In part I, I wrote about receiving a BPD diagnosis. A diagnosis opens the door to treatments that fit. This is an important first step, but what’s next? What do we know about treatments and how can they be helpful?
What we know about working with BPD
At its heart, BPD is pattern of strained relationships. This means that people with BPD have difficulty with relationships within themselves, with others, and with the world. At the root of these problems is a troubled relationship with emotions. People with BPD experience their feelings as more intense, urgent, and often unbearable. It is common for these individuals to experience a lot of distress, and come to mental health professionals feeling desperate for some relief.
As mentioned in Part 1, the intensity of the distress can have an impact on the relationship with health care professionals, leaving the parties involved feeling frustrated and helpless. As a result, and in an attempt to reduce the suffering, the person seeking help may end up being prescribed lots of different medications—many with unpleasant side effects. Although in some cases, certain medications might help with some of the symptoms, we have more recently learned that the best approach for treating BPD is not pharmacological, but rather involves effective psychotherapy (Paris, 2017).
In the 1990s, Marsha Linehan developed a treatment specifically to help individuals with BPD understand and change their relationship with themselves and the emotions they experience as mixed and intense. She called it Dialectical Behaviour Therapy (DBT), to highlight the importance of the “dialectical”, or “the plaid” which refers to working with opposite forces. For example, this can mean accepting one’s emotions and experiences as valid, while simultaneously working to change behaviours that have negative consequences (to read more about the “Plaid” and DBT, check out Michelle’s Blog post). With robust research support, DBT has gained significant recognition. It is effective, accessible, and popular, which has led many health care professionals and people seeking therapy to equate BPD treatment with DBT.
Although DBT has virtually become synonymous with BPD treatment, it is not the only psychological treatment available and appropriate for BPD. Many other approaches to therapy use other lenses to address BPD difficulties and have been shown to be effective. Mentalization-based therapy (MBT) is a particularly good fit because it aims to help people understand their internal experiences in order to change their relationships with themselves, with others, and the world. Similarly, approaches that focus on emotions (e.g., Emotion-Focused Therapy-EFT) or relationships (e.g., Transference-Focused Psychotherapy-TFP) have also garnered research support as effective in addressing the challenges that arise with BPD (Paris, 2017).
While there are lots of 3-letter treatment options, each with its own angle, there is not much evidence to suggest that one unique type of therapy addressing personality-related difficulties is actually superior than others for BPD (Livesley, Dimaggio & Clarkin, 2015). Among many researchers and clinicians specializing in BPD, there is some consensus that the best approach is to offer therapy that integrates relevant ideas from all approaches (Livesley, 2017; Nelson et al., 2017). When it comes to therapies addressing personality disorders, no one “brand name” does better than others (Paris, 2017). This is good news, because it means most therapy approaches for BPD work, and integrating more than one is even better.
What’s important in BPD treatment
Knowing that integrating relevant ideas from different approaches is what seems to work best, how do we know which ideas to integrate?
First, since an intense experience of emotions is often what drives a lot of the difficulties, working to identify, understand and manage emotions is critical. Managing emotions might mean learning to take a step back, observe, and experience—survive the emotion without reacting. This process also helps reduce impulsivity by creating a space to be purposeful rather than immediately acting on urge. I like to think of it as having conversations with emotions. With time, these conversations shift the relationship with one’s internal experience and reduce the chaos.
Another piece of the puzzle is shifting one’s relationship with other people. This may involve learning about other people’s emotions and intentions, and about the subtleties of relationships more broadly. It often involves understanding physical, personal, and emotional boundaries (For more on boundaries, check out this blog post) as well as what makes a relationship sustainable.
There are other elements that we know contribute to progress in therapy for BPD regardless of the content of therapy or approach. This list includes having a consistent and predictable structure (e.g., regular, weekly therapy sessions), building motivation for change, and working toward self-reflection (Livesley, 2017).
Beyond all these factors, if you are looking for therapy that works, good fit with a therapist and investment in the journey itself are crucial to making therapy work. What does this therapeutic effort look like and what does this all mean about being in therapy when you have BPD?
How to be in therapy when you have BPD
Give the process a chance. Lots of big feelings might come up as you begin, challenge yourself to get started even when it’s a substantial effort that feels uncomfortable at first.
Once you’ve found a fit, stick to it and be consistent in order to build momentum. At the beginning, go weekly—even when you don’t feel like it, or if you have some other reason not to go. Therapy is a big investment of time, money, and emotional energy. If you allow yourself to build momentum and persevere, you will make it a valuable (and cost-effective) experience of personal growth.
Tolerate difficult emotions as they come up: Showing yourself you can survive intense and difficult emotions is an important part of the process.
Trust your gut, yet still challenge yourself. Ask yourself what your emotion is telling you, and whether rolling with the discomfort could possibly be beneficial to you. For example, it might look like facing your fear, giving a person a chance even if you’re angry, or getting out of bed even though you’re sad.
Focus less on the what and more on the how. Listen to the words of your stories and take a step back to understand the big picture in what’s going on. Use this often in your therapy.
Open up to talking about your emotions in therapy, especially when they have to do with your therapist. Tell them if you’re scared to talk about something, if you’ve felt sad or hurt after they said something, if you’re angry with them, etc. Lots of old and new feelings can come up in the therapeutic relationship. It’s your opportunity to work out the messy parts with someone who is qualified to help you.
Danit Nitka received her PhD from the Clinical and Research Psychology program at Concordia University in Montreal, Quebec, and is a psychologist at Connecte Montreal Psychology Group. The team at Connecte loves writing about ways to boost our mental health and bring psychology into our everyday lives. For more helpful tips, check out Connecte’s blogs, podcast, follow @connectepsychology on Instagram or like us on Facebook.
Livesley, W. J., Dimaggio, G., & Clarkin, J. F. (Eds.). (2015). Integrated treatment for personality disorder: A modular approach. Guilford Publications.
Livesley, W. J. (2017). Integrated modular treatment for borderline personality disorder: A practical guide to combining effective treatment methods. Cambridge University Press.
Nelson, D. L., Beutler, L. E., & Castonguay, L. G. (2012). Psychotherapy integration in the treatment of personality disorders: A commentary. Journal of personality disorders, 26(1), 7-16.
Paris, J. (2017). Stepped care for borderline personality disorder: making treatment brief, effective, and accessible. Academic Press.