Borderline Personality Disorder: treatment, social justice, and the at-risk population

Borderline Personality Disorder

The following research report focuses on a population at risk, those diagnosed with Borderline Personality Disorder. The report is offered in three sections. Part I provides an examination which looks at statistics related to the disorder. A definition of the disorder is given, with implicit defining characteristics of the population at risk. Causes are discussed with a relevant literature review. Social justice issues are looked at, with a discourse offered on factors of social oppression related to the population at risk. Part II discusses two courses of treatment with associated issues related to Borderline Personality Disorder, with an in-depth review of Mentalization therapy Dialectical Behavior Therapy. Part III discusses the political and social context of the issues relevant to the population at risk. Research on the NASW Code of Ethics is offered. The strengths perspective is discussed and the role of the Advanced Generalist Model is examined for finding treatment solutions to the at-risk population of those diagnosed with Borderline Personality Disorder. A conclusion is offered to highlight the salient points of the report and to synthesize the topics.

The At-Risk Population: Borderline Personality Disorder

The population-at-risk chosen for the following report are those people that have been diagnosed with Borderline Personality Disorder (BPD). This population was selected due to their high rates of hospitalization, suicide attempts, and suicide. Suicide rates for this population are estimated at 8-10% (Paris, 2002). People diagnosed with BPD typically face a chronic and long-term debilitating psychiatric condition, for which traditional therapies have proven of limited effectiveness. The lifetime prevalence of those diagnosed with BPD in the general population is approximately 5.9% according to a recent study (Grant, et al., 2008), being equally prevalent between men and women (Grant, et al., 2008). Extreme states of physical and mental disability are features of this disorder, especially among women. Psychiatric hospitalizations of those identified with Borderline Personality Disorder are on the magnitude of 20% (BPD Today, 2010).

Borderline Personality Disorder Definitions

Borderline Personality Disorder is a disorder of emotional regulation. People with this diagnosis have extreme difficulty regulating their emotions. Approximately 50% are clinically depressed, and 25% are classified with Post Traumatic Stress Disorder as well (BPD Today, 2010). Sexual abuse as a child is strongly associated with development of BPD, and some studies suggest between 40%-70% of those with BPD have been sexually abused (Bohus, Priebe, Dyer, & Steil, 2009). People with BPD often report severe childhood emotional trauma. Additionally, people with BPD may have predisposing factors, such as genetics, brain and neurobiological issues, and other environmental variables. Moreover, BPD may result from an inability to effectively deal with adolescent stress events (Zanarini & Frankenburg, 1997).

The Diagnostic and Statistical Manual of Mental Disorders defines Borderline Personality Disorder in Axis II, Cluster B Axis II disorders include personality disorders and mental retardation. Category B. includes dramatic, emotional and erratic disorders, such as BPD (American Psychiatric Disorders, 2000). Some critics have stated that BPD should not be on the Axis II disorders, but should instead be moved to Axis IV, which includes psychosocial and environmental issues that contribute to the disorder, or Axis I, which includes clinical, learning, and major mental disorders (New, Triebwasser, & Charney, 2008).

People with BPD experience episodes of intense emotional instability, such as anger, anxiety, aggression, self-injury, or some type of substance abuse. These instances may last for a few hours to a day, yet be of a chronic, long-term nature. These people have distorted cognitions of themselves, and often view themselves as of low value, bad, and unworthy. Maintaining relationships is difficult for a person with Borderline Personality Disorder, and they may range from idealization of their significant other, to devaluation of that person, based upon some small infraction that is out of proportion to reality. Due to their intense emotional disregulation, people with BPD have trouble with social relationships as well. They are extremely sensitive to any criticism, perceiving these as some type of personal rejection. Responses to their emotional distortions on others are anger, distress, fear, aggression, and depression.

The DSM-IV-TR gives the following diagnostic criteria for Borderline Personality Disorder (summarized): frantic efforts to avoid abandonment; a pattern of unstable relationships; unstable image of self; impulsive self-destructive behavior; recurrent low-injury threshold suicide attempts and self-mutilation; highly reactive mood states such as irritability; feelings of emptiness; frequent displays of temper; and stress-related ideation (American Psychiatric Disorders, 2000, p. 710).

Causes

Genetics

Borderline Personality Disorder may be attributed to physiologic biochemical factors, brain abnormalities, environmental factors, or trauma-related issues. Abuse and neglect, often as a child, are strong predictors of developing Borderline Personality Disorder, especially if the child has been identified as ADD or ADHD, with increased risk if accompanied by factors of Conduct Disorder before age 15 (Zanarini & Frankenburg, 1997). A combination of genetics and environment is thought to contribute to BPD; first-degree biological relatives with BPD indicate a five-fold increase in the possibility of developing Borderline Personality Disorder than compared to the general populace (American Psychiatric Disorders, 2000).

