Counseling and the Borderline Personality
Ashley D. Wallis
Making the decision to begin counseling, whether it is individual, couple, family, or group counseling can be a difficult choice. Depending on the situation, the counseling sessions could be short term for temporary issues or extend into psychotherapy for more long term or permanent mental health issues. Over the course of the counseling experience, a client may encounter various counseling theories and practices, as well as more than one kind of therapy. Additionally, many mental health issues have co-occurring conditions that require various modes of counseling to accomplish goals set by the counselor and client. One such diagnosis is Borderline Personality Disorder, sometimes referred to as Emotionally Unstable Personality Disorder, which is rarely diagnosed alone. With a stigma that prevails even in among the mental health helpers in the psychiatric community, the disorder is often ignored or seen as difficult to treat. Over the years, people with Borderline Personality Disorder have begun to speak out, and more effort has been made in using various therapies and counseling options for those seeking wellness.
Borderline Personality Disorder (BPD) got its name in 1938 from what New York psychoanalyst Adolf Stern called the borderline between psychosis and neurosis. (Lillenfield & Arkowitz, 2012) A misnomer, BPD is not closely related to disorders of psychosis, and the borderline patient is not the stereotypical psychotic person they are often portrayed as or perceived to be. The disorder (that affects about 2% of the population) is thought to be brought on by genetic predisposition, neurobiology, and environmental factors. People with BPD may have difficulty controlling their emotions or thoughts, lack a sense of self, fears abandonment, have problems with impulsivity or reckless behavior, and have unstable relationships. (National Institute of Mental Health) The fourth revision of the Diagnostic and Statistics Manual for Mental Disorders (DSM-IV) had nine criteria that were found prevalent in those with BPD. When a client showed recent and chronic displays of five or more of the listed criteria, they could be diagnosed. In 2013, the DSM-5 changed the diagnosing criteria for Borderline Personality Disorder, citing levels of personality functioning instead of the proposed trait system used in the previous edition. (Sarkis) Both men and women can suffer from the mental illness. Women are more commonly diagnosed, with co-conditions such as depressive and anxiety disorders as part of their Axis-I or II diagnosis. Male patients are more likely to have antisocial personality disorder or substance abuse problems as co-conditions. The overall effect of Borderline Personality Disorder is a chaotic identity marked with instability of thought patterns to include emotional regulation problems. The borderline often has difficulty with family and other relationships, and keeping a job can be difficult for some either from frequent hospital stays, troubled work relationships, or impulsivity to include abruptly quitting a job. Over the course of a day in the life of a borderline, emotions are turbulent and can change at the slightest provocation, or trigger. This emotional rollercoaster also includes moving from adoration of a person and detesting them the next in a thought pattern called splitting. The emotions of the borderline personality were explained by clinical psychologist Marsha Linehan in a quote to Time magazine in 2009: “Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin.” (Lillenfield & Arkowitz, 2012)
BPD has increased co-morbidity when Major Depressive Disorder, eating disorders, substance abuse problems, or another mental health issue is also diagnosed – up to 70% in some cases. (National Alliance on Mental Illness) With a 10% suicide rate and proclivity for self-harm, thoughts of suicide or suicide attempts, and frequent emergency room visits, people with this disorder were often institutionalized or deemed too difficult to treat in the past, leaving not much room for hope for wellness. This is now changing. Despite having a misleading diagnostic name and no medication that actively treats the disorder itself, treating the co-occurring conditions such as depression and anxiety with regulated medication and using various therapy types have increased the ability for borderlines to live relatively normal, functioning lives.
The stigma of borderlines to be manipulative and harsh with counselors has caused the mere mention of the diagnosis to cause dread for both patient and mental health professionals. Some clinicians are hesitant to diagnose BPD officially because of the stigma, and provide depression or another mental disorder as the Axis I diagnosis to insurance companies to ensure the client will get the counseling they need. This stigma is so prevalent that Harvard University psychiatrist George Valiant noted that clinicians who are frustrated with patients who are difficult to manage sometimes diagnose their client as having the disorder, often simply for being challenging. (Lillenfield & Arkowitz, 2012) As more and more people with BPD are speaking out about their experiences, this stigma is slowly starting to change. In 2011, when Dr. Marsha Linehan, who founded the most often used therapy for Borderline Personality Disorder revealed that she had been an inpatient with BPD as a teenager and dubbed “one of the most disturbed patients in the hospital” due to her self-mutilating behavior, people in the psychiatric community were shocked. After a second hospitalization, Linehan went on to earn a Ph.D. in 1971 – something considered an unsurmountable feat for someone with the disorder. (Lillenfield & Arkowitz, 2012) With new therapies and a better understanding of how the neurobiology and environmental factors work together, hope has been given to those in the BPD community who seek wellness.
