(Addendum: Some commenters have pointed out that my title on this post - we are limited to very few words - seems to imply that patients with borderline personality disorder cannot get better. Just to clarify, of course they can get better - why would I be a therapist for them if I thought they couldn't? The post is about why it is so difficult).
People who have dealt with others who have been diagnosed with borderline personality disorder (BPD) often wonder why those folks persist in their often infuriating as well as self-destructive behavior. It just seems so obvious that they are making themselves as well as everyone who cares about them completely miserable.
When I first started to treat people with BPD way back in the mid 1970's, I know I wondered about it. These patients were not psychotic, nor were they stupid, so why did they persist in dysfunctional behaviors in the face of overwhelming evidence of the consequences?
The common psychoanalytic models, some still in use, seem to presume that these patients are just too stupid to see what is happening due to their tendency to "distort" everything. Well, sometimes they seemed to do that, but in fact, with a few tricks of the trade, it is not all that hard to get them to stop doing that. Something else is clearly going on.
In order to find out, I started asking them the "magic" question proposed by psychotherapy pioneer Alfred Adler: What would happen if I could wave a magic wand and you suddenly got better and stayed better?
At first, patients would often answer with such non-answers, "I'd just find some other way to screw things up" or "I cannot even imagine what that would be like." I would not accept those "answers" and pressed on.
When the real answers finally started to emerge, I was totally amazed. One thing that might happen if a patient with BPD got better: their families would run for the hills. Exile them. Shun them. Abandon them. Anyone wonder why those with BPD have "abandonment issues?" Wonder no more.
Interpersonal psychotherapy expert Lorna Smith Benjamin lists four characteristics she has observed in families that produce offspring with BPD. Two are relevant here:
1. Parental love and concern is elicited only by misery, sickness and debilitation.
2. Family chaos—The borderline individual is subtly blamed for problems or expected to exert control over them.
(The other two characteristics: 3. Episodes of traumatic abandonment are interspersed with periods of traumatic over-involvement, and 4. Efforts by the person with borderline disorder to establish autonomy are interpreted by the family as indicated disloyalty).
What I thought may be happening in families that produce children with BPD is that the family needs a black sheep, and the person with BPD has been elected—and then voluntarily continues—to play the part. If he or she finally stops playing the part, the family then shuns them. In this situation, the family is in effect punishing the BPD children for not being who the parents need them to be.
But abandonment is actually far from the worst nor the most likely outcome when patients start to act beter.
I found that something family therapy pioneer Murray Bowen had described (which was later mentioned by Marsha Linehan in a somewhat different context) was quite real—and I then discovered that the Bowen phenomenon was just the first thing that would begin to happen before things got far far worse.
I learned quite early on that the power of family members to invalidate anything a therapist tries to teach a patient should not be underestimated. As first pointed out by Dr. Bowen, they will literally gang up on a patient with messages that scream, when roughly translated, "You're wrong! Change back!" Previously uninvolved family members may come out of the woodwork, and previously sympathetic family members may suddenly turn on the patient and scream things like, "HOW CAN YOU TREAT YOUR MOTHER LIKE THAT!?!"
I dubbed this phenomenon "clustering." Try to imagine what it would be like if everyone you know and loved started to come after you like that. If you do not think you would wilt, you are kidding yourself. And that would be true even if you came from a family that was relatively functional to begin with. Imagine having been invalidated like that for your whole life.
As I said earlier, however, that would only be the first thing that would happen if someone with BPD started to act better. The next thing that happens is that the parents start to act out in alarming and frightening ways. I'm talking about such things as the parents making suicide threats or actual attempts, increasing their drug or alcohol abuse to higher and higher levels, worsening their level of domestic violence, throwing other family members out on the street penniless, or abusing or neglecting any children left in the home. You know—minor, inconsequential stuff.
Furthermore, as described by Lorna Smith Benjamin, all these problems would be blamed on the patient, who would be subtly expected to somehow exert control over them.
Think you would be able to turn your back on your family if all this happened to you? Very few can. Even if you could, it would only be because your family would, through their own behavior, engineer your dismissive attitude—so that you would not only continue to be their scapegoat, but so they could label you an uncaring S.O.B as well.
Americans like to think that they don't care what their families think of them. Horse manure!
In response to all of this, individuals with BPD usually start to actively undermine ("spoil") any efforts anyone might make to encourage them to continue with their "good" behavior —without telling anyone (including a therapist if they have one) about any of their family's reactive behavior—and revert right back to acting the way they had always done.