The Essential Family Guide to Borderline Personality Disorder

by Randi Kreger

  Chapter 5

  Treating BPD

  When faced with a complex situation, realize it cannot be solved quickly or with one simple solution.

  • I Ching •

  First, let’s address the $64,000 question: Can therapy help motivated individuals with BPD overcome the disorder? The answer is unquestionably “yes.” New medications and innovative types of psychotherapy have led to measurable improvements. Anecdotal evidence shows the same results; when an author put out a call on the Internet for people who felt they had largely recovered from BPD and wished to share their experiences, she received more than a dozen replies.

  Medications

  Distinguished clinical professor of psychiatry Robert Friedel says that scores of mental health workers—even those experienced with BPD—don’t know that medications play a dramatic role in treating borderline symptoms. Yet just as many studies show the effectiveness of medications as those that report positive therapy outcomes. Medications can provide the stability that people with BPD need to get the most out of therapy.

  What Medications Can and Cannot Do

  No medication can change someone’s personality, save that heady potion that transformed Dr. Jekyll into Mr. Hyde. What medications can do is reduce BPD symptoms such as depression, mood swings, dissociation, aggression, and impulsivity. Medications do this by normalizing the brain’s neurotransmitter functioning, just like another medication might change the levels of “good” and “bad” cholesterol.

  On his Web site, psychologist Joseph Carver explains how medications work:

  • Some imitate neurotransmitters, triggering a response as though the original neurotransmitter were present.

  • Some make neurotransmitters more available in the synapses (those all-important spaces between the neurons).

  • Some force the release of neurotransmitters, causing an exaggerated effect. (Some street drugs do the same thing, which is one reason why taking these drugs is called “self-medicating.”)

  • Some increase the supply of certain neurotransmitters; others reduce or block their production.

  • Some affect the storage of neurotransmitters, which makes them lose their potency.1

  Finding the Right Medications

  Even though we know a great deal about the medications, each person’s biology is unique. The same drug in the same amount may affect different people in a variety of ways. Frequently, patients use two or more medications at the same time, because different drugs work on different brain chemistry problems.

  Therefore, there’s a period of trial and error to discover which medication (or combination of medications) and dosage provide the best results. The goal is to use the lowest dose possible to treat the symptoms effectively while minimizing the chance of side effects. Depending on how much medication a patient is taking and how long it takes to reach maximum effectiveness, this can be a lengthy process.

  And the trial-and-error period isn’t fun, either. Clients want relief now, and some drugs take six weeks to take effect. On the positive side, we’re lucky to have so many medications to choose from. The key is to work closely with the doctor and to monitor symptoms on paper. In the end, it’s usually worth it. Many people with BPD have found that the proper medications turn their life around.

  2

  If a psychiatrist proposes using a medication, ask

  • What is the drug used for? Many medications have a primary and a secondary effect. Some are “helper” drugs that intensify the effects of another drug.

  • What is the beginning dosage? The maximum allowable dosage? Psychiatrists start at lower doses to minimize side effects and then go up as necessary. This process is called titration.

  • How long does the drug take to work? Popular drugs that affect the transmitter serotonin (such as Paxil and Prozac) can take six weeks. In contrast, some anxiety-reducing drugs such as alprazolam take effect right away.

  • Is a generic version available? The newest ones are the most expensive—often ridiculously expensive. Some pharmaceutical companies have patient assistance programs that provide meds to people who can’t afford them. Find out more at www.rxassist.org.

  • What are the side effects? Drowsiness and dry mouth are two common ones.

  • What are the side effects of discontinuing the drug? This is an important question that is often missed, and the pharmaceutical companies are not free and easy with this information.

  • If the medication is for a minor child, ask if any research has been conducted with children.

  Over time, the number of medications a person is taking can add up, especially if he’s seen more than one psychiatrist. Each health care provider, including family doctors, needs a list of all the medications the patient is taking, including what the drug is for, what the dosage is, and when it’s taken.

  The Internet is chock-full of Web sites about medications. Consult one that is reputable. Pharmaceutical companies may paint very rosy pictures, so make sure you look at some unbiased ones as well. Another great way to find out about any medication is to ask a pharmacist. Because drugs are their only business, they can be just as informed about the drug itself as your doctor—sometimes even more so.

  Medications in Hospitalization

  Blaise Aguirre, MD, who specializes in children and adolescents with BPD, says that borderline patients often enter the hospital taking a mixture of medications.

  Often, at each of these hospitalizations, the treating psychiatrist is presented with a single part of the whole picture: We call this the “admitting symptom”: for example, the patient is “depressed,” “manic,” “anxious,” or “psychotic.”

  Usually, past psychiatrists prescribed a medication for each of these symptoms. In subsequent hospitalizations, medications were seldom removed, so we see kids on all the meds from previous hospitalizations.

