Healing Borderline Personality Disorder (Often, Managing It)

This is an article in my Catholic Healing Series, where I talk about the most prevalent mental health issues of our time, who the best thinkers are, what the theory is, and how to heal the issue.  If you enjoy this, feel free to check out other articles or videos!

The Issue

About 4.5 Million people in the United States have borderline personality disorder.  Borderline personality disorder involves intense mood swings, impulsivity, self-harm, and a fear of abandonment.  Splitting, also known as idealization and devaluation, is very common.  In an effort to avoid the confrontation of difficult feelings in a relationship, a person with borderline personality disorder defines others as being all good or all bad.  This gives the borderline person an excuse to idealize and overlook tough issues or an excuse to devalue the other person and flee from the challenging relationship situation.  Borderline personality disorder often causes relationship issues between a person and family of origin or between a person and her or his spouse.  While borderline personality disorder often is triggered by childhood trauma, it is possible to occur due to genetic predisposition alone.  Borderline personality disorder is caused by issues with serotonin levels in the brain, and it is likely that dopamine dysfunction also may occur.  It is a myth that only women have borderline personality disorder.  At least one third of people with borderline personality disorder are men.

The Thinkers

Dr. Chris Aiken, MD is a psychiatrist and psychotherapist who became a leader in the field after encountering friends who suffered from depression and mood issues.  His personal experience led him on a lifelong journey of helping people with depression and mood disorders to heal.  His personality is very telling in terms of understanding what is required to heal from depression and mood disorders.  He is very calm and methodical.  A lot of what is required to heal these issues involves taking a systematic approach that focuses on what is effective.  There needs to be a healthy skepticism of thoughts and emotions in the world of depression and mood.  Not all of a person’s thoughts and emotions can be trusted, and in many ways, thoughts and emotions need to be interviewed to see if they are helpful.  Aiken favors an approach that is mindful.  This approach fosters awareness and also can focus on behavioral activation to help people engage in more effective behaviors—in many ways, less “affective” and more “effective.” Dr. Marsha Linehan, PhD developed Dialectical Behavioral Therapy (DBT).  She is creative, thoughtful, and empathetic.  In terms of DBT, she describes it as extremely validating behavioral therapy.  It offers people validation and empathy, while also giving them practical tools for effecting change in their lives. Katelyn Baxter-Musser, LCSW is vibrant, upbeat, and relational.  She has a gift for taking the concepts of DBT and making them accessible to clients, even clients who are under a lot of stress due to crisis situations. Dr. Janina Fisher, PhD is a former Harvard Professor who likely has done more to help people understand and to heal from shame than any other figure in the field.  In the world of psychology that is full of surprising and eccentric figures, Fisher could be the most surprising and most eccentric.  A good friend of Dr. Bessel van der Kolk, MD, who also is known for his personality, Janina Fisher is soft and gentle in affect.  Very importantly, she giggles a lot.  At the same time, she makes jokes of all kinds of situations that can be darkly humorous.  Then, she giggles more.  What she is doing is, in fact, extremely therapeutic.  Fisher has discovered how to help people laugh at themselves and situations so that they can confront them with courage and a healthy sense of experiment.  She specializes in working with people who struggle with perspective, and laughter is the medicine that provides a healthy sense of objectivity.  In terms of Borderline Personality Disorder, she artfully uses Internal Family Systems Interventions to help people understand parts of the self and to partner with them.  This is particularly helpful in terms of helping people to bond with parts of the self that have good intentions but that offer destructive strategies as solutions.  After people connect with these parts in curiosity and understand them, they are able to collaborate with them to pursue healthier strategies. Healing Borderline Personality Disorder (Often, Managing It) Disclaimer:  these are just some of the tools that can be used with borderline personality disorder.  Also, I cannot guarantee healing or benefit.  This entire article represents my opinions and applications of the tools, nothing more and nothing less.  This article does not constitute medical, psychological, mental health, or any other advice.