As there is no one medication that treats the disorder, medications that treat underlying conditions such as depression and anxiety tend to work for some time with the patient, but inevitably become ineffective. The personality of the borderline does not change; even twenty to thirty years after treatment, those diagnosed with BPD may still retain the aspects of personality that are chronically troubled. This includes the instability of relationships and dissatisfaction with their lives with continued social isolation. (Kernberg & Michels, 2009) Although this seems like a bleak outlook, current therapies are showing to help patients move into a place of “recovery.” Likened to any common chronic medical condition, people with BPD can have relatively normal lives and function well in society as long as they take their prescribed medications, attend therapy as needed, and learn to manage their emotions. Cognitive Behavioral Therapy (CBT) was used for BPD patients before Marsha Linehan’s Dialectical Behavior Therapy (DBT) was established by modifying CBT to fulfill the needs of self-harming borderlines. DBT, a psychosocial therapy, teaches the patient mindfulness and grounding similar to Buddhist teachings and even yoga practices in individual, group, as well as on-call therapy. Many borderlines that undergo DBT develop a routine involving meditation to keep them grounded and to feel balanced. Another therapy that is currently being tested is Mentalization Based Therapy (MBT). MBT forces the patient to stop and look at their thoughts before acting, asking them to take others into account. A major problem with borderlines that cause emotional eruptions is hypermentalization, or the misreading of social cues that cause spiraling negative thoughts and can cause the borderline to self-harm or have suicidal thoughts. Using DBT and MBT, or pieces of each therapy that work with the individual client, show to greatly improve the daily life of the borderline personality and their ability to cope with urges and impulses caused by their emotions. Learning the ability to cope with these symptoms gives the client diagnosed with BPD increased functionality. Maintaining some sort of stability and control through medication, counseling, and skills learned from the various therapies gives hope to the hopeless, and the strength to overcome the darkest moments when suicidal thoughts would have been the norm.
The pervasive instability of the emotionally dysregulated BPD patient is not the hopeless cause it has often been regarded as. Borderline Personality Disorder is a mental illness that can be treated with monitored medication and counseling rooted in humanistic theory, continued psychotherapy, other forms of therapies such as DBT and MBT, or a mixture thereof that best suits the patient. Not the monsters they are commonly believed to be, patients with Borderline Personality Disorder can overcome the worst of their symptoms and learn to control their urges in a safe, secure, and emotionally validating environment. Using a variety of counseling method skills on a daily basis that over time become part of their normal routine, those with Borderline Personality Disorder break the stigma thrust upon them by the very community that should be helpful to them. Marsha Linehan created a groundbreaking counseling option which is remarkable in its own right, but coming forward and sharing her own story as a BPD sufferer shows others with the disorder that the stigma against them is unjustified, and that they as individuals and as a community can achieve wellness and help each other find a way to rewrite the characterization of the disorder.
Kernberg, O. F., & Michels, R. (2009). Borderline Personality Disorder. American Journal of Psychiatry, 505-508.
Lillenfield, S. O., & Arkowitz, H. (2012, January 4). Diagnosis of Borderline Personality Disorder is often flawed. Retrieved from Scientific American: http://www.scientificamerican.com/article.cfm?id=the-truth-about-borderline
National Alliance on Mental Illness. (n.d.). Mental Illnesses: Borderline Personality Disorder. Retrieved from National Alliance on Mental Illness: http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=44780
National Institute of Mental Health. (n.d.). Borderline Personality Disorder. Retrieved from National Institute of Mental Health: http://www.nimh.nih.gov/health/publications/borderline-personality-disorder/index.shtml
Sarkis, D. S. (n.d.). Borderline Personality Disorder: Big Changes in the DSM-5. Retrieved from Psychology Today: http://www.psychologytoday.com/blog/here-there-and-everywhere/201112/borderline-personality-disorder-big-changes-in-the-dsm-5