  Often, our approach is to be clear as to the clinical criteria that make the diagnosis of depression or psychosis. If there is no clear sense that these diagnoses are correct, we gradually remove the medication. Often, the problem behavior began after a relational conflict, and, unfortunately, there is no medication that can cure a broken heart.3

  Psychotherapy

  Some people enter therapy because they want to figure out why they feel so stuck in certain areas of their lives. Some want to work on specific issues, such as overeating or an inability to control their anger. Some just would like to feel happier, less anxious, or more relaxed.

  Therapy is especially helpful for people who find themselves falling into the same unsatisfying patterns over and over again: for example, getting into destructive relationships, losing job after job, or acting in self-destructive ways. Often people try to get out of these patterns by themselves. But they can’t get out of them because they don’t know how they got into them.

  Whatever the reason, the purpose is the same: to help people enjoy their life more, feel better about themselves, improve their relationships, and achieve their goals.

  Clinical “Orientations”

  Throughout the decades, different schools of thought, or “orientations,” have emerged about how to best treat people with mental illnesses. There are hundreds of them: psychoanalysis, solution-oriented therapy, brief therapy, psychodynamic therapy, and cognitive-behavioral therapy, to name just a few.

  Most therapists, however, combine bits and pieces from different schools of thought and then draw from their education, training, personal experiences, and personal style. This is called the eclectic approach. (Eclectic is a word that means composed of elements drawn from various sources.) In essence, each eclectic clinician’s approach is unique. In these cases, evaluating the clinician and the approach is essentially the same thing.

  With standardized treatments, practitioners undergo the same education and training, and the therapists trained in that method will use similar techniques and approaches, whether the therapy takes place in Buffalo or Beijing. This consistency allows researchers to con
duct studies that measure the outcomes of these therapies.

  Eclectic Therapy

  Although there are probably hundreds of different types of theoretical orientations and techniques, most eclectic clinicians use techniques largely from two schools of thought: psychodynamic therapy and cognitive-behavioral therapy.

  Psychodynamic Therapy

  In psychodynamic sessions, the therapist and the client work together to uncover and examine the client’s feelings and past experiences. The goal is to see if unresolved conflicts and old business are triggering the client’s counterproductive behavior.

  For example, a man who loses job after job because he can’t handle authority figures might discover in therapy that his anger and unresolved issues with his authoritarian father are costing him well-paying and interesting jobs. Armed with that knowledge, the client can begin to look at his boss more objectively, and he and his therapist can work on his father issues during sessions.

  Bennett Pologe, a clinical psychologist in New York City, says:

  What you want most from a session is the experience of insight. You will know when it happens. It is not like intellectual learning. You will find yourself suddenly feeling clearer, saner, more hopeful, more decisive, more energetic, and your symptoms will clear up. This is the one magic that psychotherapy offers. When you feel the things you’ve been trying not to feel, when you become aware of things you’ve avoided, you feel better, and you function better.4

  Cognitive-Behavioral Therapy (CBT)

  One drawback of psychodynamic therapy, some say, is that insight doesn’t necessarily lead to any changes in thoughts, feelings, and actions. This is where cognitive-behavioral therapy (CBT) comes in. The National Association of Cognitive-Behavioral Therapists explains CBT in this way:

  Our thinking causes us to feel and act the way we do. Therefore, if we are experiencing unwanted feelings and behaviors, it is important to identify the thinking that is causing the feelings/behaviors and to learn how to replace it with thoughts that lead to more desirable reactions and behaviors instead of depending upon external things like people, situations, and events. This way, we can feel better even if the situation does not change.5

  CBT is essentially the thought-feeling-action approach presented throughout this book.

  The Eclectic Combination

  Merging psychodynamic and cognitive-behavioral therapy (and, in some cases, others as well) to create an eclectic approach allows for a lot of flexibility. The therapist can provide what the client needs when the client needs it.

  For example, let’s say an overbearing boss is making life miserable for a man in therapy. The boss makes unreasonable demands on the man’s time, and his family is complaining that they never see him. The therapist and patient might discuss how the boss reminds the man of his own demanding father, which gives the man insight into why it’s so difficult to set boundaries with his boss. Armed with that insight (thinking), the therapist might help the patient feel more confident (feelings), thus enabling him to improve his practical limit-setting skills (actions).

  Most clinicians use eclectic therapy, though they may call it something else (or not call it anything).

  Standardized Therapies

  Three structured therapies used to treat BPD are dialectical behavior therapy (DBT), Systems Training for Emotional Predictability and Problem Solving (STEPPS), and schema therapy.

  Dialectical Behavior Therapy

  Dialectical behavior therapy (DBT) is one of the fastest-growing forms of treatment for lower-functioning conventional BPs, because it significantly reduces the rate of self-injury and suicide, as well as lowers emergency room and inpatient hospital visits.6

  The word dialectical means that two opposite things can be true at the same time—in this case, that patients need to accept themselves, warts and all, yet recognize that by changing their destructive coping methods and by learning new skills, they can have lives worth living.

