A discussion of Borderline Personality Disorder in terms of five areas of functioning.
The World Health Organisation (WHO) (2007, web accessed February 2014) defines mental health as being not just the absence of a mental disorder, but rather as a state of well-being in which each individual is able to reach their own potential and cope with the normal stresses of life.
Borderline Personality Disorder (BPD) is one of the most common disorders found in both inpatient and outpatient settings and yet is often overlooked (Beck et al, 2007, p.196). This essay aims to identify the possible aetiology and diagnostic criteria of BPD, to conceptualise it in terms of Waverley Integrative Framework’s five areas of functioning and to show how counselling research informs practice. It further aims to discuss how psychiatric treatment with medication could affect the counselling process and critically evaluate the use of a medical model. Finally, to discuss how counselling skills could facilitate therapeutic change and identify when referral may be necessary.
Possible aetiology and diagnostic criteria.
A combination of factors contribute to the aetiology of BPD and Grohol states (2013, web accessed March 2014) that most professionals subscribe to a biopsychosocial model of causation. No single factor is the cause but rather a combination of factors including biological, genetic, social and psychological factors.
In identifying the possible aetiology of BPD Cowen, Harrison and Burns (2012, p.145) indicate that research proves the importance of genetic factors and that first-degree relatives of BPD patients are ten times more likely to be treated for the same disorder. Grohol (2013, web accessed March 2014) supports this and states that research shows that individuals with BPD have an increased risk for this disorder to be passed down to their children.
NHS Choices state (2012a, web accessed February 2014) that neurobiological studies show brain chemicals play a part and it is thought that people with BPD have altered functioning of the neurotransmitters serotonin, dopamine and noradrenaline. MRI scans further reveal that in many BPD patients, parts of the brain were either smaller than estimated or had unusual activity levels.
Holmes suggests (2002, p.35) that patients with severe personality disorders demonstrate insecure patterns of attachment. Most patients also seem to have experienced some form of maltreatment by parents (Beck et al, 2007, p.191). Lemma agrees (1996, p.190) and states that there is now substantial evidence supporting the significance of traumatic childhood backgrounds and distressing histories are common in those functioning at borderline level.
Royal College of Psychiatrists state (2013, web accessed March 2014) that research shows personality disorders fall into three groups and the accepted criteria for diagnosis in England is The American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in which BPD (2013, p.659) is categorized under Cluster B category: dramatic, emotional or erratic.
DSM-5, APA (2013, p.663) define the main feature of BPD as ‘a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts’. For a diagnosis, DSM-5, APA (2013, p.663) state that five of the following must be present: (1) Frantic efforts to avoid abandonment. (2) Patterns of unstable, intense relationships alternating between idealization and devaluation. (3) Identity disturbance. (4) Impulsivity in at least two potentially self-damaging areas. (5) Repeated suicidal behavior, threats or self-mutilation. (6) Affective instability. (7) Chronic feelings of emptiness. (8) Intense anger or difficulty controlling anger and (9) Stress-related paranoid ideation or severe dissociative symptoms.
DSM-5, APA (2013, p.761) further proposes an alternative model in which disorders are characterized by impairments in personality functioning. Here, the DSM-5, APA (2013, p.766-767) diagnostic criteria are subdivided into two categories. In category A the criteria are characteristic difficulties in two or more of four areas: identity, self-direction, empathy and intimacy. In category B the criteria are four or more of seven pathological personality traits (one of which must be either impulsivity, risk taking or hostility): emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, risk taking and hostility.
An alternative diagnostic measure is the WHO, International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10), (2010, web accessed March 2014) and although BPD is not identified as a disorder, there is a disorder that is conceptually similar called anEmotionally Unstable Personality Disorder. This has two subtypes, the impulsive type and the borderline type.
In contrast, Linehan and Dexter-Mazza (2008, p.366) have summarized the diagnostic criteria into five specific domains; emotional dysregulation, behavioral dysregulation, cognitive dysregulation, dysregulation of the sense of self and interpersonal dysregulation.
The Waverley Integrative Framework’s five areas of functioning.
In looking at how BPD affects the five areas of functioning, Kallmier suggests (2011, p.73) that what occurs in one area will affect all other areas as each is inseparably integrated. Beck et al believe (2007, p.187) that BPD pervades many aspects of functioning including relational, self-image, affect and behaviour. Although all interlinked, in order to conceptualise BPD, each area of functioning is considered in turn :
Physical: Kallmier highlights (2011, p.122) the interaction between psychological and physical problems. BPD affects the physical area of functioning and DSM-5, APA suggest (2013, p.664) that individuals may binge eat, abuse substances, behave recklessly and display repeated suicidal or self-mutilating behaviour. In addition to this Salters-Pedneault argue (2009, web accessed March 2014) that BPD is associated with many serious health conditions such as chronic pain, fibromyalgia, chronic fatigue syndrome, arthritis, obesity, and diabetes.
