Navigating the Borderline : A Therapy guide
In a world that seems to shift on its axis faster and with a greater dynamism nowadays, our emotional and mental health are exposed to newer experiences at a much faster rate than ever before. The availability of multiple social media platforms have on some level created a greater degree of awareness and dialogue for people who experience mental health challenges. Consistent efforts by critical online campaigns like #bellletstalk have enabled momentum for people to speak about their struggles and survival on an unprecedented scale. On the flip side, the abundance of mass information bombarding our senses on a daily and even hourly basis means that our psychological strength is also challenged in newer & perhaps more stressful ways. As a psychologist, on the one hand I feel very satisfied with the openness of conversations surrounding mental health but on the other, I do suspect there to be an unfortunate skew in our willingness to speak about acceptance for certain mental health conditions like anxiety & depression spectrum while alienating &/or shaming others like borderline personality disorder, bipolar spectrum et al. These unfair and discriminatory viewpoints emerge from beaten-to-flat-tin psychology tropes in popular culture that do nothing more thanto labour towards propagating false dichotomies.
Borderline personality disorder, particularly, gets a bad rep and those who experience it are often deeply stigmatized & pathologized due to the nature of the condition.
Originally “borderline personality disorder” was called ““borderline personality organisation” to reflect how a personality organised itself around borderline tendencies in terms of cognitive and behavioral display in an individual. Diagnostic language in psychiatry/psychology is of utmost significance in how it can help healing or how it can direct imputation. It was a classification criteria for clients/patients who were neither psychotic nor neurotic but somewhere in between, hence : borderline. The pathologizing taxonomy shifted itself into place (disorder, disease etc) on account of excessive scripting (medicating), drugs placement and pushing in an array of psychopharmacological “cures” that were perhaps more focused on merely selling medicines at one point. Very rarely are clients/patients explained the etiology of the condition. The greater challenge in bpd is both emotion regulation & processing. This is in some ways on a different tangent to, say, clinical depression where emotion processing in itself is the root of depressive/dissociative cycles at times. BPD is one of the most commonly diagnosed conditions and often the most controversial. It also requires — as is the case with any Axis II condition aka personality “disorders” — prolonged therapeutic approach which helps in dealing with self-destructive and defeatist thoughts. There is also a pervasive socio-cultural component to BPD and we must be aware of how deep-rooted discrimination and poor treatment of certain communities on account of race, gender, class, caste, sexual orientation, among other identity-based differentiation is equally relevant for consideration when looking at borderline personality. A personality “disorder” is as much a function of innate or instinctive behaviours as it is a product of environmental reinforcement/punishment schedules.
Common to BPD therapy is an education and realisation of coping mechanisms that should understand the specific requirements and challenges of a client while also collaborating with them on reengaging their perspectives in how emotions are regulated without extreme sways in idealization/devaluation binary. BPD is a complex condition and the mental healthcare community needs to take empathic and necessary steps in preventing its monstrification.
What is Borderline Personality Disorder ?
BPD is classified as one of the 10 personality disorders that fall under Axis II of the Diagnostic Statistic Manual-V which is used by quite a few clinical psychologists for diagnostic purposes and case formulation. It is marked by sudden shifts in emotive states, moods and behaviours that frequently cause unexpected episodes of impulsivity, heightened irregularity in managing emotions along with a prolonged impairment in the ability to establish and sustain healthy relationships. BPD patients/clients also report depression, anxiety, irritability as well dissociation — separately or co-morbid — on an ongoing basis where each may last for a matter of hours to days and even weeks.
Here is short guide that sheds light on some prevalent and useful forms of therapies available to folks who are battling BPD and are considering getting help -
1. Dialectical Behavioural Therapy
DBT was developed by American psychologist Marsha Linehan who herself had survived an exacting battle with mental illness. It traces its origins to Cognitive Behavioural Therapy but has been modified from the original CBT model to concentrate on the impulses and emotional requirements of people who experience emotions in a far more unsteady yet an all consuming way. DBT is the most widely practiced form of therapty for Borderline Personality Disorder and has shown particularly good results when it comes to tackling self-harming tendencies, suicidal ideation, impulsivity binges & relationship dysfunctions. In a nutshell, the “dialectical” part of DBT branches into striking a balance between two seemingly disparate positions — Acceptance & Change. In a lot of cases, people with Borderline Personality might experience repeated negation from self and others about their emotional issues. In DBT, the focus is two fold — allowing a client to experience acceptance from the therapist and themselves while also figuring out ways to improve and change the harmful patterns of thinking and behaving that lead to dissonance and damage.
