Changing Ideas About the Treatmentof Borderline Personality DisorderW. John Livesley Journal of Contemporary Psychotherapy, Vol. 34, No. 3, Fall 2004 ( C° 2004)
“The problems presented by the typical patient include symptoms, situational difficulties, maladaptive traits, maladaptive interpersonal relationships, dysfunctional self and interpersonal cognitions, and core self and interpersonal pathology. Few therapies incorporate interventions that cover this range. Most therapies are based on the assumption that there is a single core dysfunction underlying borderline problems”
“A potential problem with eclectic treatment is that therapists, faced with a complex array of problems and the pressure of the patient’s demands will continually switch intervention strategies leading to a confused and disorganized form of treatment. This eventuality may be avoided by addressing problems in a sequential manner.”
“It is not only ideas about treatment that are changing; major changes are also occurring in ideas about the etiology of borderline pathology. Until recently, both psychosocial and biological perspectives tended to assume that there was a major cause for the condition. Psychosocial models tended to stress the contribution of adversity, especially childhood sexual abuse and trauma, and biological models offered explanations in terms of a relationship with mood disorder or dysregulation of specific neurotransmitter systems. The origins of borderline problems, however, are more complex. Multiple lines of evidence indicate that borderline is a psychobiological entity that is influenced approximately equally by genetic and environmental factors.”
Borderline personality disorder: Psychosocial considerations and rehabilitation implications
Mary Hennesseya,∗ and Connie J. McReynoldsbaVocWorks, Inc., P.O. Box 534, Kent, OH, USAbDepartment of Educational Foundations and SpecialServices, Kent State University, Kent, OH, USA
“Psychotherapy plays a central role in the treatment of BPD. It is the cornerstone of treatment because it is a stable and consistent process, especially because the disorder itself is marked by instability and inconsistency”
In terms of structuring the therapeutic relationship, Johnson (1991) advanced an eight-point framework for professionals working with clients who have BPD. The tenants of this model are paraphrased below:
Practioner and client contacts should be structured, with clear rules regarding meeting times, fees, and procedures established at the outset of the initial meeting.
The practitioner must take an active role during the sessions to keep the client in reality and minimize transference distortions.
The practitioner must be able to endure the client’s potential verbal abuse without retreating or reciprocating.
The practitioner must continually remind the client of the harmful results of self-destructive behaviors such as substance abuse, binge eating, casual sex, and reckless driving. The focus needs to be placed on the results of the behaviors, not on the motives behind them.
The practitioner’s role is to help the client forge a connection between his or her actions and feelings when the client engages in self-destructive acts.
The practitioner must set limits on client behaviors that threaten the safety of any person interacting with the client. State mandatory reporting laws and ethical codes of the practitioner’s profession must be expressly followed.
The practitioner should present all interactions as occurring in the present, not the in client’s past.
The practitioner needs to monitor his or her reactions to the client as a means of avoiding acting out. The client with BPD can be frustrating and irritating to counsel, but these are the very symptoms that require the highest degree of patience and professionalism to treat effectively.
Adapted from: H. Johnson, Borderline clients: practice implications of recent research, Social Work 36 (1991), 166–173.
Children At-Risk for BorderlinePersonality DisorderMarsha J. Harman
Adult patients who have been diagnosed with borderline personality disorder (BPD) have provided valuable information about events and family dynamics that are frequently associated with BPD. Clinicians who work with children are frequently aware of family or individual characteristics that may put a child at risk for developing BPD. Such situations frequently involve attachment issues with the child’s caregivers and can include sexual abuse, divorce, alcoholism/substance use, illness/ death, and neglect. Child characteristics such as learning difficulties and temperament may also predict BPD. Yet, many children are resilient and seemingly unaffected by these events or situations, especially when early intervention may prevent development of BPD.
Frequently, the characteristics associated with a specific personality disorder do not manifest themselves until later adolescence or young adulthood. Nevertheless, a growing number of articles discuss children with personality disorders. One, in fact, describes therapy with a four-year-old who was treated for BPD (Nilsson, 2000).
Personal Accounts: A "Classic" Case of Borderline Personality Disorder Lynn Williams
The first misconception most people have about borderline personality disorder is that its dramatic manifestations such as reckless or suicidal behavior are merely deliberate, manipulative attempts to get attention. That is not true. The distress is real