This therapy modality may help us get to the core of this complex mental illness
Borderline Personality Disorder or BPD has been notoriously difficult for mental health professionals to treat. Part of the problem is that most mental health professionals don't understand the core issues and problems that drive the disorder outside of childhood trauma and the various factors that are involved in that sense. Most therapists are generally lost when they are trying to treat this disorder.
DBT and EMDR
DBT or Dialectical Behavioral Therapy has been the industry standard for treating BPD and while DBT offers a lot of excellent skill sets, it's proven to be largely inefficient for BPD. Some people get help from it but most of the time they don't. People struggle with the initial connection process. DBT is a bit complicated and can be very abstract so it can be difficult to understand and it's hard to plug into it and to start seeing value in it in a short amount of time. DBT requires patients and practitioners to devote time in building the foundations for it; it has a steep learning curve. Most BPD patients aren't able to see the process through and so DBT hasn't proven to be as effective as we hoped that it would be.
The relatively ineffectiveness of DBT has left us to conclude that BPD is just difficult or almost impossible to treat when we should probably more closely examine the limitations of our understanding of the disorder and we should admit that the therapy approaches that we have so far might not be getting to the core of the problem. I once had a BPD client describe DBT as "cruel" which I thought was interesting. I think the value in DBT is in it's structure which I think is needed for BPD but unless they are connected and bought into it, they aren't going to benefit from it.
The limitations of DBT have funneled many individuals with BPD into EMDR which, if you aren't familiar, is a therapy model specifically designed and targeted for trauma. The hope for many BPD patients is if they can resolve past trauma through using EMDR then the personality disorder would automatically clear up but that hasn't proven to be helpful either. And EMDR has problems and they're big problems. One of EMDR's biggest problems is that the mental health community at large lives in a state of denial about those problems. They want EMDR to be the miracle that some people promised to be and so they ignore the issues with it.
"EMDR can be extremely intense and it's a bad idea for those who struggle to manage or soothe their emotions and other symptoms"
The biggest issue with EMDR is that many people report that the process of the therapy causes them to relive their trauma and that their trauma worsens. EMDR often retraumatizes people. EMDR therapists are often doing a poor job with properly equipping their patients with the proper methods and tools to cope with and manage their PTSD and dissociative symptoms. These poor people are reliving their trauma with some serious intensity that is actually harming them and exacerbating their symptoms. New patients frequently ask me if I do EMDR and I often find myself recommending that they hear my criticisms of EMDR before they pursue it.
Those with BPD are often seeking EMDR when EMDR only gets good results from patients who are well equipped to manage their emotions when their trauma is triggered. EMDR is a bad idea for people who struggle to manage their PTSD or dissociative symptoms. Those with borderline can often find themselves feeling completely out of control and when done poorly and incorrectly, EMDR can easily cause their mental state to deteriorate. One of the biggest issues with treating the disorder is found in the challenges that they face in trying to soothe their emotions even on a day to day basis, let alone when their deep seeded trauma is deliberately triggered. They find themselves unable to cope with the things that have been brought up in therapy when they're between sessions.
In my professional opinion, EMDR is a poor choice for BPD. If you have been diagnosed with BPD, I would strongly recommend that you avoid EMDR and instead look at Internal Family Systems or IFS.
Working with different parts
IFS builds it's theory and practice on the idea that all of us are made up of different parts and that we experience personal conflict and chaos of thought, emotion and behavior because those internal parts are working in conflict with the core self as well as each other. IFS does a deep dive into how human psychology actually works. It describes the cogs of this machine in such a way that when explored in an honest way, people find it to be highly relatable. The IFS model of human psychology resonates with some people on a deep level.
In IFS, there are basically three types of parts starting with the core self which is a bit like a computer mother board. In IFS it's just called the self but I call it the true self or the authentic self, it's at the core of who are we are. The creator of IFS asserts that every single person has this part to them whether or not they are able to recognize it. I make the argument that the level of functioning observed in an individual with BPD is likely a correlated to the degree they are able to connect to the authentic self and put it in the drivers seat. The general aim for IFS is to recover the different parts and integrate them into the authentic self so that they are working together instead of in a state of conflict or competition.
