Borderline Personality Disorder Through the Bower Place Lens

Borderline personality disorder is, in its generation, perpetuation and resolution a relational issue. In Australia it is usually diagnosed according to the Diagnostic and Statistical Manual for the Social Sciences-V which describes it as ‘A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.” One of the most stigmatizing of all conditions, it was once viewed as life-long and untreatable. Therapy is a relationship and the instability characteristic of others in the person’s world is also played out in the therapeutic relationship. Some of the diagnostic criteria including, frantic efforts to avoid real or imagined abandonment, unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation routinely occur between client and practitioner. Add to this the impulsivity in at least two potentially damaging domains including spending, sex, substance abuse, reckless driving and binge eating and suicidal behaviours, gestures and threats and self-mutilation and you have a potent and potentially frightening raft of challenges for the practitioner. Finally intense inappropriate anger which may be directed at the practitioner and severe dissociation which can encapsulate a whole session make this work additionally stressful.

How does a person come to manage the world in such a painful and patently ineffective fashion? One useful analogy comes from attachment theory which suggests that repeated childhood experiences with caregivers during childhood create templates or schema of self and others which guide and dictate our understanding of relationships. Those who attract this diagnosis, have been found to come from families which are unsafe and unstable, harshly punitive and depriving. These are families where the needs of the child come second to that of carers who may be abusing substances or have a diagnosis of schizophrenia or other major mental health condition. While childhood trauma, including childhood sexual abuse, is a common it is not necessary or essential for the development of these qualities. This early learning teaches the child what to expect in interactions with others, and the emotional rules for processing information and situations. Essentially it is the early relational conditions that teach the child that those who they should be able to trust and rely upon cannot be and leave a legacy of difficulty regulating emotions and impulses, achieving satisfying and long-term relationships while demanding others will be engaged and caring in a consistent way, and of establishing a positive sense of self and identity and acceptability. The therapeutic relationship is second only to an intimate relationship for creating the conditions that will trigger the fears of abandonment and punishment that such a history has created.
Yet of course no two people are the same and while the attachment lens is perhaps the most common through which two view this issue it is not the only variable to be considered. The richer the analysis the easier it becomes to find a way through these challenging situations. Reference to the Bower(method) meta-frames provides a Fuller description of a situation and more options to respond to it.

The Bower(method) Metaframes

Politics

This refers to the question of power and justice that render this individuals’ life more unequal than that of another. The family circumstances including major mental illness in parents, drug and alcohol issues and violence and abuse that often attend this set of features render the person unequal to others irrespective of the diagnosis.
Politics also refers to power struggles which ensue around ownership of a problem, who in the system has the power to effect change and who is willing to accept responsibility to ensure this change occurs. People with the set of relational patterns described above are often prone to mismanage these issues in a way that is both infuriating and confusing for those with whom they are in relationship. The intense fear of abandonment, emotional lability and dissociation can effectively shift responsibility from the individual to others in a way that blames them for causing the problem. This underpins the excessive number of fractures apparent in the ecogram which represent a cessation of relationship either by the client who decides the other is too flawed or by those who decide the outbursts of anger and gratuitous and sometimes nasty actions against the self or them is too much to bear.
This pattern is replicated in therapy where the practitioner finds themselves initially lionized and then the recipient of disappointed fury. Frequent acts of self-harm and suicide attempts which are then attributed to failings in the practitioner add to the burden experienced working with this pattern.
Proper alignment of authority and responsibility from the beginning of the therapeutic process is crucial in successful work. Making clear that the practitioner understands that they may disappoint the client and that it is safe and acceptable to express, outbursts of rage and abuse will not be tolerated. It is not uncommon for practitioners to ‘make exceptions’ for the clients and in doing so breach boundaries in terms of time and availability that must then be redrawn causing distress and triggering accusations of abandonment. At times like this is it is not uncommon for the client to threaten to end the therapeutic relationship.
Keeping questions of authority and responsibility forefront in the practitioner’s mind and as a guide to what can and should be accepted and agreed to is the most protective stance. This is especially important when suicide and self-harm is threatened, and the practitioner must take a clear position that the client’s safety will be guaranteed irrespective of their agreement. Sometimes this entails a trip to hospital.
The second layer where authority and responsibility may be played out is between professionals. This may take the form of an unwillingness for anyone to be responsible and attempts to shift responsibility away from each person to the next. This can be compounded when the client carries messages between helpers or tells one person how much better they are than another, creating fractures and dissent in the helper system. Clear transparent lines of communication and agreed areas of responsibility can protect all parties from these dynamics.

