Peter Walker – Clinical Psychologist
Borderline Personality Disorder (BPD) is a condition that affects approximately 1 percent of the Australian population. It is, unfortunately, one of the most misunderstood, stigmatised and mistreated psychological conditions. Therefore it is important that this condition be clarified.
BPD is a condition that causes severe distress and instability and is very often associated with a history of childhood abuse, factors that you would imagine should be met with a sense of empathy and non-judgmental concern for others. However, in stark contrast to this, those experiencing BPD report a degree of hostility, neglect and blame that is not directed at other physical or even psychological problems. Disappointingly, experienced mental health workers will often call the behaviour exhibited “manipulation”, “attention-seeking”, “a waste of valuable health resources” or “acting out.” Thus, they often blame the individual for their condition as if it could be turned on or off at will. So, despite significant advances in the last few decades, both in our understanding of BPD and its treatment, the condition still remains poorly understood by mental health clinicians and the public, and too often goes untreated.
There is also doubt connected to the terminology used in association with BPD. Let me explain further. BPD is one of 10 Personality Disorders described in the influential Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Personality disorder refers to sets of enduring problematic behaviours that occur alongside disability or distress in adults. The name “borderline” was derived from a now largely discredited theory associated with Adolf Stern in 1938. He had thought that clients moving from anxiety problems (neurosis) into more disabling psychotic conditions (schizophrenia or mania) entered a prodromal period that he referred to as a “borderline” state. Due to the antiquated quality of this theory and the potential of those diagnosed with BPD to experience stigma, many clinician’s including this author, reject the use of this terminology and prefer to use terms such as “emotional dysregulation.”
To be classified as having BPD you must meet five of nine specific criteria. These include the following:
- Efforts to avoid real or imagined abandonment;
- Unstable and intense interpersonal relationships;
- Identity disturbance;
- Recurrent suicidal behaviour or threats, or self-mutilating behaviour;
- Mood instability;
- Feelings of emptiness;
- Inappropriate, intense anger; and
- Paranoid ideation or dissociation.
Historically, this population has been considered difficult to treat psychologically due to the intensity of emotions, the fluctuating nature of symptoms, the nature of the clients’ attachment to the clinician and the anxiety associated with the risk of suicide. Further, until recently there have been few treatments, either psychological or pharmacological, that have been demonstrated to be effective. This may have contributed to the therapeutic nihilism often associated with mental health practitioners who work with clients with BPD. If you can’t cure a patient, it might be simpler to blame them.
In the last 20 years there have been dramatic advances in the psychological treatment of BPD with the development of a range of empirically validated treatments. The most influential treatment is Dialectical Behaviour Therapy (DBT) and is associated with the North American clinical psychologist Marsha Linehan. Linehan developed the treatment after having repeated failures using traditional cognitive therapy with BPD populations. She adapted and extended cognitive therapy to suit that instability, and, at times, contradictory nature of the condition (hence the term “dialectical”). The treatment uses a range of behavioural, emotional-regulation and meditation-related techniques to assist an individual develop greater emotional stability. With increasing stability DBT assists people to develop a “life worth living” through the establishment of healthy relationships, the development of affect-regulation skills and vocational rehabilitation. Despite being labour intensive for staff (clients expected to attend weekly individual sessions of an hour and group session of two hours each week for a full year), DBT has become widely available in metropolitan areas in Australia. An encouraging by-product of the availability of DBT has been the cultural change that it is producing within mental health settings. Anecdotally, there have been increasing reports from clients with BPD of positive, warm and non-judgemental experiences in Emergency Departments, on Psychiatric Wards, in GP practices and from families that had previously been absent.
If living in NSW, call 1800011511 for more specific information on your local NSW Health DBT program. Private psychiatric hospitals also offer programs which can be affordable for those with private health cover. Privately practicing mental health clinician’s with expertise in DBT and other evidence based interventions for BPD can be found through their representative body’s website (www.psychology.org.au/FindaPsychologist).
