Once you or someone you love is diagnosed with Borderline Personality Disorder, what does anyone do? This is what happens in therapy after the diagnosis. A deeper understanding of the disorder may help one with BDP or those around her.
This article draws from insight from one psychiatrist’s book on the disorder and the “care plan” for persons with BPD offered in a psychiatric nursing guide.
First, a quick summary of symptoms and diagnosis: People with BPD have a dysfunctional way of thinking, perceiving situations and relating to others. (www.Mayoclinic.com)
A borderline “experiences a repetitive pattern of disorganization and instability in self-image, mood, behavior and close personal relationships.” That most likely causes problems at work and in friendships. (Corelli, Stanford.edu)
Someone with BPD has intense, stormy, and unstable relationships; may manipulate others and have difficulty trusting them; has frequent changes in mood; and can be unpredictable and impulsive. (Corelli)
For a diagnosis, the person must display 5 of the following 9 symptoms: (Yahoo Health and Nursing Diagnostics)
1. Frantically avoids perceived or real “abandonment”;
2. Shows unstable and intense interpersonal relationships because of over-idealization and devaluation of others (switching between loving admiration to hatred);
3. Has an unstable self-image;
4. Acts impulsively in two areas: spending; unprotected promiscuous sex; substance abuse; binge eating; reckless driving; shoplifting;
5. Has recurring suicidal thoughts, or attempts suicide, or self-mutilates;
6. Emotionally overreacts or has intense mood swings – lasting a few hours to one or two days;
7. Expresses long-term feelings of emptiness;
8. Has intense anger problems;
9. May be overly suspicious of others (paranoia) or loses the sense of reality (disassociates; feels a discontinuity of experience).
Psychotherapy can help people with BPD by allowing them to talk about present difficulties and past experiences with a non-judgmental therapist, preferably in a structured setting on a regular basis.
Therapy should permit “increased self-awareness with greater impulse control and increased stability of relationships.” The goal is to “alleviate psychotic or mood-disturbance symptoms and generally integrate the whole personality.” (Stanford.edu)
How does one understand this type of personality disorder? The affected person often does not have the insight, but a trained professional or observant outsider may spot it.
With long-term treatment, one can usually experience gradual improvements; “the symptoms of this disorder can be reduced in both number and intensity.” (Allpsych). Becoming whole again takes time. While healing, “You may remain vulnerable in some areas that have healed, while you develop unusual wisdom and strength in others.” “As your boundaries become more clearly defined, you will detect more quickly when others violate them.” (Moskovitz)
In his book “Lost in the Mirror: An Inside Look at Borderline Personality Disorder,” Richard Moskovitz, a psychiatrist who worked with BPD for years, started a group in 1989 for borderlines in an inpatient unit. In that setting, a name was given to the disorder (patients were given booklets), and it created a framework for developing goals.
According to Moskovitz, his patients could be manipulative and seductive, luring the less-experienced or less-alert therapist into a codependent relationship. He learned that, in therapy, you could become an enabler if you took on the responsibility of trying to prevent their risky behaviors; you became “hostage” to the treatment process. (Most patients were females so feminine pronouns are used.)
People with BPD must have your trust; they had to learn boundaries and they had to understand what those were, upfront. The patient had to agree “by contract” that she would not make suicidal attempts or self-mutilate; she had to take responsibility for herself.
Contracts work because of the black-and-white kind of thinking that borderlines have with their strong sense of what is right and wrong. Words are important to them, and their honor is important so they tend to keep contracts they make. But they are also very good at “loopholes,” so the agreement must be very clearly laid out.
Because they transfer feelings onto others, by talking through angry feelings with a trusted person, that may allow people with BPD to perceive the situation more realistically. Because they tend to cling to one person, a private therapist must always be aware of the game-playing and not get enmeshed in it – “Why can’t you help me? Why should I trust you? I’ll never get well with your help.”
In an inpatient setting, two staff members should share therapeutic duties so the game cannot be played.
Persons with BPD may bait others into a conflictive drama so they can watch it play out while disavowing any part in the outcome.
“Family secrets are a way of life for most people with BPD.” Dr. Moskovitz characterizes the sadness and desperation of someone with BPD as “an elusive character lacking in identity, overwhelmed by a barrage of painful emotions, consumed by hunger for love and acceptance, and careening from relationship to relationship and impulse to impulse in a desperate attempt to control these feelings.”
Borderlines often use “splitting” as a learned defense. They have difficulty seeing the good and bad in the same person, so they label one either as all-good or all-bad. Whereas most mature people can see two sides of the same person, the borderline cannot.
People with BPD also learn to “dissociate” themselves from situations with a kind of mental detachment. “Reconnecting experiences” is important to recovery because someone with BPD cannot connect-the-dots from past to present to develop a sense of personal identity.
If you’re borderline, you are in a “constant search for clues about who you are. You struggle with a vague feeling of insubstantiality and may feel, at times, that you could suddenly vanish. You may cling to relationships in a desperate attempt to maintain a frame of reference for your own identity.”
As a borderline, you “lack an enduring trust in the goodness of your love objects and yourself; you have little tolerance for flaws in yourself or others, and you are unable to comfort yourself while alone.”
Group therapy cannot substitute for one-on-one therapy (actually both forms should be tried simultaneously), but it can allow people with BPD to perceive others with the same problems and recognize inappropriate behaviors and the distorted perceptions that lay behind them – as if seeing themselves in mirrors.
Thus, the group offers an “opportunity to learn new ways to make decisions, communicate effectively, and manage your relationships. It is a chance for members to try on new behaviors and model their effectiveness for each other.”
As you develop boundaries and communicate feelings and expectations, if someone does not respect your limits, “you will move on to more emotionally nourishing relationships.” Without those boundaries, you feel like you experience other people’s feelings as your own (to “empathize” to the nth degree).
Self-healing, becoming whole, involves several steps. Dr. Moskovitz lists 9 activities that work interdependently to help the borderline become healthy.
1. Keep your body healthy. By eating, sleeping, and exercising on schedule, a healthy body can go a long way in keeping symptoms at bay.
2. Don’t use alcohol or drugs, including prescription drugs and pain medications that affect memory and learning and make therapy impossible.
3. What makes you vulnerable? Hunger, exhaustion, seasonal changes, over-scheduling, being around certain people, etc. can play into your moods. Keep a diary. Self-awareness leads to self-control.
4. Control your surroundings. Sights, sounds, ideas, graphic violence on TV, and music do affect you, and you can control many of those things.
5. Be forgiving of yourself if you slip up. You are on a new path. Forgive, and move on.
6. Join a support group for personal support, safety, security and self-control as you continue to improve.
7. Develop positive rituals. Routine and predictability are important to the borderline; they offer continuity and feelings of connectedness.
8. Talk to your therapist. You must communicate and work through a tangle of feelings, and a trained therapist can guide you and offer support.
9. Talk to yourself to help you re-focus. By giving yourself audio messages in your own voice, you can reconnect yourself “with moments of clarity and insight.”
From a nursing viewpoint, in working with a patient with BPD, the short-term goal is to teach a patient to seek help if she thinks of harming herself. The long-term goal is for the patient to not harm herself or another while in the hospital.
Interventions with selected rationales: (Psychiatric Nursing: A pocket guide)
The nursing staffs are told to watch the patients carefully to ensure their safety (and others’), but to “avoid appearing watchful and suspicious.”
Make a contract. “An attitude of acceptance of the patient as a worthwhile individual is conveyed.”
If the patient self-mutilates, do not reinforce the act with sympathy or extra attention. Simply attend to the patient with professionalism.
Encourage communication. Ask the patient about the feelings she experienced before the act. “In order to problem-solve the situation with the patient, knowledge of the precipitating factors is important.”
Act as a role model for the handling of angry feelings. Reinforce the patient if she attempts to conform.
Redirect aggressive behavior with physical outlets like running, jogging, using a punching bag, exercising. Relieve pent-up emotions.
“Indicate a show of strength” in the number of staff available. This announces “control” of the situation while offering security to the staffers.
Use tranquilizers if necessary. These may calm the patient and prevent aggressive outbursts.
Finally, if necessary, use restrictive interventions like restraints or an isolation room. Most states require the physician to renew the order every three hours. Observe a restrained patient every 15 minutes. Assist with nutrition, hydration and elimination. “Patient safely is a nursing priority.”
During a crisis, a patient may need one-on-one care. “Because of their extreme fear of abandonment, leaving patients with BPD alone at such a time may cause an acute rise in level of anxiety and agitation.”
For life-long behavioral changes, a patient with BPD should learn relaxation techniques for anxiety; learn to discuss “maladaptive patterns of expressing anger” with a nurse before discharge and gain insight into the original source of the anger. She must also learn to “interact with patients and staff on the unit in both social and therapeutic activities without difficulty.”
Before discharge, the individual must also “be able to distinguish her own thoughts, feelings, behaviors, and image” from others’. She should “exhibit increased feelings of self-worth” – as evidenced by talking about positive aspects of herself, her past experiences and her future goals.
To return to Dr. Muskovitz’s book, in which he presents the “composite” story of a borderline known as “Sara,” he says, “For years, we have kept your diagnosis secret from you for fear you would be wounded and flee. By keeping secrets, we have promoted misunderstandings and misalliances, both with you and among those involved in your treatment. We may have inadvertently reenacted some of the same family dynamics that have caused you pain for years, for family secrets are a way of life for most people with BPD.”
“This book is intended to let you in on the secret.”
Lost in the Mirror: An Inside Look at Borderline Personality Disorder. Richard A. Moskovitz, M.D. 1996. Selected quotes throughout book.
Nursing Diagnoses in Psychiatric Nursing: A Pocket Guide for Care Plan Construction, Third Edition, Mary C. Townsend, 1994. “Borderline Personality Disorder.” “Interventions with Selected Rationales.” “Short-term goals” and “Long-term goals” for borderline personality disorder and anxiety.
“Borderline Personality Disorder – Treatment Overview” on Yahoo! Health. “Symptoms” and “Management of Symptoms.” Author: Jeannette Curtis; medical review by Kathleen Romito, M.D., family medicine and Lisa S Weinstock, M.D., psychiatry. Last updated 3-26-07. Retrieved 5-27-08.
http://www.mayoclinic.com/health/personality-disorders. “Definition” of BPD. Retrieved 8-1-09.
http://www.stanford.edu/~corelle/borderline.html. “Borderline Personality Disorders.” “Diagnosis” and “Etiology.” Richard Corelli, M.D. Retrieved 5-27-08.
http://www.allpsych.com/disorders/personality/borderline.html. “Psychiatric Disorders.” Borderline personality disorder. “Prognosis.” By Allpsych and the Heffner Media Group, Inc. Last updated May 15, 2004. Retrieved on 8-1-09.