In order to develop a treatment plan for any client, one must first develop a deep understanding of the diagnosis at hand. It is imperative that both the therapist and the client understand the weight, stereotypes, and historical value the diagnosis carries. And before creating a unique Humanistic Approach the therapist must fully understand the trials and errors of the approaches before in order to weigh all of the treatment options.
Borderline Personality Disorder or BPD is classified under the Diagnostic and Statistical Manual for Mental Disorders (5th ed.) or the DSM-5 as a personality disorder in cluster B along with antisocial and narcissistic personality disorders. According to Sadie F. Dingfelder, Treatment for the ‘Untreatable’, at least one personality disorder can be found in up to 30% of patients who require and seek out mental health services. A personality disorder can be “characterized by abnormal and maladaptive inner experience and behavior” (1).
The DSM – 5 classifies BPD as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following.” The possible requirements include efforts to avoid real or imaginary abandonment, alternating between extreme idealization and devaluation in unstable and often intense relationships, and a consistently unstable self-image. Other requirement options include impulsive behavior, such as spending, substance abuse, binge eating, etc., patterns of suicidal behavior, intense moods swings generally lasting a few hours, a continuous feeling of emptiness, inability to control and express anger appropriately, and major dissociative symptoms along with stress-induced paranoia.
According to to the Harvard Mental Health Letters article Treating Borderline Personality Disorder, BPD can affect up to 2% of American adults. Adults with BPD make up about 10% of patients in psychiatric outpatient units and they can make up around 20% of patients in psychiatric in-patient units. Among the 2% of American adults, “69% to 80% of patients with BPD engage in suicidal behavior” and “up to 9% of the patients with BPD die by suicide” (1).
Borderline Personality Disorder often begins to develop in early childhood and is thought to have a direct association with childhood abuse, particularly early sexual abuse however it is only diagnosed in about 3% of the adolescent population. In Borderline Personality Disorder: An overview of history, diagnosis, and treatment in adolescents, Linah Al-Alem, MSc and Hatim A Omar, MD state that “BDP manifests itself in adolescence in the form of uncontrollable anger, self-mutilation, dissociation, and other such behaviors” (395). There has been the exploration to the ties of BPD and sexual abuse, that it perhaps is some of PTSD, but there has been no clear evidence. BDP can often be associated with patients with a traumatic childhood and unstable family life.
Throughout history patients with Borderline Personality Disorder have been labeled as hopeless, inconsistent, and extremely difficult to treat. According to Al-Alem and Omar, the term borderline itself developed due to the fact that “patients were believed to lie on the borderline between psychosis and neurosis” (395). It was Adolph Stern who first came up with the term “borderline” however it wasn’t until 1980 when “borderline” was accepted as a psychological termed and used in the DSM III.
The dominant form of treatment for clients with Borderline Personality Disorder is psychotherapy. Therapy tends to be a slow and often erratic process for the client and Al-Alem and Omar state that “about two-thirds of borderline patients drop out of treatment within a few months” (399). While the best route of treatment is still up for debate it is clear that the patient-therapist relationship is vital to the success of therapy. The ultimate goal is to reduce the “borderline” habit the client presents while retaining and re-enforcing a trusting relationship.
The mainstream psychotherapy treatments for BPD are Dialectical Behavior Therapy (DBT), Schema Focused Therapy, Mentalization-Based Therapy (MBT), Systems Training for Emotional Predictability and Problem – Solving (STEEPS), and Transference-Focused Therapy. Although these are all viable sources of therapeutic treatment, four of these forms of therapy strike me as options that qualify as a Person-Centered Approach.
A Person-Centered Approach to therapy has five main goals according to Saybrook Universities article The Best Treatments for Borderline Personality Disorder Are Deeply Personal. The five mailed bullet points or goals of Person-Centered Therapy in reference to BPD are increased accurate awareness, internal locus of control, assimilate previously threatening experiences, defensiveness to acceptance, increased of other, and reliance on self-evaluation (3). These five main points of therapy are, in my opinion, the key to understanding. Once you have determined these goals you may then assume the best way to go about treating and working with your patient.
Adam Quinn references four types of therapy that have proven to be effective within the BPD community. The four therapies noted in his article, A Person-Centered Approach to the Treatment of Borderline Personality Disorder, are four concepts that I would ultimately consider for a client who has been diagnosed with BPD. These four types of therapies are Transference-Focused Therapy, Mentalization-Based Therapy, Schema-Focused Therapy, and Dialectical Behavior Therapy.
