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.

An Outpatient Approach to Treating Mothers with Borderline Personality Disorder and When Hospitalization May be Necessary

Treating Mothers Who Have BPD Extensive empirical evidence supports a psycho-educational intervention for the identified patient as well as the spouse and children (Cohen et al., 2008). Psycho-educational information about childhood developmental stages and milestones from infancy forward would aim to reduce family stressors and risk of relapse (Cohen et al., 2008; Gunderson et al., 1997). A systems-based approach in treating mothers with BPD would encourage the patient to form or join a support network comprised of other mothers with BPD (Cohen et al., 2008). Presently no manualized form of structured treatment exists, although treatment models have been proposed, and at least one peer reviewed article has been written (Stepp et al., 2012) on the efficacy of treating the entire family. In-Patient Hospitalization for Suicidal Patients with BPD Many people with Borderline Personality Disorder cannot afford ongoing psychoanalysis, and may require hospitalization during a crisis. Further, psychoanalysis may prove to be more harmful than beneficial to patients in crisis, because inherent transference and countertransference problems can derail therapy altogether (Gabbard, 2000). In addition, insurance and managed care companies are less likely to pay for long-term psychoanalytic therapy than the more time-limited cognitive behavioral treatment (Gabbard, 2000). Therefore, hospitalized care is often a crucial component of a good outcome for patients severely impaired by BPD (Gabbard, 2005). A three-step model has been proposed (Ogden, 1979) for BPD patients who have been admitted to a hospital in-patient treatment program, based on the following concepts of projective identification (Gabbard, 1990; Goldstein, 1991; Sandler, 1987): (1) the self-or object representation is unconsciously projected from the patient onto the treater, (2) the treater unconsciously identifies with the patient’s projected self- or object representation, and (3) the treater psychologically processes the projected material, which then becomes modified and re-introjected by the patient. Patients tend to recreate internalized patterns of attachment, perhaps in an attempt to master previously experienced trauma (Gabbard, 1988). Patients with BPD may try to provoke hospital clinicians to gain both the auspice of control and the mastery of similar situations which had eluded them in early childhood (Gabbard 1988). The four forces theorized to contribute to the patients’ perpetuation of transference patterns are: (1) to actively master previous traumatic experiences that he or she was passive in (Pine, 1990), (2) to maintain attachment patterns (Gabbard, 2005), (3) to invite help from others who could protect them (Gabbard, 2005), and (4) to transform their lives (Sandell, et al., 2000). Conflicting and therefore irreconcilable self- and object representations become split off from the patient and projected onto hospital staff members. Rather than merely a defense mechanism, projective identification of fragmented and externalized self- and other material serves as a potent way for patients to communicate, and expresses their hope for a better outcome from a repeated and familiar pattern (Gabbard, 1988). Guntrip (2011) refers to this as “the object and self both being transformed into the fantasy relationship for which the patient longs.” Although unable to verbalize their internal experiences, nevertheless inpatients may be able to evoke similar experiences with hospital staff as an unconscious way of managing affect and primitive anxieties that exert psychical pressure (Gabbard, 1988). There are four identified primary features involved in the phenomenon of splitting that inpatients undergo: (1) the splitting is unconscious; (2) dependent on the patient’s internal object representations, different staff members are perceived differently and, sometimes, these differences are dramatic in their projection; (3) through the process of projective identification staff members react to these projections by taking on the projected aspects; and (4) treaters’ opinions of the same patient can become polarized to the point of causing frictions and falling-out among the staff during discussions (Casement, 1990; Gabbard, 1989a; Ogden, 1987). Corrective measures should include assuring the patient that the treater can tolerate and manage intense feelings without the retaliation or abandonment the patient had experienced in similar situations in the past. Rather than reacting, the treater instead responds to the patient, reducing the patient’s primitive anxieties. This, in turn, stops the patient from having to split, or disavow, painful introjections. Initially, the treater may attempt to contain the patient through a willingness to serve as the patient’s “bad object.” The treater can subsequently vent privately to colleagues to discharge any anger provoked by the patient. Treaters who lack the internal resources to prevent a harsh reaction to the patient may be characterologically unsuited to implement the holding and containing process the patient needs in order to change (Brune, et al., 2010; Carter, 2006).