Peter Walker has over 12 years experience working as a clinical psychologist. He has worked in both public and private practice, having specialised in complex presentations. He established his private practice, Peter Walker & Associates, clinical psychologists, in 2002 as a service to provide psychological treatments for those experiencing difficulties with anxiety, depression and couples in distress. In addition, the practice was relatively unique in that it offered specialised treatments for those experiencing psychotic disorders and bipolar disorder. At the time Peter Walker & Associates was established the development of psychological treatments for these conditions was in its infancy and Peter was considered an innovator in this field. Peter provides clinical supervision for mental health practitioners, is a sought after presenter and has experience providing expert opinion in the media. In recognition of his experience treating mood disorders he has been asked to take on a role at the Black Dog Institute in 2013.
Jay Spence – Clinical Psychologist and PhD Candidate
Borderline personality disorder (BPD) is one of the most common personality disorders and affects about 2–6 percent of the population. For a long time, having a diagnosis of BPD meant a very bleak lifelong outlook. However, new treatments that have been researched over the last 20 years have brought considerable hope to those suffering from BPD.
Although there are many potentially effective ways to treat BPD, only a few have been researched thoroughly. The following treatments have been shown to be effective:
- Schema Focused Therapy (SFT)
- Dialectical Behavior Therapy (DBT)
- Mentalization-based Therapy (MBT)
- Transference-focused Psychotherapy (TFP)
These treatments are incredibly time intensive and those undertaking treatment should be prepared for what is required in order for the treatment to work. For example, DBT requires weekly individual therapy (1 hour), plus weekly attendance of a group to learn skills to help manage symptoms (2 hours). Additional time is sometimes required for phone coaching when attempting to change a long-term behaviour or to deal with a crisis. DBT, MBT and TFP all have similar time requirements of several hours per week. One exception is SFT, which requires less time per week (1-2 hours). However, there are additional homework exercises required that occur outside the session.
In Australia, these treatments are offered by some hospitals and community mental health centres for free. Waiting lists are often very long so it’s best to be proactive and put your name down early as it may take months or even a year to get in. Private hospitals also offer treatment. What many people don’t know is that these treatments are often covered, even if you are on a low-level of care. What’s more, if you signed up for private health cover today, many insurers approve treatment within two months.
My experience in treating people with BPD is that it is one of the most painful of all the mental health conditions. I have heard it described as akin to having no skin, so that daily events that others barely notice become excruciatingly painful day-in and day-out. The extreme behaviours such as suicide attempts, fighting with others and self-harm are only understood through listening to the often horrendous childhoods that many of those with BPD have endured. Recovery from BPD is a long path but the research shows that people improve eventually and stay well. Those with BPD require more support than most and being there can be tough. If you have a friend or family member with BPD, then agencies like AREFEMI (www.arafemi.org.au) and ARAFMI (www.arafmi.org) can help support you to be there for the person you care about.
Jay Spence is a Clinical Psychologist and PhD candidate who specialises in adult and adolescent mental health. He was joint recipient of the Gold Prize at the Australian and New Zealand Mental Health Service Achievement Awards (2010) and of the St Vincent’s Health Australia National Invention and Innovation Award (2010) and was the recipient of the 2011 New South Wales Institute of Psychiatry Fellowship. He has published numerous papers on the treatment of post-traumatic stress, social phobia, and panic, as well as generalized anxiety and transdiagnostic anxiety processes. He held a conjoint lecturer position at the University of New South Wales from 2009 to 2011, lecturing on the treatment of anxiety and depression. He is currently completing a PhD on internet-based interventions for post-traumatic stress disorder (PTSD). He is developing these treatments as part of the Centre for Emotional Health at Macquarie University because PTSD is the most prevalent anxiety disorder in Australia. However, many people do not have access to effective treatments. He sees patients in private practice in Darlinghurst, Sydney.
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