Locating a Place on the Spectrum

Although Borderline Personality Disorder is a single diagnosis, it can be helpful to think of it as a spectrum disorder.  That means that some people who have borderline personality disorder have milder symptoms than others.  People in the middle and high end of the spectrum are more likely to benefit from Intensive Outpatient Programs (IOPs) and medication.  People on the lower end of the spectrum are more likely to manage the personality disorder with mindfulness and skills (although sometimes medication still helps).

DBT Skills One:  Mindfulness

Mindfulness helps people to observe, describe, and participate in the present moment.  It can help to track how a person is feeling throughout the day on a 10 point scale with 1 being totally calm and 10 being totally impulsive or totally depressed.  It can help to track about four times per day how a person is feeling and why.  Over time, a person will get a sense of what triggers are, because triggers will be at places where numbers spike.  Also, a person will get a sense of what her or his baseline stress or depression is.  That will be the average of all numbers.  Mindfulness can also be helpful when considering what things people are doing to improve situations.  What are things that the person is doing to improve depression or impulsivity that are effective? Mindfulness can be very somatic (body oriented) when it comes to DBT.  A person can sit and mindfully breathe.  She or he can also check in throughout the day with how she or he is doing in terms of body scans.  Wherever there is tension in the body, a person can focus on relaxing it.  Mindful listening, eating, and even walking can help a person to live and respond to life more effectively and intentionally. In terms of how a person can interact with the environment, here is a good progression.  First, a person can simply observe what is happening internally (thoughts and feelings) and externally (in the situation around the self).  Then, a person can describe what she or he is seeing in a non-judgmental way.  Third, a person can participate by engaging fully in the present moment.  Fourth, a person can acknowledge thoughts and feelings without labeling them as good or bad.  Finally, a person can focus attention on one thing at a time. Fear of abandonment is the hallmark of borderline personality disorder.  Mindfulness can help to shed light on aspects of this symptom.  When is it that feelings of fear of abandonment arise?  Those likely are triggers.  When does a person feel impulsive?  There might be triggers that lead to that impulsivity. In interpersonal relationships, it can be helpful to consider what is challenging.  Whenever a person feels upset, which can be an intense experience in the case of borderline personality disorder, she or he can ask why.  Then, she or he can consider what she feels like doing.  Often, she or he will feel like devaluing and fleeing.  Is that an effective strategy?  Is that going to lead to the outcome that the person is looking for? Does the person experience suicide ideation or does she or he engage in self harm?  What needs do those activities meet?  What are positive activities that meet those needs?  Here it can help to use a parts approach.  The suicidal part of the person has a harmful strategy, but it has a good intention.  What is it trying to achieve?  It likely is seeking peace or a way to run away from a problem.  It might be trying to keep the person safe in its own way.  That is an understandable intention.  What is a better strategy?  Often, it involves distress tolerance—the next DBT skill!

DBT Skills Two:  Distress Tolerance

Distress Tolerance is a productive next step beyond the first step of mindfulness.  A person is progressing from awareness to response.  Victor Frankl famously talked about the space between a stimulus and a response as being the place of freedom.  Distress Tolerance helps a person to respond positively and effectively in this place of freedom. Self Soothing is a good practice for a person to calm herself or himself through sensory experiences.  One of the best practices for self soothing is muscular relaxation.  There is the noodle, where a person can sit in a hard backed chair with feet flat on the ground.  From there, a person relaxes all muscles and goes limp.  Sit at rest, just present in one’s body, focus on where there was tension.  If a person does that for 30 seconds or more, it is impossible for the mind to stay in fight or flight mode.  Another good practice is butterfly tapping.  There are many good videos for that on YouTube.  Other self soothing practices are taking a bath, listening to music, sucking on candy, and aromatherapy—especially smelling lavender. A person is aiming to achieve Radical Acceptance.  Radical Acceptance is a sense of “it is what it is.”  That is to say, a person might not like what is happening or think it is a good thing, but a person can come to an acceptance of the fact that it is happening.  Certain skills help with this.  The STOP Skill helps a person to Stop, Take a step back, Observe, and Proceed mindfully. Also, TIPP is an acronym for Temperature, Intense exercise, Paced breathing, and Progressive muscle relaxation.  Going through these progressions helps a person to process through challenging emotions and experiences. Distress Tolerance can be very helpful in overcoming borderline symptoms.  If a person can thoughtfully process through fear of abandonment, she or he can avoid frantic, destructive behavior.  If a person can endure stress in relationships, then she or he does not need idealization and devaluation, self harm, or suicide ideation.  Finally, if she or he can manage stress well, she or he is more likely to be able to choose a positive activity over a negative, impulsive one.

