What to look for in Borderline Personality Disorder (BPD) therapy

You can identify with traits of Borderline Personality Disorder (BPD) without being officially diagnosed. This does not mean that what you experience is any less painful or valid. Recovery from Borderline Personality Disorder is difficult, but not impossible. Treatment for BPD is available and it is effective, but it may take time and effort to find the right therapist.

Borderline Personality Disorder (BPD) is also known as Emotional Dysregulation Disorder, or as ‘emotionally unstable personality disorder’ (World Health Organization, 1992). Despite being named as ‘personality disorder’ in the diagnostic manual, many have proposed that personality disorder is best understood as disorganisation of the capacity for regulating emotions. This means that one can sometimes experience emotions as spiralling out of control, overwhelming, and changing rapidly.

Emerging needs for new treatment possibilities

The shift in psychiatry from psychoanalytic to biological paradigm in recent years has radically changed the treatment protocol for people with BPD. Recent research challenges the old assumption that long term intensive treatment is essential for good outcomes; plus, it was found that therapies with various integrative modalities can have equally positive outcomes.

Several new forms of treatment for BPD have been developed over the past few years. Approaches that have been developed and subjected to outcome research have included Transference-focused therapy (Kernberg, 2001), Mentalization-based Treatment (MBT), Dialectic-Behavioral Therapy (DBT) (Linehan, 1993), and Cognitive Analytic Therapy (CAT) (Ryle, 1990).

Many of these new therapies for BPD share a theoretically coherent and manualised structure. Most commonly found within the NHS are DBT or MBT-informed models of care-coordinating or therapy. However, because of the limited availability of training opportunities, the place for these specialised therapies within generic mental health services remains in question.

In the real world, only a small percentage of individuals with BPD can have access to long-term treatment. As there is no evidence that any other types of therapy are particularly helpful, currently the NHS’s advice for the general public is for one to choose psychotherapy ‘based on a combination of personal preference’ and the availability of specific treatments in ones’ local area.

If you identify with traits of Borderline Personality Disorder but feel reluctant or are unable to access treatment in the NHS, the journey to recovery may feel lonely and confusing. Given the variety of therapeutic approaches, knowing what to look for in a therapist can be difficult. Existing research and literature into the essential therapeutic elements in successful treatment with BPD may be able to provide some guidance.

Four essential elements for successful treatment of Emotional Dysregulation Disorder

1. Therapist’s responsivity flexibility

Although it can be tempting to paint people with BPD with a single brush, considerable evidence suggests that the BPD diagnosis is highly heterogeneous. People with the same diagnosis may have different presenting issues, and therefore want different things from therapy. Real therapeutic work comes from working collaboratively, honouring both your goal and your therapist’s expertise.

Either across individuals or within one person, therapeutic goals should not be reducible to one theory-driven meta-goal. For instance, one cannot assume that the therapeutic goal of a client with BPD is ‘all about’ correcting dysfunctional cognitions or ‘all down to’ aligning self-concept. 

It is also likely that a person with BPD would have very different needs at different times. It is particularly crucial for the therapist to be flexible enough to tailor each session based on your affective state and arousal level. The therapist needs to be able to ‘meet’ you in terms of the intensity of feelings, whilst remaining centred and grounded. This can be a real challenge but is fundamental to a working relationship. For instance, when you reach out to your therapist in crisis, or in a heightened emotional state, her being cold and distant might leave you feeling rejected and abandoned. Yet, on the flip side, you don’t want your therapist to be so drawn into your emotional turmoil that she becomes just as lost.

2. Collaborative stance

On revision of the existing treatment protocol for BPD, client involvement is one of the most important factors for creating changes. Essentially, treatment for BPD would not succeed unless the therapeutic alliance is built on the agreement of therapeutic goals and strategies.

In other words, a case formulation should be a ‘shared understanding’ of the origin and nature of the presenting problems. It is not something that the therapist alone decide on, but an ongoing thread of discussion and negotiation.    

3. Your therapist needs to have faith

This refers to a hopeful outlook in both the prognosis for borderline personality disorder treatment in general and in your potential to change. Unfortunately, despite recent evidence, there are still clinicians who hold the view that personality disorder is ‘incurable’. This dogmatic belief needs to be challenged, but it should not be your job to prove your therapist wrong.

The BPD journey is a painful one, and there may be times when you feel hopeless; this is when your therapist can offer an alternative perspective, teach skills or provide a temporary holding environment. Your therapist may be more directive in offering guidance and advice in the beginning, especially if you did not have relevant containing parenting experience in early life.

However, just like a good parent, your therapist’s ultimate goal is to help you recognise your own strength and agency rather than fostering dependency. Your therapist is also there to help you recognise your uniqueness and abilities, and eventually make use of them. Eventually, you will be able to internalise the hope your therapist holds in recovery, and the faith your therapist has in you.

4. Emotional validation

Validation of your emotions is a central component for therapeutic alliance in all the empirically effective individual therapies for BPD. A therapist’s ability to resonate with your painful emotions and to tolerate the intensity of them can be transformative.

The therapist must show a willingness to mindfully explore the process and content within the therapeutic relationship, and demonstrate acceptance of a wide array of experiences, including the unpleasant ones. This does not mean agreeing with all that you do, especially when it comes to behaviours such as self-harming or disordered eating.

However, this does not take away the validity of the painful emotions behind these coping behaviours. By experiencing and learning that your feelings are tolerable within the relationship, you may gradually be able to develop the capacity to self-regulate in a healthy fashion.

Owing to the unique nature of BPD, effective treatments call for a high level of responsivity/flexibility from the therapist, a collaborative stance, trust and shared authority. These are perhaps essential qualities in all therapies but are particularly important for BPD clients. Psychotherapy for BPD should only be delivered by a trained professional. Do not be afraid to ask about their experience.

This article was written by Imi Lo.