Being a victim of some type of violence, especially rape, is a strong predictor of an adult developing BPD. If the violent event has resulted due to poor judgment or risky behavior, these factors support a diagnosis of Borderline Personality Disorder as well (Bohus, Priebe, Dyer, & Steil, 2009).

People diagnosed with BPD often display abnormal brain neural circuitry regulation in emotion regulation. The prefrontal cortex of the brain is involved in dampening fear and stress responses which originate in the amygdala, located in the deep brain structures. MRI imaging of people with BPD show a marked decrease in prefrontal regulation of amygdala-generated neural responses (Ruocco, Medaglia, Ayaz, & Chute, 2010). Additionally, people with BPD have decreased activity in certain brain neurotransmitters, such as serotonin, dopamine, acetylcholine, and norepinephrin, likely due to genetic factors that are aggravated in stress situations (Steele & Siever, 2010). Drugs that act to enhance and sustain levels of these neurotransmitters in the neuron's pre-synaptic gap for longer periods tend to reduce symptoms of Borderline Personality Disorder. Drugs that stabilize the inhibitory neurotransmitter GABA are shown to help stabilize the mood of those with BPD as well, reducing the ideation-mood disturbance episodes common in BPD (Stoffers, Vollm, Rucker, Timmer, Huband, & Lieb, 2010).

While there is a complex interplay of the causes and triggers of BPD, studies exist which attempt to explain discrete elements of the causes of the disorder. Distel et al. (2009) report that 35-45% of the variance in BPD can be explained by genetic factors, though the study did not find much evidence of the cultural transmission of the disorder from parent to offspring, suggesting a strong role for genetics (Distel, et al., 2009).

Bornovalova et al. (2009) state that results from longitudinal twin studies supports a causal link for genetics and environment in BPD, with an overall decline of BPD characteristics with advancing age. This last factor also supports the role of genetics being influenced by the environment in BPD, as greater stability in work, social, and personal relationships tends to be increase in the fourth decade of life and beyond (Bornovalova, Hicks, Iacono, & McGue, 2009).

Abuse, Neglect, Violence, and Trauma

People with Borderline Personality Disorder have reported to be the victim of some type of traumatic event, most likely a violent abuse situation, with sexual abuse being the most commonly reported abuse for women. This event typically occurs in childhood, though BPD can result from adolescent and adult-related trauma as well (Paris, 2002).

McLean and Gallop (2003) report that women who have experienced sexual abuse as a child had significantly higher associations of developing BPD than if they experienced the abuse as an adult, though both groups exhibited early symptoms of both Borderline Personality Disorder and post-traumatic stress disorder (McLean & Gallop, 2003).

People with BPD often verbally attack and verbally abuse those they have relationships with. Indeed, the BPD person was often similarly verbally abused in their past as well. Borderline Personality Disorder often follows the patterns of abuse that the person with BPD has experienced in the past, with the BPD person inflicting domestic (spousal) abuse, physical and emotional abuse of strangers, child abuse, and self-abuse. Breaking the cycle of pain and abuse entails a comprehensive therapeutic approach in both cognitive psychiatric services and pharmacological intervention (Grant, et al., 2008).

Social Justice Issues

The concept of social justice has different meanings in different paradigms of study and thought; for purposes of this report, social justice refers to those diagnosed with Borderline Personality Disorder who have experienced inequality and unfairness due to their disorder. This social justice aspect of the disorder contributes to the risk that this population is encountering.

People who have BPD encounter difficulty in the work environment. This presents a challenge to employers as they struggle to deal with the disability issue at hand. The employee with BPD may not be recognized as having a mental illness, and instead seen as a disruptive element in the workplace. They may be ostracized, demoted, or even fired from employment (McDonald, 2002).

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.

Conflict Resolution

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.

Dialectical Behavior Therapy

People with Borderline Personality Disorder who seek psychological treatment often have terminate sessions early due to problems of therapist prejudices and perceived personal attack. Traditional approaches to managing this disorder have included pharmacological management, social learning theory, and conflict resolution (Avirim, Brodsky, & Stanley, 2006). Conflict resolution has a window of opportunity in helping people with DBT learn how to effectively 'deal' with other people, but it does not get at the root cause of the personality disorder (Sperry, 2003). The efficacy of traditional treatment approaches for BPD is dismal, and has led to the need for better therapies that are geared to the specifics of the disorder (Posner, et al., 2002). One approach is Mentalization based therapy, which has been recognized as having clinical bases in the etiology of the disorder via attachment theory. Another promising avenue of therapy practice for treatment of Borderline Personality Disorder is dialectical behavior therapy (DBT) (Bohus, Priebe, Dyer, & Steil, 2009).