Emotional: Kallmier argues (2011, p.110) that emotions are closely linked to thought processes and are often the result of interpretation and reaction to life experiences. Cowen, Harrison and Burns confirm (2012, p.138) that individuals with BPD are overwhelmed and dominated by intense, fluctuating emotions and are continually disappointed in attempts to gain affection and intimacy. DSM-5, APA add (2013, p.664) that individuals can further experience periods of anger, panic, despair as well as chronic feelings of emptiness. Lemma (1996, p.189) describes feelings as ‘impulsive and unpredictable’ and Lineham and Dexter-Mazza support (2008, p.366) this in saying that emotional responses are reactive.
Volitional: Kallmier believes (2011, p.101) that choice affects others and that choices always have consequences, some of which have far-reaching effects on the life of the individual as well as on the lives of others. Individuals with BPD generally have poor judgement in lifestyle choices and as per the DSM-5, APA (2013, p.766) exhibit instability in areas of goal setting, ambitions, values and career planning. DSM-5, APA add (2013, p.767) that behaviour is often impulsive and engagement in dangerous and potentially self-damaging activities is a common factor. DSM-5, APA (2013, p.665) further states that individuals also display a pattern of undermining self just as a goal is about to be reached. Linehan and Dexter-Mazza add (2008, p.366) that individuals exhibit behavioural dysregulation with extreme destructive, impulsive behaviour.
Rotational: Kallmier believes (2011, p.94) that many individuals have developed unhelpful and damaging, recurring thought patterns which result in self-protective strategies. Linehan and Dexter-Mazza add (2008, p.366) that individuals with BPD can experience transitory nonpsychotic cognitive-dysregulation such as depersonalisation, dissociation and delusions. BPD further affects the rational area of functioning and Beck et al add (2007, p.192) that characteristic of BPD’s are specific assumptions of which the themes are loneliness, unlovable, rejection, abandonment, viewing self as bad and a sense of being deserving of punishment. DSM-5, APA state (2013, p.664) that expressions of anger can often be followed by feelings of guilt and shame which contribute to thoughts of being evil. DSM-5, APA add (2013, p.663) that individuals will make desperate attempts to avoid real or imagined abandonment.
Spiritual: Hughes argues (2002, p.137) that God has built into each individual, a desire for relationship with Him. Kallmier adds (2011, p.78) that individuals are created for a dependant and intimate relationship with God. This would prove to be difficult for individuals with BPD and DSM-5, APA (2013, p.664) reinforce this in arguing that individuals experience patterns of unstable and intense relationships and are prone to dramatic changes in their views of others. Holmes states (2002, p.31) that BPD patients are likely to be assessed as having a disorganised attachment style on the Adult Attachment Interview. Gerhardt adds (2008, p.153) that fear is very often a factor of a ‘disorganised’ baby’s experience due to inconsistent care.
It can therefore be concluded that this disorder has the potential to adversely affect all five areas of functioning.
In looking at how research informs practice when working with a client with BPD, outcomes vary. Cooper states (2013, p.43) that recent research for the treatment for BPD show psychodynamic treatment programmes to have notable results with reduced use of medication, fewer outpatient visits and lowered depression but adds that Dialectic Behaviour Therapy (DBT) has proved to be effective in reducing self-harming and parasuicidal behaviours.
Swenson (2014, in Hopwood et al, 2014, p.108) describes DBT as both life enhancement therapy and suicide prevention therapy. By encouraging the client to put a life worth living into place, suicide as a necessary destination is eliminated.
Research also supports the effectiveness of other therapies. Winter, Bradshaw, Bunn and Wellsted argue (2013, p.174) that outcomes show that in suicide prevention a range of therapies should be provided in order to match client preferences and that there is no justification in limiting therapy to only the more researched therapies such as DBT.
Bellino, Bozzatello, Blandamura and Bogetto (2010, p.15) dispute this and argue that psychodynamic therapy is recommended for BPD on the grounds of the positive results of several randomized controlled trials. They add that DBT has been found to be effective in the treatment of suicidal attempts, but is not effective in reducing depressive symptoms.
In discussing how research informs practice in terms of the therapeutic relationship, The British Psychological Society (BPS) state (2009, p.25) that 6% to 8% of BPD patients can be associated with insecure attachment with indications of disorganisation. A study conducted by Bedics, Atkins, Comtois and Linehan (2012, p.66) shows positive change during DBT and outcomes support the importance of affirmation and control in the therapeutic relationship.
Attachment type further impacts on the counselling process and in an interview based research study conducted in Germany (Strauss, Mestel and Kirchmann, 2013, p.282) the importance of counsellors focusing on attachment when planning interventions is highlighted. Results show that features of preoccupied/ambivalent attachment were less significant after seven weeks of therapy in women with BPD.
