Borderline Personlity Disorder (BPD)
Counselling in Perth
Borderline Personality Disorder
Borderline Personality Disorder (BPD) is complex and can be complicated by trauma and substance use/abuse. A diagnosis should be undertaken by a mental health professional who is proficient in this type of diagnosis as it has overlap with other disorders and runs a risk of being misdiagnosed.
The term Borderline Personality Disorder was first used in the late 1930s when psychiatrists needed a term to describe people who were neither psychotic nor neurotic, rather somewhere on the border between them.
People with BPD often struggle with having a sense of identity. It seems that whatever their experience was like growing up, they were not provided the opportunities to develop their own sense of identity, developing their own set of values and beliefs, so they end up searching for these externally, desperate to find out who they are. They may feel unsettled, with a need to fit in, but ultimately feeling like they are not understood. There is often a deep feeling of aloneness and isolation in their experience.
An individual with BPD can oscillate quite quickly between feeling secure and feeling abandoned. When they are feeling good, everything is OK. They feel cared for and secure. Connected. However, when they are not feeling so good, this feeling of connection and security rapidly disappears, and the person with BPD turns on the other person, which is confusing for the other. Although it is probably quite normal for some of us to fear being abandoned by the ones we love, for a person with BPD, this reaction is extreme. For example, a loved one not returning a phone call or arriving home later than expected, can trigger their fear of abandonment which is acted on as if it were true – they don’t love me...they are going to leave me...possibly resulting in behaviour such as constant calling or texting, saying cruel and hurtful things, which are received by the other as frantic and clinging. Whereas the reality may be that their mobile phone was flat and they were unable to call. For the loved one, this response is confusing as they cannot understand the intensity of the reaction. Eventually the other person can’t take it anymore and says that they want to leave, which triggers the fear of abandonment again. This type of cycle can happen in any relationship, not just intimate ones. In a workplace, for example, receiving criticism or a negative comment may trigger the same reaction. This is where the skills learnt during treatment are so powerful.
Emotional dysregulation and distress intolerance are common in someone with BPD. As a child they have never learned how to regulate or self-soothe effectively, so they seek out external ways to attempt to regulate and soothe. This often results in risky and impulsive behaviours. For example, sex with a stranger may not be about the sex or the risk, rather about trying to achieve a sense of connectedness and closeness. Alcohol and substance use may be about changing their current emotional experience. Self-harm about trying to feel something physical rather than feeling numb emotionally. And in this moment of desperation, the need to change how they feel in the moment somehow makes it seem like this particular behaviour is the right thing to do at the time. This type of behaviour is rarely about seeking attention or being manipulative, rather, the function is to get rid of the intense psychological pain they are experiencing.
With the right treatment, people with a diagnosis of BPD can experience marked improvements in emotional regulation and distress tolerance, which can have a positive effect on their interpersonal relationships, education and employment. It’s about developing a life that is meaningful and worth living. Treatment is long-term and a solid commitment must be made by the individual as they enter treatment to minimise ending the therapy prematurely due to the therapist being devalued or “turned on” in a hostile manner. For example, the therapist informing their client they are going on annual leave may trigger an intense fear of being abandoned resulting in consequences such as explained earlier.
The treatment with the biggest evidence-base is called Dialectical Behaviour Therapy (DBT), although as with every therapy, it is not effective with 100% of people. It is a skills-based therapy which requires lots of practice between sessions (hence the commitment required).
Dialectical means that two ideas can be true at the same time, seeing another’s point of view, or letting go of “black and white” thinking. Skills training is focused on teaching 1) mindfulness, 2) interpersonal effectiveness, 3) emotional regulation, and 4) distress tolerance. Mindfulness is usually taught first as it is considered to be the foundation of the therapy, the others are usually taught according to what the therapist sees is appropriate for each individual.
- Mindfulness: is about paying attention to what is happening in the present moment, without judgment. Learning mindful awareness is vital in order to explore what is going on physically, emotionally, cognitively in the moment in order to explore how the behaviour happened. Without awareness, it is difficult for the individual to describe what is going on – what emotions and/or urges occurred just before the behaviour. Learning how to recognise it in the moment, as it starts, is essential. Once you have awareness, you have choice. Mindfulness allows you to step out of the emotion and see things more objectively, not just black or white.
- Interpersonal effectiveness: individuals with BPD often struggle with personal relationships – this may be their family, colleagues, friends, or partner. Learning different skills and then being able to use them appropriately and contextually helps people to respond to situations in a way that is healthy, effective and most likely to get their needs met. For example, learning how to communication assertively (rather than aggressively or passively), or learning how to say “no”. Learning that others may have a different point of view, and being open to listening to it without judgement.
- Emotional regulation: learning how to identify and label emotions is the first step to being able to regulate effectively. It can be very difficult to regulate emotions if you don’t understand where they come from or why they have been triggered and mindful awareness helps with this. Once you can understand this it is much easier to decrease the intensity of them and their effect on you. Emotions are a normal part of being a human, and the natural urge is to avoid the painful and uncomfortable ones. No-one can stop emotions from happening, but you can learn how the respond to them in a different way.
- Distress tolerance: the mindfulness skills learned at the start of treatment helps to allow you to stop (when you start to feel distressed), take a step back, observe (objectively to what is happening), and then make a choice about how to proceed from a place of mindful awareness (not habit or auto pilot). It’s about responding to distress not reacting to it.
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