  Dialectical behavior therapy combines elements of CBT and Zen concepts of radical acceptance and mindfulness. These ideas, which we’ll talk about later, anchor the program in place. “People who meet the criteria for borderline almost always hate themselves,” says DBT originator, Marsha M. Linehan, PhD. “So I figured that I needed to accept them myself, and then teach them how to accept themselves, because if you don’t accept yourself as you are, you actually can’t change. It’s kind of a paradox but true.”7

  FUNDAMENTAL DBT CONCEPTS

  • Patients are motivated and willing to change. DBT patients have tried to conquer their pain and loneliness on their own. But it’s all been too much for them. They’re tired of feeling like failures, fearing abandonment, and taking impulsive actions that end relationships or put them in the hospital. Thus, they have a strong and conscious commitment to change.

  • Radical acceptance is essential to recovery. Radical acceptance means that before you can move toward positive change, you must accept yourself as you are right now, without judgment or blaming. Radical acceptance is a lifetime project and a key tool for all of us, not just those with BPD.

  For example, let’s say that every time a young man loses a romantic partner, he falls apart for months, sobbing, panicking at the thought of being alone, and needing to rush into another relationship—and, at the same time, he hates himself for doing it. Everyone tells him to get over it already and “be a man” about it. He suffers both the end of the relationship and the shame of his vulnerability.

  Radical acceptance, Linehan says, will release him from the shame. “This is the way I was made,” he could tell himself calmly. “I wish it were not the case, but it is.” Ironically, once we release our judgments about ourselves, we can truly move forward.

  • Mindfulness is the key to managing emotions. Anger, frustration, grief, and other emotions often involve the past or a potential future. Mindfulness enables us to step back for a moment, observe what’s happening inside us and all around us, and live and breathe in that moment, not the past or the future. “You’d be amazed how much suffering is due to thinking about the future or ruminating about the past,” Linehan says.8

  Let’s revisit the high school reunion we talked about in chapter 4. In addition to Charlie, you spy your first love, Chris, who broke up with you many years ago. You notice the familiar pangs in your stomach. You even recognize other emotions—for example, the thankfulness and the sorrow that you’ll never be that young and innocent again. You notice your feelings at a bird’s-eye level and observe them rather than get caught up in the emotions. (No one said this was going to be easy!)

  Mindfulness also means living in the moment during the good times. It’s taking a walk through the park and being totally in the moment, soaking in the beauty of nature instead of being absorbed in the past or the future.

  Mindfulness is for everyone, not just people with BPD.

  • People with BPD need validation. Briefly, validation is listening empathetically to a BP’s feelings and accurately reflecting back what he said without necessarily agreeing with him. It’s avoiding phrases that tell BPs how to feel, such as “There is no reason to get angry about this.” An alternative validating phrase might be “I can see you feel really angry about this.” Note that you’re not agreeing with the reason for the anger.

  PROGRAM COMPONENTS

  At the heart of the program are (1) a two-hour weekly group skills training session led by a therapist, and (2) a weekly hour-long session with an individual therapist. Telephone crisis management is available if needed.

  Group skills training sessions follow a strict schedule and cover four interrelated topics: distress tolerance, core mindfulness, emotional regulation, and interpersonal effectiveness.

  • Distress tolerance. “I tell clients that distress tolerance is about getting through a crappy moment without doing something to make it worse,” says social worker Michael Baugh. “DBT offers a large collection of ways to distract attention that are more positive than planning suicid
e attempts, taking street drugs, or jumping into abusive relationships.”9

  • Emotional regulation. The goal of emotional regulation is to decrease the intensity of patients’ anger, fear, shame, and sadness. To fit in with less emotionally sensitive people, some people with BPD ignore their emotions. They don’t know how they are feeling until the emotion overwhelms them.

  • Interpersonal effectiveness. The aim of this training is to decrease patients’ interpersonal chaos and lessen their fear of abandonment. To do this, the skills trainer teaches them to have a more positive outlook about their environment, their relationships, and themselves. The content is very similar to that of an assertiveness training class, with lessons in the following: asking others to meet their needs in a more positive manner, asserting their limits, and proactively doing things to keep relationships going well.10

  • Individual sessions. Once a week, each patient meets with her private therapist, preferably one affiliated with the DBT program. During sessions, the therapist’s first priority is to discuss self-injury and suicidal behaviors during the week. The second priority is “therapy interfering behaviors,” such as coming late to sessions and phoning the therapist at unreasonable hours. The next priority is troubles that lessen the patient’s quality of life, such as depression and substance abuse. Finally, the therapist finds out how well the patient is progressing with skills training.

  LIMITATIONS OF DBT

  DBT offers great hope and a way to counter the oft-repeated (and demonstrably false) maxim that there is no treatment for BPD. Many patients say DBT has improved their lives tremendously. However, DBT is not a miracle cure. As you evaluate treatment alternatives, keep these limitations in mind:

  • DBT has been shown to lessen suicidal thoughts and reduce instances of self-harm. Studies have not shown that it relieves depression or makes clients happier (although many individuals say it does).

  • DBT is appropriate only for patients who acknowledge their illness, want to learn about it, and will work hard in therapy. Higher-functioning invisible BPs do not meet this criteria.