The next type of part is what IFS calls protectors and according to this model, there are two types of protectors the ones that are proactive in their protection efforts and then the ones that are reactive in their efforts to protect. Their goal is to protect the authentic self but I'll get back to that later. Most people have a lot of protectors and some people can have what can seem like dozens of protectors. There are usually more protectors than anything else. They are a busy bunch and they are working hard to protect the individual from harm. They often show up as a trauma response. If a child is harmed, abused or traumatized, a protector usually shows up and starts getting busy spending time behind the wheel in order to protect that individual from additional harm. Sometimes they are serving a good purpose and they are actually helping but they often over do it as people grow older.
Those with BPD have protectors that are over achievers. They have protectors that exist for good and valid reasons and protectors that were extremely helpful at certain points in their lives but they've often taken it to far and they continue to try and protect the authentic self without realizing that they are causing harm and distress.
The last type of part is what IFS calls the exiles because they have essentially been ejected or exiled from the persons psyche and they hide deep in what foundational psychologist Carl Jung called the shadow. Most people are aware that exiles are hanging out somewhere in there but they strongly prefer to ignore them or avoid them entirely. People usually tell me that they are afraid to connect with or explore the exiles because the exiles are the source of most of their internal pain. They are afraid to connect with the exiles because they are afraid that the exile will hijack the whole system and cause their life to fall apart and breakdown or they're afraid that they will turn into some kind of destructive monster. The protectors don't just work to protect the authentic self from external things, they work to protect the authentic self from the exiles as well.
There aren't usually very many exiles, they are the core wounds that we often talk about in therapy. There's usually a core wound happening with the exiles that have to do with love, being loved, seeing oneself as worthy or deserving of love. The exiles get so little attention when they need attention that they often take any opportunity they can break out of their cage and demand some of that attention. We have a tendency to just keep burying and burying them when it doesn't work. As much as we want to get rid of them or be permanently severed from them, it's impossible. They are part of us and they inseparably connected so we basically have a choice to either live with the pain and chaos they can cause or we can put in some effort to work with them and heal them so that they can integrate with the authentic self and we can find peace.
No bad parts
IFS insists that we take a caring and loving approach to all the parts, regardless of what is happening with them and that includes the exiles. Accessing the exiles gets tricky when there is likely going to be multiple protectors who are trying to protect the authentic self from them. In order to heal, we need to access the exiles but sometimes we can only do so by working with protectors who can put up a big fuss if we just try and directly access an exile.
What's interesting is how each of the parts seem to have their own identity of sorts. The creator of IFS asserts that each part is truly like their own person with their own pain and personality and that our individual chaos is simply the result of them having their own agenda. Sometimes we're experiencing different protectors interacting with each other and competing for their individual agenda and they can often work against each other, leaving the individual in a state of chaos.
For years I've been saying that a personality disorder is the result of a person and their core self being in a state of fragmentation as though they've been shattered like something made of glass. I've been using the word fragment for several years when the creator of IFS has been calling them parts. When I learned this, it was quite validating to me and my own theory about human psychology and especially something like Borderline Personality Disorder. When I sat back and watched their behavior it became quite apparent that they have a fragmentation of their personality and different fragments can easily find themselves in the drivers seat, pushing their own agenda for the whole self and creating chaos.
We've traditionally had a tendency to look at BPD individuals as agents of chaos who are harmful and destructive and ones who even do it deliberately when it's much more effective to chalk their behavior up to their perceived desire and need to protect the whole self and every part that is involved. Almost everything that they do is motivated by the desire to avoid pain and keep themselves safe.
There are a few reasons why I like IFS and why I believe that it holds a lot of promise for the treatment for BPD.
It brings a safe, kind and compassionate approach. One of the core values of IFS is to regard a person as not having any bad parts and to regard each part as a child who is in the middle of a trauma response and is in need of support and caring rather than an angry or intolerant response. IFS challenges therapists to approach each part as a misguided child acting out in attempt to protect and for us to remember that there are no bad parts. The best way to access a part is to support it and love it. This can honestly be a tall order for a lot of people, therapists included, we have to do our best to move away from the tendency to see an individual and their misguided efforts to feel loved as bad even, and this is the hard part, when they harm other people in the process.
