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When I first meet with a patient who, somewhere along the path of life has been diagnosed with borderline personality disorder (BPD), my heart goes out to them and to their family. Before I learn the details of their unique family history and what has brought them into my office, I know that they have suffered a great deal. They have suffered as their family has tried o make sense of this seemingly incomprehensible disorder. They have suffered as they have tried to meet the demands of school, work, or societal roles. They have sometimes even suffered at the hands of fellow mental health professionals, who have, with good intention, attempted to treat the patient’s Axis I presenting problems, but lacked the experience or awareness of the force and drive of the Axis II subterrain – the infrastructure underlying many Axis I diagnoses. Most of all – these good people have long suffered in their own minds, hearts, and souls – struggling to understand who they are, and why they are the way they are.
The most sobering and cutting description of BPD that I have ever seen is not contained within the DSM-IV list of diagnostic criteria. It actually is spoken about one of the main characters in a Jonathan Kellerman novel, “Silent Partner”:
“The borderline patient is a therapist’s nightmare…because borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology. At first glance, they look normal, sometimes even supernormal, holding down high- pressure jobs and excelling. But they walk a constant tightrope between madness and sanity, unable to form relationships, incapable of achieving insight, never free from a deep, corroding sense of worthlessness and rage that spills over, inevitably, into self-destruction. They’re the chronically depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed-hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench sitters with arms stitched up like footballs and psychic wounds that can never be sutured. Their egos are as fragile as spun sugar, like a jigsaw puzzle with crucial pieces missing. They play roles with alacrity, excel at being anyone but themselves, crave intimacy but repel it when they find it. Some of them gravitate towards stage or screen; others do their acting in more subtle ways.
No one knows how or why a borderline becomes a borderline. The Freudians claim it’s due to emotional deprivation during the first two years of life; the biochemical engineers blame faulty wiring. Neither school claims to be able to help them much.
Borderlines go from therapist to therapist, hoping to fine a magic bullet for their crushing feelings of emptiness. They turn to chemical bullets, gobble tranquiliers and antidepressants, alcohol and cocaine. Embrace gurus and heaven-hucksters, ant charismatic creep promise a quick fix of the pain. And they end up taking temporary vacations in psychiatric wards and prison cells, emerge looking good, raining everyone’s hopes. Until the next letdown, real or imagined, the next excursion into self-damage.
What they don’t do is change.
When encountering such an individual, in real life or as a therapist, one immediately registers that this individual is very different – even more so than the average person who has encountered their fair share of conflicts on the road of life. In my professional training in the early 1970s, I was taught that borderlines were not treatable, that they did not get better, and that they only sucked the life blood out of the best intentioned therapist. It was common practice to hear from my supervisors back then that if a therapist decided to treat a BPD patient, than only one patient at a time should be treated in a single practice. Needless to say, as I began my own practice in 1987, there was a certain amount of conditioned fear that I experienced when encountering a young person who seemed to fit most or all of the DSM-IV criteria. The negative schemas that plagued me back then included most, if not all of the following:
Fortunately, much has changed over the past forty years. With the seminal work of Marsha Linehan and the genesis of Dialectical Behavior Therapy, Jeff Young’s groundbreaking contributions in the field of schema therapy, and Jon Kabat-Zinn’s revolution in the introduction of mindfulness to the Western world of psychotherapy, therapists today need not fear the diagnosis of BPD. While it is true that treating this population may require a different skill set than required in treating non-BPs, there is also the good news that they DO get better, that they CAN lead productive lives, and that those therapists who decide to treat them WILL – with determination and a great deal of patience – be able to witness positive change and good therapy outcomes over time.
As a cognitive therapist by training, and as a student of mindfulness in recent years, there is a certain set of beliefs that has helped me in treating my BPD patients with the respect and care that they deserve. This list is a work in progress, and I welcome the wisdom and life experiences of those therapists who have done this work for many years in adding to this list. The more optimistic outlook that I carry with me into my work with borderline patients today includes the following:
Success will be defined, as so eloquently defined by Marsha Linehan, in helping to restore our patients’ lives to lives worth living.
Finally, I offer a new set of hopeful beliefs to BPD patients themselves: