People living with mental illness are often marginalized, demeaned, and seen as being outside the normal boundaries of society. For people with BPD, this is doubly painful as it reinforces their sense of worthlessness and victimization, and may even lead to suicide attempts. For those who can recognize they have BPD, yet not know how to deal with it, the social stigma may lead them to attempt to cope with the disorder on their own rather than seek medical treatment. This is a failed situation that has no good outcome (Paris, 2002).
As chronic sufferers of BPD are often victims of abuse themselves, the pain associated with the early trauma may turn into a perpetuating cycle of repeated suffering as they struggle to cope with their disorder. As one doctor notes, there are nine potential symptoms of the disorder, and over 200 potential presentations; the possibility that the disorder may be misunderstood by society and by therapists is high (Hoffmann, 2007). A concept known as 'surplus stigma' is attached to the disorder, due to misunderstandings associated with the disorder. These misunderstandings resulting in surplus stigma include the schizophrenogenic-mother concept, a refusal by therapists to treat those with BPD, unfavorable public information about the disorder, and controversy over the legitimacy of the disorder as a true clinical disorder worthy of treatment (Hoffmann, 2007).
Avirim et al. (2006) report that BPD is viewed negatively by therapists and clinicians. This negativity affects the treatment that the BPD sufferer receives. In society the person with mental illness is often marginalized and stigmatized, with great social distance put between them and the 'normal' population. Therapists may perpetuate this distancing by emotionally distancing themselves from their BPD patients. While the therapist's response may be one related to self-protection in dealing with the BPD patient, the response is one that may be expected when relating to the person with Borderline Personality Disorder who is unusually sensitive to criticism and rejection. Therefore the consequence of such a therapist/BPD patient relationship perpetuates the cycle of mental illness, as the BPD patient does not receive the treatment that they need and instead receive treatment that reinforces their mental illness due to the stigmatization given to them by their therapist (Avirim, Brodsky, & Stanley, 2006).
Summary of Part I
People who have been diagnosed with Borderline Personality Disorder have intense emotional disregulation and an inability to deal with relationships. They are often victims of abuse themselves, and causes of the disorder are a complex mix of environmental factors and genetic factors. A person may be predisposed to BPD if they are a first degree biological relative of someone who has BPD. Additionally, there may be inherent genetic factors that are aggravated by stress or trauma and that predispose a person to developing Borderline Personality Disorder. Sexual abuse in childhood is a predictor of developing BPD for abused women; Post Traumatic Stress Disorder may also accompany BPD, along with associated mood disorders such as depression and anxiety. People with BPD often act inappropriately with others, exhibiting aggression, irritability, disassociation, blame, and ideation. Social injustice issues related to those living with BPD relate to a misunderstanding by society of the disorder which contributes to marginalization and stigmatization. Therapists also may perpetuate the cycle of the mental illness by treating their patients with surplus stigma, and distancing themselves from their patient which exacerbates the condition. People with BPD have high suicide attempts and suicide rates, and often engage in self-mutilation and self-abuse. The need to find effective treatments for the population living with Borderline Personality Disorder is paramount. Effective treatment would result in better social outcomes for the BPD person and their families. Work relations would improve, and BPD patients could enjoy positive social experiences that are self-reinforcing. Rates of hospitalization would decrease for this population, resulting in a decrease in the burden on the healthcare system in treating these patients within a crisis situation, which is often costly. Decreasing suicide rates, enabling BPD patients to enjoy a life of optimum mental health and not just a life with minimized discomfort, and reducing hospitalizations would all benefit the social system within which this population resides.
Part II: Practice Approaches in Treating Borderline Personality Disorder
Traditional therapeutic approaches of cognitive behavioral therapy and medication management have proven to be of limited effectiveness is treating those with BPD. Low rates of compliance for pharmacological management and a tendency of this population as a whole to terminate psychotherapy have perpetuated the negative effects of this disorder for those diagnosed with the disorder and for those dealing with the person with BPD. There is a clear need for a better treatment approach, a best-practices model for treating Borderline Personality Disorder. Traditional approaches of limited efficacy include conflict resolution and social learning theory. A brief look at the role of conflict resolution in treating Borderline Personality Disorder is offered to set the stage for a discussion on more effective therapies. A discourse follows on the conflict resolution review, which examines two different practice approaches: Mentalization in the group approach, and dialectical behavior therapy at the individual level.
This brief review is offered as contextual material for understanding the limitations of therapeutic approaches that do not deal with the base personality disorder, which relates to the distorted cognition of those with BPD.
Conflict resolution has been used as treatment strategy in Borderline Personality Disorder to help people management their relationships better. The downside is that it ignores the root causes of the problem and so offers only a partially effective treatment with an unknown effective duration. However, conflict resolution can be very helpful in BPD patients to learn how to approach and effectively deal with issues arising in their relationships, with relevance to the nature of their disorder. A person with BPD encounters a base dysphoria that may be broken by episodes of anger, extreme sarcasm, or another marked reactivity of mood. This can cause a serious hardship in the relationships of the person with BPD, especially upon family, children, and co-workers. Using conflict resolution strategies can enable those with BPD to have an acceptable and appropriate framework for approaching relationships in a positive manner (Sperry, 2003).
Not surprisingly, people with BPD are reported to have difficulties in attentional neural networks associated with the ability to resolve conflict. Posner et al. (2002) report that BPD patients showed greatly reduced ability to resolve conflict among various study stimulus dimensions than did temperament-matched controls, notably in the areas of a reaction-time task and self-reported effortful control (Posner, et al., 2002). Clearly there is a role for incorporating conflict resolution strategies within a larger therapeutic framework, yet this method should be seen as an adjunct to therapy which deals directly with the cognitive problem of the personality disorder.
Mentalization is a form of psychodynamic psychotherapy with an aim of revealing the underlying psychic tensions of Borderline Personality Disorder. It was developed especially for BPD patients, with a theory that BPD patients have not developed a normal Mentalization framework for attachment relationships (Bateman & Fonagy, 2008). Mentalization refers to the ability to understand oneself and others based on obvious behaviors; Mentalization is also seen as a form of mental activity that allows one to recognize behaviors based on internal mental states (Busch, 2008). Four major aims of Mentalization-based treatment are to improve behavior, mood stability in response to stimuli (affect regulation), have better relationships with others, and have the ability to go after goals in life (Bateman & Fonagy, 2008).
Treatment typically involves a two-week cycle of treatment, with the therapist alternating the treatments between individual and group treatments. For purposes of this particular review of Mentalization, the focus will be on group treatment. In Mentalization therapy, the therapist attempts to form an attachment bond with the patient. This establishes a safe and appropriate attachment bond that the patient can relate to, thereby increasing their ability to understand their own behavior and the behavior of others; this process is increasing the patients Mentalization (Busch, 2008). In these safe attachment bonds the patient is encouraged to explore issues of their cognition, recognize those problems, and develop positive psychological mechanisms. Through the safe attachment bond, the affect recognition arousal issues can be moved from the state of dysfunctional disorganized attachment to positive and appropriate attachment Mentalizations (Bateman & Fonagy, 2008).
In the group therapy sessions, the therapist guides the patient to form safe attachment bonds with members of the group. The group dynamic offers a way for the BPD patient to understand 'how' to form safe attachment bonds and understand their own distorted cognitive processes. In one study, those patients treated with Mentalization therapy showed significant improvement over those treated with standard group treatment therapy options in measures of reduced suicide attempts, reduced emergency room visits, reduced use of pharmacological therapy in a five-year follow-up (Bateman & Fonagy, 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-based treatment vs. Treatment as usual, 2007).