Working with PD |
| Common misconceptions and generalisations of BPD |
| Also see Treatments |
What is Borderline Personality Disorder (BPD)?
The term ‘borderline’ was coined by Adolph Stern in 1938. This name was used to describe patients who were on a ‘borderline’ between neurosis and psychosis. However, the symptoms of BPD are not so simplistic as to be defined in terms of neurotic and psychotic. The diagnosis of BPD is based upon signs of emotional instability, feelings of depression and emptiness, identity and behavioural issues rather than signs of neurosis and psychosis. However, the name Borderline has remained even though the definition has changed. Throughout Europe, the same disorder has been given the more appropriate and less misleading title of ‘Emotionally Unstable Personality Disorder.’
What are the symptoms of BPD?
One of the core signs and symptoms in BPD is the proneness to impulsive behaviour. This impulsiveness can manifest itself in negative ways. For example, self-harm is common among individuals with BPD and in many instances, this is an impulsive act. Sufferers of BPD can also be prone to angry outbursts and possibly criminal offences (mainly in male sufferers) as a result of impulsive urges. Other characteristics of this condition include reality distortion, tendency to see things in ‘black and white’ terms, excessive behaviour such as gambling or sexual promiscuity, and proneness to depression.
How is BPD diagnosed?
For a person to be diagnosed with BPD, at least five of the following criteria need to be met:
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Frantic efforts to avoid real or imagined abandonment.
Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
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A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
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Identity disturbance: markedly and persistently unstable self-image of sense of self
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Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
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Recurrent suicidal behaviours, gestures, or threats, or self-mutilating behaviour
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Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
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Chronic feelings of emptiness
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Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Is there a cure for BPD?
BPD is not usually diagnosed before adolescence as the personality is said not to be fully developed. It has been suggested that BPD symptoms can sometimes improve as time goes on or even disappear all together. This is not always the case however as BPD can continue to affect sufferers well into later life.
Prognosis
Personality disorders are regarded as lifelong conditions with periods of improvement and worsening. It is believed that clients with personality disorders within clusters A and B have symptoms that become less intense and severe by the time they reach middle age. Those with personality disorders within cluster B (such as Borderline Personality Disorder) however, are particularly prone to substance abuse and suicidal behaviour which may have a direct impact on their life span. Figures suggest that 80% of borderline personality disorder clients, who are hospitalised, will attempt suicide at some point during their treatment, from which 5% will succeed.
Despite the obvious negativity surrounding the prognosis of personality disorders, due to them being regarded as ‘incurable’, there are a number of treatment options available to clients which can help to improve the symptoms of personality disorders and help make life for clients more manageable. These treatments encourage clients to develop the necessary skills required to manage both the ‘highs’ and ‘lows’ associated with personality disorder and enable them to lead a life as normal as possible.
Common misconceptions and generalisations of BPD
All too often it is a consultant psychiatrist who has very limited knowledge on the specific area of personality disorders that diagnoses someone with a personality disorder. The way in which the illness is explained is nothing short of installing hopelessness into their already hopeless patient.
Often, newly diagnosed patients are told that they have a personality disorder, it is very complex and there is no cure. A lot of psychiatrists believe that medication does not work on people with personality disorders and therefore should not be prescribed, so patients are often also told there is no medicine available that will help. Due to the behaviour of someone who has a personality disorder they are commonly called manipulative, attention seeking, demanding, and obstructive. I would like to go through these individually.
“People with BPD are manipulative”
This is a very harsh comment to make about someone that is using the best skills they have available. Try to imagine what someone with a personality disorder has gone through, and then think about what extremes you would go to protect yourself. Isn’t it true that life is a fight for survival or would it be seen that way through the eyes of someone with a personality disorder?
“They are just attention seeking”
There are many people with personality disorders; they may be considered attention seekers but let me ask you, if you had a cold, what is it you look for from your partner or friends? Isn’t it comfort, reassurance and attention? So why would it be any different from someone suffering from severe emotional distress? The other point to note on this is people with personality disorders have often had their behaviours reinforced. As an example should someone with a personality disorder threaten to cut themselves with a knife because their partner was going out for a drink with a mate and in turn the partner said ok I won’t go, this reinforces the behaviour and makes it more likely to occur again.
“He / she is demanding”
Imagine having a broken leg, you know there is treatment and with a little patience you will be better before you know it. With a personality disorder you are likely to experience the problem for many years with no real hope of a cure but your symptoms are likely to lesser as you grow older. Unlike a broken leg you can not exactly see what is wrong but you can definitely feel it. I am sure everyone will agree this would make anyone quite demanding and impatient.
“They are obstructive”
People with mental health issues have been often through mental health services for years. Having a personality disorder you are likely to be involved with services for much longer than the standard mental health patient. You are offered so many services and therapies that have different names but often mean the same. I suppose you end up feeling like a bit of a guinea pig, and reluctant to continue with another service or therapy.
Working with a client who has a diagnosis of BPD
Why is it important to develop a therapeutic relationship?
The therapeutic relationship between your client and you is the most important part of treatment. Your client may never of had a stable relationship before, the central difficulty in many of the personality disorders is building and maintaining relationships. Therefore it is important you take the therapeutic relationship very seriously. Your client will effectively be learning how to develop and maintain relationships through their work with you.
What positive personal attributes do I need?
Empathy & Acceptance
You may not experience the same emotions and issues that your client does but make every effort to make sure you are accepting of what’s happening within them.
Honesty
Always be honest with your client. This is very important to your relationship with them. Do not make promises you cannot keep. Should you agree to ring them, then offer a period between two times, then keep to these.
Boundaries
Make your boundaries clear and concise. Regularly go through them, ask your client what they expect and what their boundaries are?
Positive regard
First name basis; include your client in decision-making. Put them in charge of their care. Ask them what they think, ask for feedback.
Receptive and attentive
Watch for negative responses in your client. Just because what you have said or done may not have affected you, do not make the mistake of believing it would have affected them. Misconceptions regularly occur, it’s important you are attentive to these.
The therapeutic relationship has broken down. How do I fix this?
Do not allow things to become out of control. Should there be a breakdown in your relationship with the client. Make every effort to understand what’s happened and put it right. Should you allow a session to end on a negative note it’s likely your client will suffer emotionally.
How can I be self-aware?
Make sure you take responsibilities for yourself. Should you be late, make it perfectly clear that you take responsibility for this and you are sorry. Understanding your own values, beliefs, feelings, prejudices & how these affect others.
How do I make my role clear?
Do not make promises you cannot keep. Make it clear you are not working with your client to cure them but to help them along their journey.
My work with a client is finishing soon. How do I end our work together?
It is always best practice to start on an ending. Have a period of time in which you have mutually agreed to be involved for. Review the progress of your work together regularly. Make sure you leave adequate time towards the end of your involvement to deal with this issue.
Why do I need supervision?
In working with personality disorders it’s considered vital to have regular supervision. It should not matter in which area you work with this client group, whether you’re a therapist or support worker supervision should always be made available.