2. Systems training for emotional predictability and problem-solving (STEPPS)
STEPPS is a value-added therapeutic intervention that helps reduce excessive dependency on therapy which can be an unwanted outcome of BPD specific treatments. It follows a 20 weeks, manual-based group therapy plan and has been inculcated from an evidence based therapeutic approach. Evidence based therapy combines applied clinical expertise with tested empirical research that has satisfied scientific criteria. STEPPS is modeled on a psychoeducational format and therefore is largely oriented towards teaching clients resonant ways to handle their distress through coping mechanisms. It again bases itself largely on the CBT framework and strives to create a shared language in the group. There is an emphasis on managing the condition and shifting position from blame to awareness. It is not as effective in handling suicidal ideation as DBT but on account of its value-added angle, it has shown repeated success in reducing depressive symptoms and helping clients find ways to relax during agitated phases.
3. Mentalization-based therapy (MBT)
MBT is an integrative form of therapy that draws its influences from Cognitive Behavioural models, humanistic and existential psychology, psychodynamic approaches as well as socio-ecological aspects of understanding mental health. Mentalization refers to an individual’s ability to understand mental states as pertaining to themselves as well as those with whom they engage or interact. The ability to successfully participate in mentalization allows us access to perception, imagination and recognition of human (& other) mental states in context to ideas, desires, wants, needs, beliefs, values, A common feature of BPD tends be lack in affect regulation — waxing and waning cycles of understanding the nature and direction of emotional responses in a more consistently healthy way. Sudden emotional outbursts without an immediately traceable trigger tend to populate the BPD spectrum. MBT helps create specific mental awareness for clients where they have space to comprehend how they feel in addition to how others feel and how they can respond to those feelings. This form of therapy benefits clients in reducing conflicts within their intimate relationships.
4. Transference focused psychotherapy (TFP)
TFP is built on Otto F. Kernberg’s object relations model of borderline personality disorder. It centers itself on a psychodymanic approach and has a very clearly defined, highly meticulous and structure-bound treatment path. This form of therapy is aimed at gaining insight and analyzing what internalized representations and structures a BPD client might hold about their own self as well as others in their environment. It tries to harmonize the “broken off” facets to self and others and tries to focus its lens on the distortions in a client’s perception of themselves and others.TFP is keenly directed towards harm reduction and detouring clients from suicidality while facilitating improved behavioural control and developing the abilities needed for emotional regulation that help meaningful relationships.
These are some of the more widely accepted therapies that have proven to be useful for patients and clients who experience Borderline Personality Disorder. Apart from these specific therapeutic options, Minfulness Based Therapies that include meditative and self-compassion streams of cognitive, behavioural and emotional pattern restructuring, including Jon Kabat Zinn’s Mindfulness Based Stress Reduction, have shown to work well with clients in alliance to the earlier mentioned therapeutic models. Apart form these, somatic/bodywork styled interventions as well as art immersions and creative expression can also contribute towards wellness. It is important to remember that taking care of physical health can show marked improvement in managing emotional homeostasis and vice versa. Spending time in nature, listening to soothing music, activities such as swimming, dancing or cycling, guided meditation, journaling, spending time nourishing your mind and body can all work towards creating holistic and longterm wellness.
I always remind myself as well as my clients of something Leslie Jamison wrote in “The Empathy Exams: Essays” ―
“Feeling something was never simply a state of submission but always, also, a process of construction.”
Scherezade Siobhan is a psychologist, writer and a community catalyst who founded and runs The Talking Compass — a therapeutic space dedicated to providing mental counseling services and decolonizing mental health care. She is an award-winning author and poet whose work is published or forthocming in Medium, Berfrois, Feministing, SPR, Jubilat, DATABLEED, Nat Brut, Winter Tangerine, Cordite among others. She is the author of “Bone Tongue” (Thought Catalog Books, 2015), “Father, Husband” (Salopress, 2016) and “The Blues Kali” (Forthcoming, Lithic Press). Send her chocolate and puppies — nihilistwaffles@gmail.com. Find her online @zaharaesque on twitter/FB/IG.