Dialectical behavior therapy combines cognitive behavior therapy with emotion regulation techniques, utilizing therapist directed and patient self-tests of reality through a framework of mindfulness (Linehan, 1993). A fundamental aspect of DBT is the establishment of a strong therapist and patient relationship, and a willingness by the patient to undergo treatment. In this model, therapists need to move themselves out of the role of adversary in the patient's view, which seeing others as adversaries, especially therapists, has been a chronic problem for those with BPD. The therapists recognize during DBT that the borderline patient requires a great deal of validation, while having the patient accept that criticism is not an attack and to accept responsibility for treatment (Dimeff, Linehan, & Koerner, 2007).

Lynch et al. (2006) studied potential mechanisms of change that result from DBT. They distilled the research review to finding that DBT reduces nonproductive behaviors resulting from emotional disregulation. Further, they report that DBT helps patients cope with life in a positive way even when they are in the grip of an intense emotional episode, through using mindfulness and other DBT techniques (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). This is an empowering mechanism, and may underlie one of the core strengths of the dialectical behavior therapy approach.

Koons (2008) reports on the success of DBT in reducing suicide rates and hospitalizations among women diagnosed with Borderline Personality Disorder. Koon describes aspects of DBT that the therapist can begin to use in the clinical setting such as structure and focus' of treatment (Koon, 2008). Linehan et al. (2006) studied the effects of DBT vs. non-behavioral psychotherapy in women with BPD. The study included 101 women with a clinical diagnosis of Borderline Personality Disorder, who had attempted suicide or had caused themselves self-injury in the 5-year period preceding the study, with at least one incident within 8 weeks of the study. The participants were randomly assigned to either the DBT group or the non-behavioral psychotherapy group, over a two-year period of treatment. Results indicate a significant reduction in suicide attempts among the DBT group vs. The control group, though no difference was noted for self-injurious behavior reduction. Additionally, those women assigned to the DBT group were more likely to continue with therapy (Linehan, et al., 2006).

The success of DBT for Borderline Personality Disorder patients is likely due to the approach over traditional methods. The therapy course of DBT has four major modules, which include mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (McKay, Wood, & Brantley, 2007). Diary cards can be utilized that record the BPD patient's affective behaviors during therapy that interfere with therapy goals (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).

As with Mentalization, one component of the DBT treatment is in individualized therapist/patient sessions, and another component is in group therapy. Tools and methods are explored in individual sessions, and applied in group sessions. The four modules of DBT therapy relate directly to the personality disorder characteristics of a person who is considered borderline. Hence, the methods and process of DBT are especially effective for treating, recognizing, and empowering the BPD patient (Dimeff, Linehan, & Koerner, 2007).

Within the psychiatric treatment of those with borderline therapy disorders, a therapists approach is critical in setting the stage for a successful outcome. As noted, therapists have a tendency to emotionally distance themselves from the BPD patient (Hoffmann, 2007). In the case of a therapist utilizing dialectical behavior therapy, however, there is a noted adjustment on the part of the therapist to be involved with the patient for an optimal outcome (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).

Dialectical behavior therapy has shown success with a broader swath of the population in achieving successful outcomes. Rathus and Miller (2002) trialed DBT with suicidal adolescents who exhibited features of Borderline Personality Disorder. Participants in the study were assigned to either a DBT treatment group, or a TAU (therapy as usual) group. Those in the DBT group displayed significantly reduced hospitalization rates and significantly increased rates of therapy completion (Rathus & Miller, 2002). DBT is also a promising treatment for the elderly who have BPD. The elderly population has higher rates of suicide compared to the general population, which is compounded by BPD. The use of DBT may be of potential use in this critical population in reducing suicide attempts and suicides (Lynch T., 2000).

