Therapy for Borderline Personality: Why It Takes So Long

Fear, shame, and sheer complexity make therapy for BPD a game of 3-D chess.

Posted Sep 08, 2017

Wikimedia Commons,Sisyphus Tries the Other Way by Dam Beebe/Ecotrust, CC by Attributes Share Alike 3.0
Source: Wikimedia Commons,Sisyphus Tries the Other Way by Dam Beebe/Ecotrust, CC by Attributes Share Alike 3.0

The type of psychotherapy I do with my patients who suffer from personality disorders is called Unified Therapy. Most of the psychotherapy treatment protocols for significant personality disorders practiced today require long-term therapy, and my model is no exception. 

Unified Therapy integrates ideas from most of the main schools of psychotherapy about both the causes and the treatment of significant and ongoing self-destructive behavior patterns that lead to chronic anxiety or mood problems. 

Briefly, it posits that the parents in the patient's family of origin experience ambivalence and emotional conflicts about the demands of certain family roles that they believe are required of them. They had learned these roles from their own families of origin, and the roles were initially culturally determined.

As a consequence of this ambivalence, they make contradictory demands on, and give double messages to other members of their own families about what is expected of them. The ambivalence in the parents, in turn, is created by learned and ingrained family rules which became obsolete when the ambient culture changed quickly. In other words, the family rules lag behind changes in the requirements of the ambient culture.

The double messages are believed to reinforce (in the behaviorist sense and on a variable intermittent reinforcement schedule) the patient's conflicts over how to behave and the resultant dysfunctional behavior. The patient's responsive behavior then simultaneously reinforces ambivalent, dysfunctional behavior in the rest of the family.

It usually takes between 70 and 120 sessions - sometimes more - which take place at a frequency of once every two weeks (most other therapy paradigms are based on weekly sessions). I wish I knew of a faster way to help these patients. If I could find one, I would be the first to employ it.

So why does it take so long? 

The first reason is that the therapist has to gain the trust of the patient in the beginning of treatment. Most of these patients feel that they have been betrayed in one way or another by their own close family members - the very people whom they are supposed to be able to trust the most. Furthermore, they feel ashamed of both their own and their family's behavior.  

Even more important, they feel guilty if they don't keep the family's deep dark secrets to themselves.  

Given their experience, they would have to be idiots to blindly trust a therapist, a complete stranger, right out of the box. 

Even after they begin to open up, it takes a while for the patient and therapist to get to the bottom of what motivates all of the patient's family's bewildering behavior. Even figuring out the right questions to pose can be a challenge for the therapist. 

The reasons that problematic patterns exist usually involve historical events that have taken place over at least a couple of generations, and sometimes start even further back than that. Important historical events may not even be discoverable because there are no longer any relatives alive who are old enough to know about them.

However, that is not the primary reason for the length of therapy. The main reason is that personality disorders are not only highly complex and complicated, but extremely well ingrained into the brains of sufferers. Neuroscience has shown that behavioral reactions to the social environment are literally branded into the primitive part of our brains known as the limbic system over many years due to repetitive interactions with parents and/or other primary caretakers.

Patients are sometimes able to change their problematic behaviors fairly quickly over the short term, but the changes do not last. Doing short-term interventions may seem to work if one does not follow the patient for very long, but these interventions work sort of like a fad diet. Those who go on fad diets may lose a lot of weight quickly, but if you look at them a couple of years later, they have usually gained it all back. Often they gain back even more weight than they initially lost.  

For this reason, psychotherapy outcome studies that do not look at behavior patterns and psychological symptoms two years after treatment has ended can be highly misleading.

Dealing with the family members who feed into the patient's self-destructive behavior, whether inadvertently or on purpose, leads to a whole new level of complexity. Their behavior patterns are also branded into their brains for the very same reasons! Not only that, but as family-systems therapists first pointed out decades ago, the whole family automatically pushes back against someone attempting to change the old patterns. 

This is called family homeostasis. Everyone literally gangs up on the poor patient trying to change patterns with invalidation of his or her new behavior. It is accompanied by the implicit instruction, "You are wrong, change back." I listed some of the ways this is done in a previous post.

Altering these dynamic family interactions is like a game of three-dimensional chess, but with even more dimensions. Whenever I coach a patient on strategies concerning how to respond to a parent's problematic behavior, each move leads to a countermove on the part of the parent which is designed to keep everything unchanged. 

These countermoves do not necessarily occur immediately after the patient initially does what we have decided on in therapy sessions, but may occur suddenly at any time - often when least expected.

For therapy to work, the therapist and patient have to come up with a whole series of moves and responses in order to address each of the countermoves. Countermoves may also include a parent trying to rope in a third party, such as the other parent or a sibling. The patient and I try to anticipate two or three of these moves in this game in advance.

Furthermore, all of us have a seeming natural reluctance to discuss sensitive family dynamics with our parents and other primary attachment figures, so this whole process is usually interrupted by significant periods of time in which patients procrastinate or resist doing their homework assignments.

Therapy therefore requires a major investment of time, money and energy. It requires courage, nuance and subtlety as well. The alternative, however, is not only the continuation of the patient's personal misery, but the likelihood that dysfunctional patterns will be passed through to future generations of the patient's family.