Space

The space meta-frame comprises both the inside neurobiological world of the person and their outside relational world.
People with a diagnosis of borderline personality disorder are, by definition, highly emotionally reactive, especially when interactions trigger the fear of abandonment. Dissociation which can last an entire session or explosive affect are not uncommon and can make therapy arduous and unpredictable. Dialectic behaviour therapy which teaches better ways to manage strong emotions and reactions is a useful adjunct to systemic therapy.
On the outside the pattern of interactions with others in the world is often highly ordered and predictable while appearing chaotic and dysregulated. Those who attract the diagnosis have highly disrupted relationships, marked by frequent and bitter conflict followed by cut-off. Alternately the fractured relationships may reflect those in the person’s life who can no longer carry the repeated episodes of self-harm and suicidality and the recognition that no matter how much is given it will never be enough. This is dramatically represented by the ecogram where red lines radiate from the client to family, friends, colleagues and professionals. Where green lines are present these relationships are idealized and the seeds for another red line are in the process of being sown.
Idealization followed by demonization is also reflected in relationships with past professionals who are represented in highly negative terms in contrast to the current practitioner who is ‘the best ever’. This is a powerful warning and unequivocally embracing the praise and accepting criticism of others is dangerous. The repeating cycle of closeness followed by distancing can be exhausting and infuriating for both client and practitioner as the pattern of childhood are played out again and again. As a person with authority in the relationship it is easy for the practitioner to be confused with those who did not nurture and care for the child and for the strategies that allowed survival through these harsh times be replicated. Withdrawal may take the form of anger and attack or dissociation and inability to respond to the practitioner.

Time

Time past and the injuries and injustices suffered in childhood are often powerfully and sometimes inaccessibly present. The person may, at the outset of therapy have little memory of their childhood and the experiences which have shaped their response to the world in the present and these may unfold in the course of the work. Reactions that have appeared irrational may begin to make more sense and as this happens the person often experiences a greater sense of agency and control over their lives.
The palsying effects of the past are different for each person. For some a productive future has been possible where they conduct themselves in a mature, effective and adult way, carving a successful career where they are liked and admired. This may contrast with their personal lives which are marked by fracture and loneliness and anxiety about relationships. Others find relationships in all domains troublesome and struggle to maintain employment.
The task is the same in both cases. It is about inventing a different future which does not include features currently characteristic of relationships. Articulating what is to be included and what excluded in relationships with family friends and workmates is critical.

Development

The development lens includes the early experiences that have shaped the client’s attachment style and the template they use to manage relationships in a way designed to keep them safe. While some, but not all have experienced childhood sexual assault those who have not recount histories of violence, abuse and neglect of other types. For some people memories of past abuse is relatively minor at the outset but in time may prove to be an entry point to much more devastating and distressing experiences.
The task in this metaframe is to work to create a full identity ranging from productive identity, earning or learning, peer or friendship identity, sexual identity and attachment identity. Each of these domains is often powerfully affected by the dysregulation, impulsivity and anger and reactions to perceived or real threats of abandonment. Working with the client to identify and address relationship patterns that have evolved between themselves and significant others in each domain is central to this work. Of particular significance is attachment identity, our connection to family, past and present. Where the client has their own children, it is important to work on their attachment relationship and parenting in order to protect the next generation. In some cases the client may come to a s decision to permanently fracture form their own abusive or neglectful family of origin. A permanent, planful and rational fracture is very different from a temporary breach in response to a dysregulated episode or a secret distancing while maintaining appearance of connection. People rarely make and maintain such a decision without significant distress and often in the context of a realization of what childhood was really like.

Conclusion

Working with clients with a borderline personality disorder diagnosis is challenging and requires clarity by the practitioner in the face of the client’s dysregulation and distress. Bower(method) provides a template to shape the activity of the practitioner in a way that maximizes the possibility of an enduring therapeutic relationship as a vehicle for change.