DBT Skills Three:  Emotional Regulation

Emotional Regulation Skills help a person to continue to process through challenging emotions.  This involves identifying and naming emotions.  Things should not just feel “good” or “bad.”  Also, a person can identify where in the body the emotion is felt.  It is helpful to trust the primary thought and emotion and to not engage a secondary thought and emotion.  For example, a person might have a negative emotion due to someone else hurting her or his feelings.  A secondary thought and emotion often discounts the first thought and emotion.  The primary thought and emotion should be focused on because it is the valid thought and emotion. Also, increasing positive experiences is crucial.  If a person is having positive relationship connections and is experiencing joy, she or he is less likely to get overwhelmed when negative emotions arise.  Finally, a person can build a sense of mastery by journaling, or even by reflecting at the end of the day on what is good and what is bad (an Ignatian Examen can be a great way to do that).  Whatever went well with emotional regulation should be repeated.  Whatever did not go well presents an opportunity to experiment with a new technique.  If a person stays with this over time, she or he will encounter long stretches where there is more good than bad and confidence will increase significantly. Here we have another positive step toward relationship with self and others.  A person who self regulates emotions has less need to fear abandonment, less need to be impulsive, and less need to self harm. A common problem with Borderline Personality Disorder is what is called splitting or idealization and devaluation.  This happens when a person with Borderline Personality Disorder identifies a person as all good at the beginning of a relationship (idealization).  Labelling someone as all good gives the person with BPD an excuse to not confront difficult emotions and situations in the relationship.  Then, when something bad happens in the relationship, the person with BPD devalues.  She or he says that the other person is all bad.  This helps the person with BPD choose avoidance so that she or he does not have to confront difficult emotions and situations.  Good emotional regulation helps the person with BPD avoid this tendency to split or idealize/devalue.  She or he can stay in the relationship and work through difficult emotions and situations. Through the lens of Internal Family Systems, a person can work to understand the concerns of different parts of the self.  For example, a part of the self might be concerned about being taken advantage of or hurt.  It is important to understand the concern that is there.  From there, a person can collaborate with that part of the self to develop a strategy that promotes safety and that still allows the person to be in relationship with others.

