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Personality

A New Pathway to Change in Borderline Personality Disorder

New research on borderline personality shows what can lead to change.

Key points

  • People with borderline personality disorder often create more stress in their lives by virtue of their symptoms.
  • Therapy that can work for people with borderline personality disorder involves a combination of education and normalizing.
  • In a recent study, people with the disorder reported several changes after therapy, such as an improved ability to understand mental events.

With its symptoms involving longstanding and deep-seated difficulties in identity, relationships, and coping with emotions, it might seem that borderline personality disorder (BPD) might be baked into an individual’s ability to manage in everyday life. If you know someone with this disorder, you’re undoubtedly well aware of these challenges in situations in which they become afraid of losing control, unable to distinguish their own inner experiences from those of other people, and are convinced of their own worthlessness. Even after going through psychotherapy, this person may soon revert back to their prior mode of functioning, maybe stimulated by rejection in the form of a bad relationship breakup or even loss of employment.

Personality disorders are, by their very definition, regarded as immutable over the course of an individual’s life. Theoretically reflecting their disturbances in early childhood attachment, people with borderline personality disorder would seem particularly resistant to change. According to what’s called the “stress generation effect,” moreover, people with BPD create even more life challenges by virtue of their tendencies to use the maladaptive coping strategies that only exacerbate the negative experiences that come their way. Perhaps you’ve seen this firsthand as that person in your life with BPD becomes so easily enraged after, for example, a romantic partner unintentionally rebuffs this person’s advances. Rather than talk the problem out with the partner, this person angrily withdraws and ends things before any attempt at reparation can occur.

What Can Go Wrong in Understanding BPD-Focused Therapy

According to University of Eastern Finland’s Maaria Kolvisto and colleagues (2021), the four well-established methods of therapy for BPD, though effective in the short term, show a high symptom remission or relapse rate. Yet, this evidence can be challenged by the possibility that “the standardized quantitative reports of diagnostic remissions do not fully capture the clinical reality of BPD.” In other words, after therapy, people with BPD may actually experience improvement that straightforward symptom checklists or rating scales can’t capture. As indicated by a synthesis of previously published qualitative studies, this improvement can take the form of “an open-ended journey, a dynamic and gradual process that consisted of small steps, including setbacks as well as achievements.”

The Finnish research team, buoyed by this evidence, believe that by delving into the subjective experiences of BPD patients during and after therapy, they could capture the more nuanced, qualitative changes that don’t necessarily show up on symptom rating scales. The purpose of their investigation was to explore these less-than-quantifiable changes in the words of the individuals themselves. This approach, the authors maintain, could help shed light on the kinds of interventions that individuals perceive as particularly effective and therefore inform larger-scale empirical studies in the future. At the same time, the authors believed it would be important to document symptom change in the more traditional sense to accompany this less traditional qualitative approach to measurement.

Documenting Change in the Words of Individuals with BPD

Across a series of 40 weekly two-hour psychoeducational sessions conducted in group format, a set of eight patients with BPD from the city of Jyväskylä, Norway, ranging from 18 to 65 years old, were studied intensively over the course of therapy. The study lacked experimental controls, as the authors pointed out, in favor of the naturalistic design, so this is something to keep in mind in interpreting the findings. However, this disadvantage should be weighed against the strengths of the study design, which involved open-ended interviews designed to tap into major underlying themes. Moreover, the therapeutic method itself involved a combination of well-established treatment approaches and had itself been previously tested.

For the interview itself, the authors used a semi-structured series of questions focused on each patient’s experience of “personal development or meaningful change” over the course of past year in group therapy. The patients also described the elements they felt were most helpful to promoting change. It’s worth noting, before turning to the results, that two out of the eight patients remained unchanged in terms of their levels of BPD symptoms, two showed “reliable” change, and the remaining four were actually considered to have undergone remission.