Transference-Based Therapy “focuses primarily on reactivating the primitive object relations of a borderline client in a controlled setting” (4). This type of therapy could be beneficial to a patient for many different reasons. Patients with BPD often have a distinct view of the world which are not always ‘accurate’. These internal representations of the world, self, and others come from “an increased capacity to reflexivity think about thoughts, feelings, and experiences” (4). This specific type of therapy has been shown to reduce depression, anxiety, and most importantly, depression in patients. I would specifically use this form of therapy to modify the patient’s irrational paranoia of abandonment which is a key feature in Borderline Personality.
Mentalization-Based Therapy does not focus on the patients’ view of the world but rather the ways in which they mentalize it. I, along with others, agree that this use of therapy could be extremely beneficial in examining the attachment the client has to certain relationships in their life. Quinn suggests a guideline for this specific goal. The guideline suggests the following four steps:
“(a) discussing current attachment relationships; (b) discussing past attachment relationships; (c) in creating an environment promoting affect regulation, the therapist is able to encourage and regulate the client’s attachment bond to him or her; and (d) in a group setting, the therapist attempts to encourage attachment bonds between members. The therapist also encourages the borderline client to experience a titration of negative emotions through confronting aversive/traumatic memories.” (5)
If I were to choose this type of therapy for a particular client I would also incorporate Dance Movement Therapy into sessions, particularly group sessions. I would utilize movement as a different or new way of mentalizing relationships. I would perhaps have them create a movement which helps better represent their own feelings of the relationship as well as the other person’s possible feelings of the relationship. Through this process, I would hope to give the client a different way of mentalizing the attachment relationship as well as a different perspective and general process.
Schema-Based Therapy was developed by Jeffery Young and “integrates cognitive, behavioral, and experiential techniques focused around the concepts of schemas and their influences on the borderlines client’s functioning and experience” (6). A schema is a way in which was organizes or categorizes a particular behavior or experience I would utilize this specific mode of therapy in a client who has expressed trauma in their earlier life. Using this type of therapy I could work through particularly dysfunctional or toxic relationships a client has, their fear of abandonment, as well as impulsive behavior and habits.
Dialectical Behavior Therapy has proven to be particularly beneficial in a client who is prone to self-harm as well as attempted suicides. This unique type of therapy often reference the ideas and practices of. There is an emphasis on “mindfulness, acceptance, and dialectics with cognitive and behavioral change strategies” (7). The aim of these sessions is both acceptance and change from within. Personally, I would integrate this strategy into sessions with a client who has an understanding of their behavior. They must be willing to accept mindfulness and account for their actions. However, without an understanding of their action, they cannot fully commit to the mindfulness and change of their behavior.
Keeping the history, stigmas, and current techniques of therapeutic treatment of Borderline Personality Disorder in mind I would utilize components of Adam Quinns four suggested therapies, Dance Movement Therapy, Trance and specifically Progressive Relaxation from Milton Erickson, and general Humanistic approaches and ideas. The use of these techniques would vary from client to client however the general structure and purpose would remain the same.
It has become clear that, in my opinion, patients with Borderline Personality Disorder are reduced to a series of unstable and irrational emotions. Though it may come across that way to an outsider it is extremely important that one understands that the emotional rollercoaster they are experiencing is quite real. The irrational and unpredictable wave of emotions they experience is viable and important. It would be throughout the entire therapeutic process that I would utilize Erickson’s technique of going with the resistance. It is extremely important to clients, specifically with BPD, to understand and believe that you have their back and will not abandon them in time of need.
When they have a moment of fear of abandonment, rather than attempting to dismiss their worries, I would attempt to sooth them. Utilizing techniques of both Transference – Based Therapy and going with the resistance I would help them gently evaluate the way that they see their self in relation to the world. It is important to understand that this would be mainly a self-discovery and I would act as the guider. I would not push them to have the epiphany that their fear is unfounded but rather I would guide them to have a deeper understanding of the root of their fear. This abandonment they are feeling is real and it is their reality. Through that deeper understanding perhaps they would find a different perspective on their fear of abandonment in their relationships.
Though all of the ‘symptoms’ and behaviors associated with Borderline Personality Disorder can have detrimental effects on both the clients everyday relationships as well as their deeper and more intimate relationships, I would assume that the general dramatic mood swings would act as the most obvious reason people are hesitant to form long-term intimate relationships with the client. Rather than dismiss these mood swings as some chemical imbalance within the brain I would look at different modes of expression for the client. I would specifically look at Dance Movement Therapy as a form of expression. Like all of us, the client may find it hard to verbally express these dramatic mood changes. I would challenge them to utilize their body to express these during sessions.