DBT Skills Four:  Interpersonal Effectiveness

Interpersonal Effectiveness completes the relationship loop in a lot of ways.  Once a person becomes aware of what is happening, accepts it, and processes through the emotions, it is time for that emotion to drive the person to effective action. Interpersonal Effectiveness begins with good Communication Skills.  A person can begin with a soft start up.  The person can use I statements and then empathize with the other person.  Then, the person can share her or his feeling and a proposal for what can be done in a situation.  For example, a person can say, “When you said _____, I felt disrespected.  In the future, I would like you to say _____ instead.  How does that sound to you?”  Not only does this statement share an emotion and request a need, but it also invites a collaborative discussion.  Many people struggle with being assertive enough to state the need in the first place, and when they do, many struggle with stating it appropriately.  In the world of DBT, this is both an art and a science.  A person needs a good sense of template and things to focus on, but then a person needs to understand how to apply it creatively in the moment.  Good Communication Skills lead to a healthy assertiveness, problem solving, and conflict resolution. In addition to Good Communication Skills, Boundary Setting is a key component of DBT.  Setting healthy boundaries involves communicating your needs and limits while honoring the needs and limits of others.  Prior to interacting with someone else, it is important for a person to reflect on her or his own needs.  Then, they need to be communicated effectively using the Communication Skills already mentioned.  Then, very importantly, boundaries need to be enforced.  If a person crosses a boundary, it is important for a person to reassert the need and let the other person know the negative consequence of crossing that boundary.  If the other person continues to cross a boundary, the boundary setter needs to make sure that the negative consequence is experienced.  Some people do not speak the language of empathy, but far more people speak the language of consequences.  This is a really important part of Interpersonal Effectiveness.  In fact, one of the key symptoms of borderline personality disorder is having a history of intense interpersonal relationships.  These relationships are intense in part because they are enmeshed relationships that lack boundaries.  Establishing boundaries is extremely therapeutic for this reason and can lead to relational health. In terms of Internal Family Systems, a lot of interpersonal effectiveness involves Manager parts that I call Guardians.  These parts of the self keep the person safe.  They have a good intention and offer strategies that often work.  However, many of the strategies of a Manager/Guardian part are extreme.  It can help for a person to dialogue with a Manager/Guardian part to understand its concerns and to identify healthy ways of interacting with others that are moderate.

Medication

In the low to mid levels of the borderline personality disorder spectrum, medications may not be necessary.  However, in the middle to high range, medication can be helpful.  I am not a prescribing professional and I always refer to a psychiatrist to prescribe.  I do favor psychiatrists over general practitioners because of the diagnostic nuances and the wide range of medications used to treat borderline personality disorder.  On average, I do favor anti-depressants for people struggling with depressive symptoms and medications that focus more on dopamine for clients who struggle with paranoia issues. An anti-depressant is often an SSRI (Selective Serotonin Reuptake Inhibitor).  It increases the levels of serotonin in the brain.  Medications that impact dopamine levels might be from any of a number of classes of medication. Finding the right psychiatrist is really helpful and important.  In terms of finding the right psychiatrist, I think that is a really important piece of things involving medication.  I recommend that people approach psychiatrists as customer service providers.  A great psychiatrist is collaborative, cares, and accepts input from clients/patients and any family members involved.  If a person meets with a psychiatrist and the psychiatrist demonstrates those qualities, it could be a good fit.  If a person meets with a psychiatrist and the psychiatrist does not demonstrate those qualities, I recommend trying a different psychiatrist until a fit is established. A key thing to focus on when taking medications is side effects.  If bad side effects show up immediately, it is important to discontinue use and reach back out to the prescribing psychiatrist.  Also, some medications take 4 to 6 weeks of daily use for their effectiveness to show.  It is helpful to be aware of that.

Conclusion

Ultimately, compassion is one of the most important things to have in the case of borderline personality disorder.  The story from the Bible that comes to mind is Jesus asleep in the hull of the apostles’ boat during the storm.  They awaken Jesus, and He calms the storm.  In a lot of ways, borderline personality disorder is an internal storm.  A person cannot find internal peace, and that leads to relationship chaos.  The key is for people with borderline personality disorder to learn to be Christ to themselves.  They need to learn to calm the storm and then take the healthy action.  For loved ones, the challenge is to be Christ to them.  Whenever a loved one is compassionate to someone with borderline personality disorder, it is transcendently Christ-like, because it is transcendently difficult.  What a beautiful thing it is to see the human dignity of the person who is caught in the storm. Katelyn Baxter-Musser has good resources for DBT on her website:  https://www.innerawakeningscounseling.com/ Looking for therapy regarding Borderline Personify Disorder?  Reach out to The Catholic Healing Institute and Tom Weishaar for a specially trained approach from a Certified Mood Disorder Professional who is trained in Dialectical Behavioral Therapy (DBT)! www.catholichealinginstitute.com tom@catholichealinginstitute.com Tom Weishaar, MA LPCC CCTP-II CMDP is the Founder and CEO of The Catholic Healing Institute.  He lives in Steubenville, OH with his wife and three children.