Borderline Personality Disorder
Borderline personality disorder is a commonly used yet controversial diagnosis. The strict diagnostic criterion insists that 5 of the 9 criterion listed in the DSM-IV-TR are met for the diagnosis to apply.
Competing theories as to the origin of BPD abound. The most commonly held is that BPD emerges from early psychological wounding or abandonment. This may be actual or emotional abandonment, abuse or neglect. The core wound arrests the development of the emerging self. This casts the BPD person at war with their body. The war is protected by a strict code of secrecy. The resultant internal split means the BPD is their own abuser, victim and non protecting bystander, according to Miller (1994) and results in the forming of a false self. A. J. Mahari’s theory is that the false self is at the core of BPD, the resultant rage requires that narcissism be employed to protect the BPD from its pain of abandonment.
Whatever the origin, BPD is characterized by mood swings and shifts. These are supported by cognitive distortions and warped internal narratives. Chaotic and disrupted relationships where the primary fight is for control evolve. The result is continued suffering for the BPD and those who love them. The diagnosis of borderline personality disorder and self harm often go hand in hand as self harm is employed to physically express the felt emotional stress and pain .
Self harm is an attempt to cope with BPD dysregulated emotions and the pain and shame of early abandonment/abuse. Researchers offer that 48% of those diagnosed with BPD self harm, as do those with other mental health diagnoses. As borderline personality disorder and self harm coexist with serious personal and relational disruption an effective interventionist understands the power of self harm.
Effective intervention targets the pain behind the self harm rather than the action itself. The risks of self harm are infection, accidental over harm, permanent unintended injury and estrangement from others as the life of secrecy that accompanies it is maintained. Those diagnosed with borderline personality disorder are at risk of frequent, impulsive, poorly thought out and therefore more health or life threatening self harm than those without that diagnosis.
Self harm takes various forms, superficial (cutting, scratching), moderate, compulsive, episodic or repetitive. It often involves, but is not limited to self amputation, cutting, burning, bone breaking, deliberate overuse injuries, high risk sexual behavior, addictions or eating disorders. Self harm is not necessary suicidal, and is called parasuicidal. However, suicide threats or attempts are also common. An effective therapeutic approach will employ strong boundaries against these.
When working with BPD the initial goals are to decrease the potential lethality of parasuicidal gestures and suicide attempts. Harm minimalization rather than a cessation of self harming behaviors is the goal at this early stage. Another initial goal is to preserve the client’s often fragile commitment to therapy.
The client learns to recognize the triggers that lead to the emotional lability or self harming behaviors and to interrupt the negative self talk that feeds the cycle. From there the BPD develops a variety of healthy and adaptive behavioral, emotional and cognitive options.
An Intervening Technique Common To Different Approaches
Mindfulness is a key approach used for self harmers and is often employed by varying approaches to treating BPD. David Rock,The neuroscience of mindfulness | Psychology Today , describes a secular approach that divests mindfulness of its religious overtones and teaches clients to choose to focus on one thing over all others, using breathing exercises and other grounding techniques.
A Specific Therapeutic Approach Employed
Dialectical behavioral therapy approach originally presented by Marsha Linehan, is based on the bio-social of borderline personality disorder. It provides a validating program of individual and group therapy. This approach is comprehensive and encourages continued client involvement. It provides the therapist with the necessary support to work with a clientele that has proven to exhaust and demoralize practitioners.
DBT believes that BPDs react abnormally to emotional stimulation. Their level of arousal escalates much more rapidly, peaks at a more intense level and takes longer to return to baseline. The result is a series of created crises, emotional lability (shifts and moods). Because of past invalidation and abandonment the client has few resources to cope with these.
DBT involves weekly individual sessions with a therapist who is available by telephone outside of the therapy session and 2.5 hours of group therapy with a therapist who is only available during the group time. The focus of the individual therapy is to review a problem that occurred in the week, examine what led up to it, alternatives that could have been employed and what stopped the client from using their new found skills.
The group program reinforces adaptive behaviors, skills acquisition, and minimizes high risk and self defeating behaviors that interfere with life and therapy. It seeks to increase self respect, positive behaviors and other client goals. Kiehn explains that commitment from the client is required for DBT to be successful (Kiehn, 2002)
To learn more about BPD read works by A. J. Mahari; M.M. Linehan; A.R.Favazza; Barry Kiehn and Michaela Swales. This selection of researchers covers the theory behind the diagnosis, therapeutic approaches and scientific review. John Teasdale and David Rock describe Mindfulness, a collection of techniques that can be utilized across therapeutic approaches.