It's able to address the underlying trauma as well as the personality disorder and is able to do it at the same time. IFS works to isolate and access different parts and address the individual trauma there as well as the response to that trauma and how that individual part contributes to the personality disorder. Time in therapy sessions is spent accessing those individual parts, interacting with them, listening to them, understanding them, thanking them for their efforts to protect the individual and then take steps to soothe that individual part. We can then help that part look at the bigger picture and put it's individual efforts into helping the self.
It addresses the core and underlying problems and issues and is intended to do so in a manner that is non intrusive. EMDR is designed to get to the core of a problem but it tends to be far too intrusive which is one of the biggest problems with EMDR. DBT doesn't do much with the core issues and problems, it's more so focused on an effective management of emotions and behavior through the use of a set of core skills and tools. It offers almost nothing for the treatment of trauma. IFS offers a way to get to the core of the trauma without being overly intrusive. The IFS method of addressing trauma doesn't require the individual to relive the experience with intense detail. When used properly, people seem to just feel better. IFS can offer a resolution to trauma without being intrusive.
Through the process of using IFS, patients learn to be their own therapist and their own healer. Through the process of IFS, people learn to look introspectively at themselves and their lives and if done properly, they will be able to make a shift in how they have traditionally viewed themselves. Instead of beating themselves up or treating themselves harshly, the goal is for them to learn to view all of their parts in a more patient, honest and compassionate way and if done properly, they find this process to be healing instead of scary and painful. It's a supportive approach and process instead of a critical one.
I've been particularly intrigued at how IFS can be applied to BPD because of one very important distinction and which is that IFS recognized and addresses the issue that people on an individual level are fractured and fragmented. BPD is a mental health issue that shows a high level of this fragmentation and it directly identifies this issue and works with it.
The fragmentation is easy to spot and easily recognized even by those who might even be a bit out of touch. The individuals with BPD are often described as being different people or manifesting as different people at different times. The change sometimes is quite drastic and even unpredictable which is distressing for everyone involved and it's reasonable to assume that this is watching different parts take the drivers seat
One example that I've heard many times is that couples will have big ugly fights and then the next day the one with BPD is acting like nothing ever happened. The behavior is confusing to others, bizarre and scary even but it makes so much sense when you look at it from the perspective of them having different parts or fragments. One of their parts took the drivers seat during the fight and then another part is in the drivers seat the next day as a way to protect the individual from feelings of shame or fears of abandonment because of what had happened the previous day. The phrase, "I hate you, don't leave me" is one which is frequently attributed to BPD and while on the surface it appears confusing and strange but when we look at it from the perspective of having different parts it makes so much more sense. One part is hurt and scared and is lashing out and then another part quickly swoops in an attempt to recover the situation.
Several years ago I had a BPD client who told me that she was going to leave therapy and I responded by telling her that nobody was forcing her to be there and that she was free to leave at any time. She quickly and angrily fired back at me stating that I was abandoning her. Again, this can seem to be a confusing and strange display of behavior but the perspective of parts explains it perfectly. One of her parts wanted to leave therapy out of spite toward me or someone else and when I told her that she was free to go another part of her quickly took over because it didn't want to face more abandonment while another part of her wanted to avoid taking responsibility for her emotions and her behavior as a way to protect her from additional pain.
If I were to apply IFS to the same situation I would have addressed the part of her that wanted to leave therapy directly and work to understand what had caused that part of her react in this way and why that part of her believed that it was protecting the internal family. It could have been more effective if we had spent some time establishing the work of the internal family and viewed her behavior as a protective measure instead of her just being manipulative and belligerent.
The more that I study and apply Internal Family Systems, the more convinced I become that this approach to therapy could change the course and effectiveness of therapy. Not just for Borderline Personality Disorder but really for anyone who can't seem to solve some of their issues and inner conflict. I'm excited to be learning these techniques and these methods and using them to show other people how to approach themselves in an effective and supportive way and I hope, truly hope, these methods will help us provide better solutions for BPD when almost none seemed to exist. I like to believe that a solution for such a complex disorder exists, we've just haven't found it yet.
If you're interested in exploring therapy through the IFS model I hope that you will reach out and we can take this journey together. Whether you have depression, anxiety, trauma or BPD I'm happy to sit down with