The 22 areas of change that the patients described themselves as having undergone fell into five major categories, listed below along with sample interview material from the patients in the study:

1. Improved ability to observe and understand mental events in oneself and others. As stated by one participant, “I’ve become kind of very mindful of what I’m feeling and why it is that I’m feeling that way.” In the words of the authors, with this ability to notice and label thoughts, it became possible to be “less incapacitated by them and better able to engage in functional behavior.” Furthermore, the ability to take a more objective approach to their thoughts then allowed them to understand that everyone has their own thoughts and feelings, and that it’s important to allow them to engage in the same free expression. Rather than being threatened by the independent thoughts of a partner as signs of betrayal, for example, therapy allowed the individuals with BPD to avoid “unmodulated knee-jerk responses that typically made things worse.”

2. Decreased deconnection from emotions. Rather than engage in experiential avoidance of potentially threatening emotions, patients learned from therapy that they could allow themselves to express them. In the words of one individual: “I can apologize for doing something and … I now dare to really admit ‘I was wrong.'”

3. Emergence of new, adaptive emotions and decrease in maladaptive emotions. As therapy consisted in part of educating patients about the early development of BPD, participants reported being able to pull back into memory not only the “bad stuff” but recollection of some “nice memories.” They learned to experience sorrow over what had been missing then and now, as well as anger toward those who deprived them of a normal childhood. At the same time, they could forgive themselves as they learned that having BPD “was not my fault… there’s a logical reason for this.” Other new emotions that emerged were pride, self-compassion, and hope. This led to “a cessation of their previously unrelenting suicidal ideation” and greater trust in their own ability to cope with their daily life hassles.

4. Reduction of internalized harshness and emergence of their own voice. Rather than be overly condemning of their flaws, one patient reported that she could even “see myself in the mirror as I really am.” As a result, this particular patient then decided that it was time to take better care of herself and abandon some of those lifestyle habits that are known to be related to chronic health problems in individuals with BPD. This individual, in the words of the authors, showed “the waning of internalized punitiveness [that] had played an essential role in enabling her self-actualization.”

5. Self as continuous and existent. This last category of changes is perhaps one of the most impressive given the instability of sense of self associated with BPD. As stated by one participant, “I’m not like a chameleon any more… In a way I feel like I exist or I am able to see the future, too.” With a stronger sense of self, as the authors noted, she also found it less difficult to be alone.

What Worked and How Can These Findings Be Applied?

These compelling sets of changes came about, it’s worth noting, after nearly a year of two-hour weekly sessions. Although this was a substantial length of time it’s also relatively short if you consider the lifelong struggles that people with BPD can experience, even in therapy. Lessons about what worked can be helpful as you think about those in your own life with BPD and what might benefit them.

The two key elements, as the authors discerned from the interviews, were learning and normalizing. By sharing with participants some basic background information on BPD and its development, the therapists could engage them in a more mature type of self-change process in which they could, as one participant noted, “get a clearer sense of my experiences.” Normalizing, similarly, helped the patients be able to engage in “more compassionate self-observation.” They could, given the group format of treatment, also learn from each other.

These findings not only provide hope for the possibility of change in people with BPD, but also some pointers for how you might help guide people in your life with this disorder into treatment directions you might not have previously considered. Psychoeducation might be a new approach to try, including one involving a group modality.

To sum up, as discouraging as it might be to imagine reduction of the symptoms shown by someone with BPD, the Finnish study suggests there can be room for hope. Change may not be quick or easy, but it is still possible for individuals with BPD to find fulfillment as they learn not only about the nature of their disorder but about how to see their thoughts and feelings in a new and different light.

References

Koivisto, M., Melartin, T., & Lindeman, S. (2021). 'If you don’t have a word for something, you may doubt whether it’s even real'—How individuals with borderline personality disorder experience change. Psychotherapy Research, 31(8), 1036-1050. doi:10.1080/10503307.2021.1883763

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