Do not confuse these sessions of being composed of some long and intricate choreographic dance but rather something much more simple and primitive. It would be simple no necessarily extravagant manipulations of the body in some sort of rhythmic time. For example, perhaps the client is skipping to show a particularly happy and energized mood. Next, they are laying on the floor moving their feet to show a mood of helplessness, sadness, and emotional restraint. With discussion upon the movement in both individual and group sessions it would become another tool of expression for the client. And through the drama of their movement, they could perhaps create a different view on their moods that would elect change from within.
Patients with Borderline Personality Disorder are prone to creating a habit of excess and addiction. This can range from anything like shopping or excess spending of money to binge eating and drugs. Faced with a client who is particularly prone to these habits, for example, binge eating and bulimia, I would utilize components from Mentalization Based Therapy as well as the practice of Reframing one’s perspective. Together we would attempt to begin to understand the way in which they process their habit. This might be asking the client to help me better understand their view of food in their life. Rather than focusing on the outcome, binging, I would focus on the process and the mentalization for the client. Being careful not to in any way challenge them or threaten them I would slowly, along with them, create different avenues and perspectives on food. Keeping Erickson’s technique of going with the resistance in mind at all times and continue accepting their lived realities and experiences.
It is well known and understood that many clients, though not all, with Borderline Personality Disorder experienced a particularly traumatic, if not abusive, early life or childhood. Trauma is something that should be treated delicately and with care. If the client chooses to present a past or even present trauma I would utilize both Schema-Based Therapy as well as Trance Therapy. I would process them with them in order to have a better understanding of how their trauma affects them in the present day. This would be a careful and respectful process. I am hopeful that through this particular process the client would come to better understand the trauma, the way in which it affects the behavior as well as their relationships.
It is when we both have a clear understanding of their trauma and the intricate ways in which it affects them that I would possibly bring Suggestive Trance Therapy into a session. Personally, I would begin with progressive relaxation to calm the body and the mind. I would get them comfortable with this process throughout a couple of sessions due to the fact that therapist relationships with patients with BPD tend to be more erratic. I would not want to start a process I could not finish with them. Once they are comfortable with Progressive Relaxation I would suggest that they go to a place of peace or calm from their childhood. And in that place, they could remember all the sights, sounds, smells, and colors. Through this process, which may be repeated over in different ways throughout many different sessions, I would hope that they would have a better understanding of their childhood. If not that, just a place of peace. It seems that someone with BPD has little calm in their rollercoaster of life so I would hope that bringing Suggestive Trance and Progressive Relaxation into their lives would help bring more into their life.
Another way in which I would utilize Suggestive Trance Therapy in sessions with a client it to grasp a better understanding of their views and goals of their past, current, and future relationships. When they are in trance they are vulnerable to their most beautiful thoughts and worst fears. I would seek out the understanding of their ultimate relationships, both platonic and romantic. Perhaps, I would suggest going to the ultimate place of happiness with someone currently in their life. I would be curious to see how they felt in that moment and how they interpret how the other person feels as well. It is through this process of evaluation that we could put into perspective their idealization and devaluation of people that can so rapidly change in their lives.
In general, I would treat Borderline Personality Disorder with the ultimate caution and care. Reductionism and Behavioralism are not to be practiced or even thought of in such sacred sessions. I fear that those with BPD often have their realities dismissed and reduced when their realities, emotions, and reactions are very real to them. Focus on the present would be imperative for the reframing of their lived experience. Typically living lives of many ups, downs, and general inconsistencies I would strive to have our sessions be a consistent calm in the storm. Forming a relationship of the utmost trust and respect so that we both feel it is a safe space where their voice can be heard.
Borderline Personality Disorder has puzzled and scared of many therapists. It does not fit into our box of rationality yet it makes up 2% of the general population and even higher numbers of those committed to psychiatric treatment facilities. Instead of aiming to ‘fix’ these human beings with medication and the reduction of their being I believe that we should challenge our reality to meet theirs. I cannot emphasize enough that their lived experiences are very real to them even though we do not categorize them as normal behaviors in society. Respect, trust, and an open mind are the three vital things to bring to the table in any session but particularly with those diagnosed with Borderline Personality Disorder.
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