Although aware of painful or self-defeating patterns, some patients are not able to manage these patterns (Gabbard, 2004). Often, patients are drawn to emotionally unavailable romantic partners and even abusive partners (Dutton, et al., 2006). For patients who are unaware of the ways they sabotage themselves, work with a psychodynamic psychotherapist can help them become more emotionally aware and thus, able to change (McWilliams, 2011; Sachse, et al., 2011; Shedler, 2010; Wampold, et al., 2002; Waters, et al., 2000 ).