Tackling the Emotions in Borderline Personality Disorder

The newest therapy for one of psychology's most challenging disorders

Posted Jun 16, 2015

If you or someone you know has Borderline Personality Disorder (BPD), then you’re well aware of how difficult life can be. Within the field of psychopathology, personality disorders are thought of as long-standing disturbances in a person’s sense of self. BPD got its somewhat curious name from the notion that it was on the “border” between neurosis and psychosis.

Currently, psychiatric diagnosis no longer includes the term “neurosis,” but the term "borderline" remains in place. In a way, it still remains appropriate. People with this disorder do have difficulties establishing boundaries between themselves and others so you can think of the “border” as one that normally separates people’s identities. You know that you’re you and not someone else because you have a boundary around your self-definition. In BPD, this distinction becomes blurred or even lost.

Extensive research on this personality disorder suggests that some of its origins may be traced to faulty relationships between a child and caregiver that develop early in a person’s life. The majority of people develop a secure attachment style in which they internalize what’s called a “model” of a healthy relationship. Their caregiver gave them, more or less, the right amount of support balanced against the chance to develop their independent identities.

In BPD, attachment processes go awry. The child forms a faulty model of the self and relationships. It’s possible this happens because the caregiver gives too much support, to the point of being intrusive, or not enough, to the point of being neglectful.  Without this normal healthy model of the self and relationships, the individual’s identity starts out in life being disturbed and distorted.

The history of therapeutic approaches to treating people with borderline personality is marked by major shifts in emphasis. In the heyday of psychoanalysis, this was the preferred method of treatment. Given that the disorder seems to arise from faulty child-caregiver relationships, such an approach certainly made sense. However, with the advent of cognitive-behavioral approaches to therapy, clinicians began to report that focusing on the individual’s disturbed thoughts and actions could also prove helpful.

Dialectical Behavioral Therapy (DBT) is somewhat related to the cognitive-behavioral tradition and is widely practiced. The goal of DBT is to help BPD clients become more effective at regulating their emotions through interactions with the therapist. One technique the DBT therapist might use is mindfulness, in which clients learn to identify their emotional state but not necessarily to act upon it.

Taking the mindfulness approach one step further, mentalization-based therapy (MBT) places almost exclusive emphasis on helping clients learn to identify and manage their emotions. Originally developed by University College London's Peter Fonagy and Anthony Bateman, and as described in an article by Australian psychiatrist Michael Daubney and Bateman, "mentalizing is the process by which we make sense of each other and ourselves…(that) renders subjective states and relationships intelligible” (p. 132).

Mentalizing allows you to form a sense of who you are and to provide a coherent account of your past relationships.  BPD, according to this view, occurs when the caregiver doesn’t “mirror” the child’s emotional experience. The world, in short, stops making sense to the child because the caregiver doesn't provide the necessary feedback for the child to be able to understand what he or she is feeling. Disturbances in attachment also lead the child to be overly sensitive to rejection or abandonment, two key emotional states in BPD.

As they grow older, people with BPD, according to Daubney and Bateman, remain unable to understand their own emotions and how those emotions relate to the reality of the outside world or what other people are feeling. If you are one of these individuals, for example, when someone leaves, even for reasons having nothing to do with you, the feeling of abandonment sweeps over you.  You assume that it’s because that person purposefully wants to hurt you.  You don’t recognize that other people have their own lives to lead and when this happens, it has nothing to do with you. Even the fact that you feel abandoned may be out of proportion with the reality of the situation.

MBT attempts to help people with BPD grab hold of their emotions through the steps of an “Intervention Spectrum.”  In the early steps, the therapist provides support and empathy, an essential ingredient of much psychotherapy.  Moving to next steps, therapists then help clients clarify and elaborate on what they’re feeling by putting their feelings at the moment into words. Now they can start to identify their own feelings and where those feelings come from. Finally, the client learns how to mentalize the relationship with the therapist as a model for mentalizing relationships with people in the client’s life outside of therapy.

In other words, in mentalization therapy, BPD clients become able to direct their attention toward how they’re feeling. Just as importantly, they learn to compare their feelings with the “reality” of the situation.  Instead of concluding that others are purposefully abandoning you, or even that they’re abandoning you at all, you recognize that your feeling of abandonment exists, but that it’s coming from you, not from the way you’re being treated by others.

Although the theoretical basis for MBT is rooted in early childhood experiences, the therapist focuses almost entirely on what’s happening in the moment, especially on what the client is feeling. Perhaps one analogy for MBT is personal training in the gym. A good trainer can watch each of your muscles as you perform an exercise and comment on which of your hundreds of muscles is moving too much or too little. Gradually, you learn the correct posture to have during an upright row or lunge because you can feel those muscles working within you.

As the evidence base for MBT grows, it will undoubtedly become more integrated into broader usage. Daubney and Bateman believe it eventually can be used for other disorders such as eating disorder, depression, and PTSD. The mentalizing process itself seems highly transferable to a variety of situations and people.

Even if you or those you’re close to don’t have BPD, it seems that there’s a valuable lesson to be learned from this approach. Becoming able to identify your feelings while they’re occurring can help you learn to adjust your reactions to the reality of a situation. Maybe your fury over being cut off in traffic by another driver has nothing to do with that other driver, but more to do with your hypersensitivity to feeling that others are taking advantage of you.  Perhaps the rage you experience when your partner fails to take out the trash is due not to the accumulation of garbage in the kitchen but to the feeling that your partner doesn’t really care about you or your home. Pulling that feeling out, examining it, and then seeing where it comes from can help you get control over it. As you do, your ability to understand yourself and your relationships may show lasting gains.

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Copyright Susan Krauss Whitbourne 2015

Reference:

Daubney, M., & Bateman, A. (2015). Mentalization-based therapy (MBT): An overview. Australasian Psychiatry, 23(2), 132-135. doi:10.1177/1039856214566830