Borderline personality disorder is notoriously difficult to treat. Many private practice therapists won’t take on BPD clients and if they do, they usually only take one at a time. Professional boards recommend therapists only take one person with BPD onto their caseload at a time. People with BPD can be exhausting to work with and unfortunately most therapists feel lost when they attempt to help them. Virtually all the therapy interventions that they have learned have little or no effectiveness and sometimes the goal of therapy is just to keep this person as safe and stable as possible; sometimes we only focus on reducing harm. Sometimes therapists feel that they have no choice but to divorce BPD clients in order to preserve their own well being and because therapy just isn’t helping.
Based on some of the things that I have been learning about BPD, here is a short list of barriers that they experience, things that keep them from improving and getting better.
They are only in therapy because someone else has compelled them to be there – This is all too common. People with BPD come to therapy under the threat of abandonment. Part of the DSM 5 diagnosis for BPD is frantic efforts to avoid abandonment. People with BPD will do virtually anything to avoid being abandoned, including going to therapy. This group has proven to be virtually impossible to help. If they are only there to avoid abandonment, their commitment level is poor and they are already running on high levels of resentment and fear. If they are only there to keep someone from leaving them, therapy won’t help.
They don’t know what’s wrong – In my experience, people with BPD have become acutely aware that there is something wrong but they don’t know what that thing is. What I have learned is that we can’t wait for people with BPD to put a finger on exactly what the problem is or how to help them; they often don’t know, their level distress is too high. I have also learned that asking them what’s wrong may be counter productive as they don’t necessarily know and it becomes frustrating to them in the process.
They are stigmatized – I really understand why BPD comes with the stigma that it does. Their behaviors are confusing, unpredictable and sometimes manipulative. While I don’t believe that they are always deliberately manipulative, it certainly seems that way. BPD comes with an intimidating stigma around it and believe me, they notice it. But imagine that you were never really given a fair chance because you happened to fall into a particular category, you would undoubtedly be defensive and unapproachable too. If a therapist treats them like they are “one of them” then the chances of treatment being effective decrease. I’ve learned that people with BPD lack true allies, people that are really on their side so to speak. I don’t believe that people with BPD can be helped if they don’t see their therapist as their ally.
BPD is complicated – Personality disorders are complicated in general but I’m convinced that BPD is the most complicated. Most mental health disorders are pretty cut and dry straight forward of what the problems is but BPD has many problems. People with BPD usually come with some childhood trauma, a lack of coping skills, codependent relationships, impulsivity, extremely low-self esteem, and significant levels of loneliness and inability to be understood; just to name a few. It’s almost like several mental health disorders wrapped into one big disorder. If a therapist identifies that a person is depressed, they treat the depression. The same is true for anxiety grief, OCD, etc. BPD is different, there are so many problems with it that it can be hard to know where to begin.
They experience crippling self-doubt – A lot of their self-doubt is rooted in a lack of identity. They feel like an empty shell of a person, they don’t know what their values are and often look to other people to help them figure this out. When I express belief and support in them, they resist me. They don’t see themselves as capable or worth it. They often give up on themselves, they don’t believe that they can get better which can cripple their ability to do so. They can get triggered into high levels of emotion and during that time they feel as though their progress is lost.