In briefly looking at how research informs practice in terms of the impact on the counsellor, Fleet and Mintz find (2013, p.45) that a range of intense emotions are experienced by counsellors working with clients who intentionally self-harm. As a result, counsellors could have a tendency to avoid focusing on the issue of self-harm and could even disassociate from the client.
In conclusion, there seems to be no hard and fast evidence to support the use of any one type of therapeutic approach when working with BPD and as this disorder affects all five areas of functioning, the Waverley Integrative Framework could prove to be an effective model of counselling.
Impact of medication on the counselling process.
BPS state (2009, p.26) that it is common practice for psychiatrists to prescribe antidepressants, mood-stabilisers or antipsychotics although no single psychotropic drug is specifically licenced for the management of BPD. Taylor, Paton and Kapur state (2011, p.443) that during periods of BPD crisis, drugs may prove useful but warn of the side effects. Cowen, Harrison and Burns add (2012, p.147) that psychiatric drug treatments could affect the biological basis of a personality disorder or could have a non-specific effect on anxiety, aggression or other symptoms. Linehan and Dexter-Mazza advise (2008, p.368) that BPD clients often abuse or overdose prescribed drugs and may experience unintended effects of these drugs.
Hammersley and Beeley state (2006, p.211) that the side effects of medication affect the counselling process and clients are often unaware of disadvantages. Drugs can limit the ability to think and may present side-effects that could be seen as part of the presenting problem.
Cowen, Harrison and Burns state (2012, p. 147) that the antidepressant, Amitriptyline has been tested as a treatment for BPD’s with some patients responding well and others not at all. The possible positive impact of this on the counselling process is highlighted by Hammersley and Beeley who state (2006, p.214) that clients can make therapeutic gains whilst on antidepressants. These would however need to be discontinued prior to ending therapy in order for repressed issues to come to the surface and to ensure that all issues had been fully resolved.
Regarding mood-stabilizers, Cowen, Harrison and Burns present (2012, p. 147) a view that anticonvulsive mood stabilizers could benefit a number of aspects of BPD including affective dysregulation and impulsive behaviour. There are reports of improvement in aggression, depression and general symptomology. Mood stabilizers could however impact on the counselling process and Taylor, Paton and Kapur state (2011, p.125) that side effects of Valproate include lethargy and confusion. This would make the active participation of the client in the counselling process difficult.
Cowen, Harrison and Burns add (2012, p.147) that there is some evidence that antipsychotic drugs could enhance some symptom clusters in BPD patients such as affective dysregulation, impulsive behaviour and cognitive perceptual disturbances. Hammersley and Beeley suggest (2006, p.214) that the side effects can both mimic psychological symptoms and interfere with the counselling process. Clients can appear distant, therapeutically inaccessible and be unable to retain gains or recall work from previous sessions.
In conclusion, Hammersley and Beeley state (2006, p.214) that rather than help the counselling process, drugs could perpetuate the tendency for clients to depend on external means as a way of coping and progress made could be attributed to the drugs rather than to the clients own efforts or the counselling process.
Critical evaluation of the use of a medical model.
In critically evaluating the use of a medical model, Freeth states (2007, p.33) that diagnosis is essential in order for a patient to receive support and correct treatment. NHS Choices (2012b, web accessed March 2014) recommends BPD patients be treated by community mental health teams (CMHTs) which provide daily support. Without diagnosis, this would not be possible.
There is however some controversy in defining the exact criteria for diagnosis and as shown earlier, the DSM-5, APA presents (2013, p.761) an alternative model in which the aim is to address the weaknesses in the existing approach. With the existence of two models an opportunity now exists for further research to compare the two and as well as to compare alternative diagnostic options (Skodol et al, 2013 p.348). Proctor concurs (2010, p.21) that the diagnosing of any disorder is subjective and although biological causes are assumed there is no physical test to establish the presence of mental illness.
Cowen, Harrison and Burns suggest (2012, p.139) that the overall criteria still remains unsatisfactory for BPD as when this was introduced into the classification system the diagnosis was applicable to young women. In addition, patients who meet the criteria for BPD also meet criteria for histrionic, narcissistic and anti-social personality disorder.
In comparing alternate diagnostic models, Cowen, Harrison and Burns (2012, p.139) highlight the differences in the names adopted by the DSM and the ICD-10 and show that several features of the ICD-10 Impulsive Type are also present in the DSM diagnostic criteria for BPD. Research studies also show The CORE Outcome Measure (CORE-10) to be an acceptable assessment measure being practical to use in primary care settings (Barkham et al, 2013, p.3).