Robins and Chapman (2004) review evidence that DBT has a potential course for psychotherapeutic treatment not only for suicidal women with Borderline Personality Disorder, but also with co-morbid or unique presentations of eating disorders, depression, attention deficit disorder, and for use with prison inmates as well (Robins & Chapman, 2004). While DBT is useful for treating BPD and other disorders where restructured cognitive thinking is beneficial to the patient, Rusch et al. (2008) note that among women in DBT therapy who have been diagnosed with BPD, those that exhibit high levels of anger and low incidences of suicidal attempts, there is a tendency for higher dropout rates. The implication is that there may be subtypes of BPD that do not respond well to DBT simply due to unique presentations of the disorder (Rusch, et al., 2008).

Cultural Competence in Dialectical Behavior Therapy

The NASW Standards for cultural competence display a framework that recognizes the strengths of the individual, and the empowerment of practice approaches for client advocacy and benefit (National Association of Social Workers, 2007). Noting that the diversity of clients is broad in the general community requires a mindset of acceptance and dedication to serve and advocate for the culturally diverse populations requiring social services. Liberman et al. (2001) notes that DBT approaches can be effectively delivered through a recognition that individualized services may be best offered with a culturally competent based understanding by psychiatrists and therapists for the patient (Liberman, Hilty, Drake, & Tsang, 2001). Cornerstones of the DBT approach are that it is empowering, strengthening, and hopeful; these aspects are felt by both therapists and patients utilizing the DBT approach (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).

It is interesting to note that in light of established studies of therapist reluctance and prejudice in working with patients with BPD, the use of DBT has increased not only feelings of empowerment of the patient during the course of their treatment, but it has also empowered the staff working with them. Sheel (1999) noted in an earlier study that DBT was indeed empowering for nurses working with patients with BPD (Sheel, 1999).

Sly and Taylor (2003) found that DBT therapy in a structured living setting for BPD women that had attempted suicide allowed the patients to raise their self-esteem, become hopeful for the future, and enriching the health of both patients and therapists working with this at-risk population (Sly & Taylor, 2003). Additionally, Nehls (2000) reports that patients with BPD who initiate the therapeutic process and use cognitive behavioral restructuring as in the DBT approach find themselves becoming empowered to overcome their disorder and engage in a process of recovery (Nehls, 2000).

DBT utilizes a cultural competence for this at-risk population of those diagnosed with Borderline Personality Disorder. Noting the diversity of the population and the social justice issues surrounding treatment of such patients, the DBT approach delivers hope and strength to both patient and therapist, offering a new model of enriching treatment that provides the self-esteem to treat and the self-esteem to be treated for BPD population.

Part III: Policies, Ethics, and the Advanced Generalist Model

The population at-risk, those living with Borderline Personality Disorder, has noted high rates of suicide attempts, suicides, and otherwise self-injurious behavior. People with BPD are high users of outpatient psychiatric services, and comprise a portion of the inmate population as identified in established reports (Sly & Taylor, 2003). Programs have been implemented to address this population, which include using best practice therapy models such as DBT and Mentalization.

Blum et al. (2002) describe a novel approach to treating BPD, known under the STEPPS acronym: Systems Training for Emotional Predictability and Problem Solving. A scale was developed specifically for this program, called BEST (Borderline Evaluation of Severity over Time), which measures how/if the BPD patient improves over time in therapy. There is strong group component to the program, which includes family members as well (Blum, Pfohl, John, Monahan, & Black, 2002). The STEPPS program was developed as an outpatient treatment program for those with BPD, and reflects a recognition that more effective therapies need to be developed for this at-risk population in keeping with an overall ethical approach to policy for establishing BPD therapies.

Coid (2003) discusses the impact of those with personality disorders on general society. He states that prevention measures should be targeted at identifying those in early childhood who are indicated for developing a personality disorder. Coid notes that BPD is the most commonly seen personality disorder for outpatient treatment, and that new policies must be developed to address prevention in childhood rather than crisis in adulthood (Coid, 2003).

Policies for addressing the at-risk population have primarily focused on development of novel therapeutic approaches, using novel therapies (DBT) to treat BPD in a variety of settings, reducing suicide behavior, and reducing hospitalizations. The cost to society for outpatient treatment of BPD that is only of limited effectiveness is high. The patient that presents at the emergency room for treatment may receive a short-term amelioration of their symptoms utilizing crisis management approaches and traditional therapeutic treatments, yet those people will tend to re-present themselves in a perpetuating cycle (Avirim, Brodsky, & Stanley, 2006). Programs aimed at addressing the prejudice toward treating those with BPD, as well as advancing novel therapies that are geared for the specific characteristics of BPD has been the trend in recent years. This general acceptance of the need to find more efficacious treatment for those with BPD has been validated in evidence-based trials to be of significant effectiveness, especially in the areas of suicide attempt reduction and reduced hospitalizations. That the patient is becoming empowered to heal their cognitive processes is also noteworthy (Hoffmann, 2007).