Dr. Jabin, Does My Girlfriend Have Borderline Personality Disorder?

I have the expressed written permission of my client to write the following blog. Recently a client asked me if I thought his girlfriend has Borderline Personality Disorder (BPD). He told me that he familiarized himself enough with the symptoms online and wanted my professional opinion on the matter. According to my client his girlfriend was moody, says horrible things to him and about him that are plain “evil,” and recently began blocking his calls while in a particularly foul “spell.” After I told him that since I have never met the woman, his girlfriend, that I cannot ethically reach an opinion as to whether or not she has BPD. I told him that while some of the behaviors he described to me seem to resemble some typical borderline pathology that ultimately there is no simple way to know—especially in this instance where I never met her. Where do doctors who diagnose BPD start? I always, and I mean ALWAYS, ask my clients to go see a medical doctor before jumping the gun and rushing into a psychological diagnoses. It is my humble opinion and with all the advanced education, training and real world experience that I tell my clients to please get a physical beforehand. My client was not thrilled with my reluctance (read: refusal) to confirm what he suspects about his girlfriend. He kept insisting, “Okay, I know what you are saying, I hear you, BUT—do you think she could have BPD?” Here is what I told my insistent client about BPD: The symptoms of the disorder are broad, overlap with many other “disorders,” and may just be the result of a physiological problem versus a psychological problem. For example, he said she is very “moody.” Well, doesn’t drug and alcohol addiction make a person tired, irritable, cranky, depressed one minute and elated the next? Of course it does. Guess what else does? A brain tumor. So do diminishing estrogen levels and/or thyroid problems. It could be anything else other than BPD—and that is where one must begin their thorough investigation. I hope I do not offend some folks who diagnose psychological problems with great ease, but Shame on you! How terrible it is to label a person with one of the most severe types of psychopathology---for which the psychological community largely feels there is no cure. After I ran down other possible things it may be other than the most vilified and disliked disorder in the DSM to my client he told me that his girlfriend did in fact have an addiction to Percocet—and alcohol. While BPD does overlap with addiction it does not mean that addicts always have BPD. Often times when people sober up they become free from demons that have played them personally and professionally. However, some people get sober only to find they don’t have an escape from severely debilitating mental health problems. There is definitely correlation between BPD and addiction—but, we need to differentiate correlation from causation. I told my client that even if his girlfriend does seek a therapist to discuss her possible BPD that a well trained, highly knowledgeable therapist will recognize the need to prioritize the addiction problem first. That is, it is first and foremost to help the client find the right resources to get the active addiction under control rather than to spend years discussing her “other” problems. Life endangering problems are to be put at the top of the list and everything else prioritized accordingly. Active alcoholism and drug abuse is a greater “real” problem than anything else a client may present with—such as BPD. After my client and I spent the hour discussing his girlfriend and the problems she may or may not have I asked my client this: “Why would you choose to be with a person whom you describe as horrible to you, abusive and suffering from drug and alcohol abuse?” He sheepishly said, “yeah, I guess we might want to look at that.”