In a critique of the proposed revisions in the APA, DSM-5, Jackson argues (2012, p.4) that psychiatric diagnoses have been applied to seemingly ‘normal’ emotions. Jackson adds (2012, p.4) that by placing the problem in the individual, other possible causal factors are overlooked.
Medical models do not take into account cultural diversity and Lemma suggests (1996, p.15) that research into the different conceptualizations show that what is defined as pathological is shaped by cultural definitions, social identities and role expectations. Jackson adds (2012, p.8) that in the DSM-5, individuals do not seem to be able to just be sad as sadness is classified as depression and shyness as social anxiety disorder. Further to this, there is the potential for the DSM-5 to promote the medicalization of normality by the lowering of some diagnostic thresholds (Welch et al, 2013, p.167).
In conclusion, whilst there seems to be a lot of controversy regarding the use of medical models Freeth suggests (2007, p.31) that with the increasing complexity it is becoming more important for counsellors to recognize the values that underpin thinking and to strive towards conceptual clarity by examining the models that inform practice.
Skills that facilitate change and when referral may be necessary.
In evaluating how counselling skills could be used effectively to facilitate therapeutic change it is important that all five areas of the BPDs areas of functioning be addressed. Linehan and Dexter-Mazza specify (2008, p.390) eight specific strategies that could possibly address these: (1) the use of paradox, (2) metaphor, (3) playing the role of devil’s advocate, (4) extending, (5) activation of the ‘wise-mind’ in the client, (6) turning negatives into positives,(7) allowing natural chance and (8) dialectic assessing.
Because of the problematic behavioural patterns of BPD clients, Kreisman and Straus recommend (1991, p.99) a method of communication that can also be used by therapists. This method, described as ‘Support Empathy Truth’ (SET) helps in containing the overwhelming emotions experienced by BPDs. Beck et al add (2007, p.206) that empathetic listening, validating feelings and requesting clients to expound on what emotions mean is also important as an intervention.
In looking at the intervention of challenge, Joines and Stewart advise (2008, p.238) that any form of aggressive confrontation is to be avoided and further advise therapists not to focus on BPD memories or dreams.
Bedics, Atkins, Comtois and Linehan state (2012, p.67) that the relationship between therapist and patient is considered to be therapeutic and can also provide a means for therapists to balance acceptance and change thereby validating patient experience and correcting dysfunctional behaviour. Joines and Stewart add (2008, p.236) that the central focus in the treatment of personality disorders is the therapeutic relationship which offers a corrective experience as well as the opportunity for the client to experience an individual who is emotionally available.
As mentioned earlier, BPDs experience intense emotions surrounding the fear of perceived abandonment and exhibit patterns of unstable and intense relationships. Beck et al suggest (2007, p.212) that BPS patients learn to tolerate strong negative emotion by the use of exposure techniques such as letter writing.
In dealing with a BPD client’s traumatic childhood, an intervention a counsellor could use would be imaginal rescripting or historical role play but Beck et al advise (2007, p.210) that patients are not always powerful enough to intervene for themselves and would need someone else to fulfil this role.
Because of the BPDs tendency to self-harm McKay, Wood and Brantley suggest (2007, p.12) that one of the most important aspects of therapy is to assist in stopping self-destructive behaviours. There are various distraction techniques and actions that can be discussed with the client and McKay, Wood and Brantley list (2007, p.13) non-harming activities such as holding an ice cube and squeezing it; writing with a red felt-tip pen instead of cutting and snapping a rubber band against the wrist amongst others.
Therapists can begin to make practical suggestions to early in therapy and this is ill advised as it would counteract the creation of the client’s attitude towards the experiencing of emotions (Beck et al, 2007, p.207).
Because of the complexity of working with BPD clients, support by CMHTs (NHS Choices, 2012b, web accessed March 2014) may be necessary. BPS (2009, p.14) recommend that a BPD in crisis be referred to a community mental health service when levels of distress and/or the risk to self or others increase. When levels of distress and/or the risk to self or others has not subsided in spite of attempts to reduce anxiety and improve coping skills, and finally when further help from specialist services has been requested by the client.
The overall management of a BPD client is complex and Beck et al confirm (2007, p.196) that as well as BPD being viewed as one of the most severe personality disorders, the high comorbidity associated with BPD adds further complications.
Fleet and Mintz highlight (2013, p.44) the impact these clients have on counsellors and state that the complexity of this phenomenon aggravates counsellor anxiety. Good supervision is therefore vital and Gabbard and Wilkinson state (2000, p.202) that counsellors can often struggle to process the powerful projective identification of BPD clients. Supervision is therefore invaluable and Gabbard and Wilkinson add (2000, p.203) that therapists can find themselves feeling challenged and isolated when being controlled or bullied by a BPD client. The role of the supervisor is therefore to act as an anchor when the therapist is overwhelmed by the demands of a BPD client.
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About Jane Bronwyn Holder
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