Souders (2009) presented on the termination of services to clients by social workers. Social workers, per the NASW Code of Ethics, are held to terminate services to clients when care is no longer indicated. Souder's investigates how social workers determine when their services are no longer effective. In this view, the social worker has an ethical obligation to serve the client, and clear evaluative methods must be in place that takes into account the ethics of treatment for the client (Souders, 2009).

Regarding ethics in social work and therapeutic treatment, Canda (1998) talks about the need to incorporate a theme of spirituality into therapeutic treatment objectives. These include concepts of well being, mutual benefit, self-determination, a holistic view of the individual, and spiritual sensitivity (Canda, 1998). Dialectical behavior therapy has roots in Buddhism, with a holistic view of healing that is empowering (Koon, 2008). There is a strong sense of ethics that is embedded within the DBT framework of treatment, which may be one reason why therapists are more committed and report a general positive outlook in using DBT treatment vs. treatment-as-usual (Robins & Chapman, 2004).

The Advanced Generalist Model Approach

The Advanced Generalist (AG) approach teaches that solutions to a problem come from a multidimensional perspective, rather than from a micro or macro practice approach. Practitioners that use AG approaches in practice use a broad-based perspective that is guided by their professional discipline. AG incorporates cultural competency, ethical advocacy, problem-solving from a multidimensional approach, and ongoing assessment and reassessment. The AG model provides practitioners with a way to professionally approach at-risk population policy is a creative and thoughtful manner (Lavitt, 2009).

The Advanced Generalist Model incorporates the following multi-dimensional elements: evaluation, intervention, assessment, skills, ethics, knowledge, communities, groups, individuals, cultural competency, empowerment, and social justice (Wichita State University School of Social Work, 2010). Reid (2002) reports that social work practice is incorporating science-based practice with multidimensional practice approach, which utilize family therapy and client services; DBT is one approach that follows a generalist approach to treatment for the BPD population (Reid, 2002).

The AG model approach uses a variety of approaches from the micro level (individual), mezzo level (group), and macro level (community), which also include approaches from the practice end including specialization and/or generalization, with both expert and junior level approaches (Lavitt, 2009). One component is utilizing the individual level, client based approach, which recognizes the resources of the individual in being responsible for their therapy and treatment. This concept is captured in the Strengths Perspective.

The Strengths Perspective holds that the therapist should help the client explore and discover their own innate resources to help them achieve their therapy goals and life goals as well. This approach has been used in alcohol abuse, mental illness, criminal justice, neighborhoods, and in emotional abuse situations (University of Kansas School of Social Work, 2010). The population of the those living with BPD, have access to novel treatments which reflect a cultural competency and ethical approach through the therapeutic approaches of DBT and Mentalization, where the Advanced Generalist model is clearly embedded, and from which a Strengths Perspective approach is likewise clearly advocated for.

Conclusion and Synthesis

The population at-risk described in this research paper includes those people diagnosed with Borderline Personality Disorder. People with BPD have high rates of self-injury, including suicide attempts and actual suicide. They are the population most often seen in the emergency room setting for psychiatric treatment. This population has high rates of therapy termination and are stigmatized as a population that is notoriously difficult to treat. The outcome for this population has been a medical and professional attitude of distancing and treatment-as-usual approaches, utilizing standard outpatient psychotherapy and traditional pharmacotherapeutics. However, there are low rates of compliance among BPD patients for their prescribed drug use. Additionally, standard psychotherapy has a limited effectiveness of treatment for this population. Novel therapeutic approaches based on a cultural competency approach and utilizing Advanced Generalist practice approaches including a Strengths Perspective, are found within the models of Mentalization therapy and of even greater efficacy, dialectical behavior therapy. Those treatments that recognize the unique and difficult to treat characteristics of this at-risk population must necessarily utilize an empowerment approach, as those with BPD often have very low self-worth. The AG model can continue to advance the envelope for treatment within DBT frameworks for people with Borderline Personality Disorder, with a great benefit being that it utilizes a strengths perspective within treatment. Evidence-based studies show that DBT and other novel cognitive treatment approaches such as Mentalization for those with BPD results in lower rates and incidences of self-injury, suicide attempts, and suicide. Additionally, those undergoing or who have undergone DBT treatment result in less emergency room treatments, and overall reduced hospitalization. There is clearly an empowering and hopeful promise in Dialectical Behavior Therapy and similar forms of treatment for those living with Borderline Personality Disorder.