Borderline personality disorder
Borderline personality disorder (BPD) is characterised by abnormal emotional behaviour, and by unstable emotional relationships with other people.
The individual suffers from a disturbance that is felt around issues of abandonment, trust and security. Someone suffering BPD is likely to be especially sensitive to the emotional atmospheres they experience, and especially quick to feel the sense of emotional change and discord.
What for most people would be an ordinary social encounter or interaction can very quickly be experienced as severely threatening and unsafe. The person with BPD symptoms and characteristics will be continually reacting to social interactions in an unpredictable and extreme way. It will be helpful to see a psychiatrist and obtain a diagnosis.
When does BPD develop?
It is often something that starts to be seen more clearly from adolescence onwards. Adolescence is a period that recapitulates the individuals’ psychological sense of identity. Issues and patterns of behaviour that before seemed manageable or insignificant, become highly charged with the emergence of puberty, hormones and rapid growth. There may be signs of the disorder in the individuals’ earlier life.
Treatment for BPD
BPD will typically be treated by a combination of medication and psychotherapy. It may be useful, particularly in cases where symptoms are more pronounced, to have a psychiatrist involved in the patients’ ongoing welfare.
The psychiatrist, standing outside the other treatments that are being used provides a valuable reference point.
What is it like to work in psychotherapy with patients suffering BPD?
In psychotherapy the therapist will likely experience an atmosphere that shifts from acceptance and possibly idealisation to something much more suspicious and critical.
The patient is likely to react to any changes in the framework and arrangement of sessions, and to be particularly quick to detect any changes in the emotional atmosphere of the work.
For example, if the therapist were to need to change the time of a session the client might appear to react easily, but this may turn out to be a surface reaction.
The therapy will likely go through a period of complicated scrutiny and testing. The client will be suspicious of the change that the therapist has introduced. However predictable the work has been to this point, now the therapeutic relationship will have to go through a period of testing and retesting while the BPD patient goes over their sense of what has happened.
How can they trust this therapist? The therapist will be tested to see if they can hold the work or if they break? This can be very draining for both parties.
- Are they safe with the therapist?
- Has this change to the established routine served to prove that the therapist like so many other people cannot be trusted?
The therapeutic relationship will have to be able to endure these periods of acute testing during which the therapist will feel the patients’ critical enquiry. It is the movement back and forth between extremes of emotions that is wearing for the patient and the therapist.
In some cases, the fact that the therapy demonstrates that it can be found to be safe through the periods of repeated testing, leads to sustainable gains in the patients sense of their emotional life.
They become able to reflect upon the changes they go through and establish an improved sense of emotional baseline.
The fact that the patient has come to trust the therapist means that they may be able to trust other environments and relationships.
In these cases, therapy proves useful and the gains can be internalised and built upon.
In other cases, these kinds of improvements in basic emotional stability may prove much harder to achieve.
This is why it may be helpful to have a psychiatrist involved with the case and in a position to review the progress of treatment plans. Similarly, the therapist will need to have good support in place for themselves, good supervision to help them process their work and experience.
The individual with BPD experiences an extreme range of emotions
It is the range of emotional movement from idealising and euphoria to paranoia and mistrust that is so hard for the patient to manage. Frequently individuals will resort to self-harming behaviour, habits such as cutting or vomiting (as part of food disorder symptoms), in an attempt to regulate their moods and emotions.
The swing of emotions into suspicion and mistrust provokes introversion and pulls the patient into themselves where the only resort is to the predictability and manageability of self-harm.
Ensure there is good support in place
To make the most of psychotherapy it will be helpful to have good supervision and psychiatric support in place.
By putting these things in place the chance of therapy having a valuable place in the patients’ life may be sustained and gains made.