Mom is not Really a Monster or a Psycho, She Just Has Borderline Personality Disorder

Attachment Theory: What it is Attachment theory is a useful framework by which to understand BPD, because problematic attachments or pathological attachment styles often serve as the basis for BPD (Bowlby, 1973; Mahler et al., 1975). Attachment theory recognizes four categories that exist between child and caregiver: 1) Secure, 2) Ambivalent/ Resistant, 3) Avoidant, and 4) Disorganized (Fonagy, 2001). When a caregiver is sensitive to an infant’s signals and appropriately responds to the infant’s needs, the child feels secure, having come to “possess a representational model of attachment figures as being available, responsive, and helpful” (Bowlby, 1980, p.242). Infants who do not develop feelings of security from a caregiver tend to become distressed in novel surroundings. These children typically exhibit clingy behavior, are difficult to soothe, and are not comforted through interactions with the attachment figure (Ainsworth, 1970). Children who are avoidant often experience the caregiver as insensitive or rejecting of their needs (Ainsworth, 1979). Such a caregiver may withdraw from helping behavior during difficult tasks and become emotionally unavailable during times of emotional distress (Stevenson-Hinde, & Verschueren, 2002). Rather than orientating to their attachment figures when exploring new surroundings, these avoidant children exhibit independent behavior. When the caregiver mistreats the child, is intrusive, or exhibits frightening behavior (all forms of child abuse) the child develops a contradictory attachment strategy, lacking in coherence. For example, such a child characteristically may approach the attachment figure with eyes averted and facing away (Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1986). Emotional distress may result when affectional bonds are threatened by loss or disruption, leading to sadness and anxiety (Fonagy, 2001). Hence, when a caregiver is either insensitive or unavailable to the infant, certain pathogenic self-deficits may result (Gabbard, 2005; Goldfried & Wolfe, 1996; Gratz & Gunderson, 2006; Ogden, 1986; Pos, Greenberg, Goldman, & Korman, 2003; Mulder, Joyce, & Luty, 2003; Pynoos, 1993; Vocisano, Klein, Arnow, Rivera, Blalock, Rothbaum, & Thase, 2004). Bowlby (1973, 1977) wrote that both psychopathological and normal development are rooted in attachment processes. Well-adjusted, “healthy” individuals have a balanced and seemingly realistic and coherent narrative about early relationships. People free of psychopathology describe attachment-related experiences as having been influential to their emotionally-sound development and later wellness (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Conversely, Bowlby (1973, 1977) wrote that early difficulties in attachment may predispose a person to vulnerabilities and resultant psychopathology. Bowlby (1973, 1977) postulated that attachment difficulties lead to the specific psychological deficits of BPD. Disturbed attachment styles give rise to emotional distress that manifests in personality disturbances, rage, anxiety, anger, self-destructive, para-suicidal and suicidal ideology, depression, and emotional detachment (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Bowlby further theorized that problems with attachment during early childhood may lead to problems with later close relationships and child rearing. Moreover, according to Bowlby (1973, 1977), attachment patterns persist with potentially long-lasting negative reverberations throughout a person’s lifespan (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Treating Mothers Who Have BPD Extensive empirical evidence supports a psycho-educational intervention for the identified patient as well as the spouse and children (Cohen et al., 2008). Psycho-educational information about childhood developmental stages and milestones from infancy forward would aim to reduce family stressors and risk of relapse (Cohen et al., 2008; Gunderson et al., 1997). A systems-based approach in treating mothers with BPD would encourage the patient to form or join a support network comprised of other mothers with BPD (Cohen et al., 2008). Presently no manualized form of structured treatment exists, although treatment models have been proposed, and at least one peer reviewed article has been written (Stepp et al., 2012) on the efficacy of treating the entire family. A pilot program called Multiple Family Group (MFG) (Gunderson et al., 1997) advocates for a psycho-educational approach to wellness for BPD sufferers. MFG is comprised of three forms of treatment: (1) Family Connections (FC) (Fruzzetti & Hoffman, 2004), (2) Systems Training for Emotional Predictability and Problem Solving (STEPPS) (Blum, Pfohl, St. John, Monahan, & Black, 2002), and (3) Multigroup Family Skills Training (MFST) (Miller, Rathus, & Linehan, 2006). FC and STEPPS focus on the sufferer within the context of the family system, while MFST focuses on the entire family. Gunderson et al (1997) furnish empirical evidence that MFG improves family communication and lessens family burden after 6 months of treatment.

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 ).