Long before the ambiguous and insulting term was coined by a male psychoanalyst 60 years ago, "borderlines" were mental health nightmares, islands of intractable misery, and the bane of many a psychotherapist's existence. A century of shifting diagnostic labels and rising feminist sympathies can't paper over therapy's signal failure with them.
Seventy-five percent are women; and about an equal percentage of all clients diagnosed as borderline report a history of childhood sexual abuse---three times the rate of clients given other diagnoses. Many try to kill themselves and nine percent succeed. Their numbers include the volatile and damaged people that Freud called "hysterics" and treated with little success at the turn of the century.
coolly defined Borderline Personality as an Axis II character disorder marked by "instability of interpersonal relationships, self-image, and affects, and marked impulsivity." Listed symptoms include "frantic efforts to avoid real or imagined abandonment"; episodes of depersonalization and dissociation; oscillation between idealizing and denigrating others; suicidality, self-mutilation, loneliness, anger, and inner emptiness; and "impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)."
But in therapists' private argot, "borderline," accompanied by much eye-rolling, has long been the shorthand for clients who never got beyond the crisis du jour---clients like the fragile and alcoholic Blanche Dubois of A Streetcar Named Desire
, eternally dependent on "the kindness of strangers." They are clients reminiscent of Marilyn Monroe (who was removed from the care of a psychotic mother and sexually abused in childhood), ever wandering into exploitative relationships and never able to protect themselves.No Emotional Skin
In the decades since, most clinicians who had a choice avoided borderline clients, while agency staff (who couldn't) went through the motions with a sense of futility. Some adopted a psychoanalytic view, blaming the disorder on disturbances of mother-infant attachment or a "constitutional excess of aggression." Therapy consisted of guarding against "manipulation" and mining the borderline's reactions to the therapist for clues to her fragmented inner world. It was hard on clients---and on therapists as well.
Then, in 1991, a study published in the Archives of General Psychiatry
(one of psychiatry's most influential journals) challenged this pervasive pessimism. The article reported on a small, NIMH-funded, randomized clinical trial that showed dramatic improvement among 22 borderline, suicidal and severely self-harming women. The lead author and researcher was not a psychiatrist, but a behavioral psychologist and Zen student at the University of Washington named Marsha Linehan; her treatment was called Dialectical Behavior Therapy, or DBT.
All of the women in her study had tried to kill themselves at least twice, and many practiced "parasuicide": they addictively attacked their own bodies in moments of emotional crisis, slashing forearms, tendons, and wrists; burned themselves with cigarettes and lighters; and even garotted themselves severely enough to risk death, unconsciousness, and hospitalization. But after four months of treatment, fewer than half were still harming themselves---compared with roughly three quarters of a control group of 22 equally self-punishing women given "treatment as usual" by therapists in the Seattle community. Over the course of the year, the DBT women steadily improved, spending significantly fewer days in mental hospitals and engaging in fewer suicide attempts and parasuicides. Tiny as it was, and limited though the improvement had been, the study established DBT as the only treatment for borderline suicidality ever validated by a randomized clinical trial published in a peer-reviewed journal.
At the core of the treatment was a set of behavioral techniques Linehan called a "technology of change," balanced by a "technology of acceptance"---a soft, almost mystical, Asian emphasis on "radical acceptance" and exercises for calming the mind by following the breath. The women had been taught how to tolerate difficult situations---and their own intense emotions---by using mindfulness meditation practices and cultivating radical acceptance. Paradoxically, they had also learned assertive Western social skills, such as "interpersonal effectiveness," to get their needs met and "behavioral chain analysis" to find out exactly what had sparked their desires to kill themselves.
Borderline individuals, Linehan theorized, had "no emotional skin" and had been raised in families where their hypersensitivity had been routinely discounted. This had bred profound self-distrust, a tendency toward extremes, and pervasive "emotional, behavioral, interpersonal, and cognitive disregulation."
Therapy, she argued, recapitulated the invalidating family environment when it offered insulting interpretations, ignored cries of distress, and inadvertently rewarded emotional explosions or suicidality with extra attention or hospitalization. At its worst, therapy had become "iatrogenic."
DBT was no walk in the park: it required team treatment, including weekly individual therapy, a year-long "skills training" class, telephone coaching, and supportive supervision for the therapist. But it was offering clients and therapists alike a way out of chaos---a systematic clinical package that integrated the technical and analytical strengths of behaviorism, the subtleties of Zen training, the warmth and acceptance of relationship-centered therapies, and the often undervalued power of psychoeducation.This blog is excerpted from “Revolution on the Horizon.” Read the full article here. >>Want to read more articles like this? Subscribe to Psychotherapy Networker Today!