The diagnosis of borderline personality disorder was once synonymous for ‘hopeless’, a lifelong sentence. Those who attracted the label showed a ‘pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood’, presenting in a variety of contexts. (DSM-V Diagnostic criteria). Self-mutilation, suicide gestures and attempts, impulsive acts like shoplifting and careless sexual encounters were challenging for therapists which were compounded in the therapeutic relationship by fears of abandonment and an intensity of connection that swung between idealisation and devaluation. It was viewed as immutable, lifelong and a truly ‘inside’ condition.
Enter DBT
The work of Marsha Linehan, creator of dialectical behaviour therapy, has changed this. DBT is a structured outpatient treatment that combines cognitive restructuring with acceptance, mindfulness, and shaping and has been shown to be effective through randomised controlled trials. Now practitioners did not have to feel so helpless. Is this enough or is there a role for systemic family therapy?
Does family and systemic therapy have a role?
Systemic therapy views all symptoms and difficulties as integrated into recursive loops of the system in which it presents, past, present, and future comprising family, wider system including helpers, and society . The challenge for therapy is to change these patterns and as a result alter the symptom. This is not to claim the symptom will resolve, but without the sustaining interactional loops the behaviours may moderate.
Choi (2018) writing in The Australian and New Zealand Journal of Family Therapy, notes that while DBT may strengthen individual psychological wellbeing, behaviour, and resilience of the client it does not address external factors, including difficult ‘psychosocial circumstances, situations, relationships, and family dynamics.’ He notes that health care systems and families become focused on managing perceived or actual risk and in doing so increasingly disempower the client and their family and that that ‘risk management culture, though usually well intended and prescribed, may serve the interests and defences of the organisation far more than the recovery and wellbeing of individual clients and family.’ In his review of the application of these approaches in acute mental health settings he concluded that they were rarely used or available making it difficult to assess effectiveness. However, he suggested that ‘psychoeducation and providing skills to manage the wider spectrum of problems, issues, and dynamics associated with this disorder’ should be explored.
The Bower Place Approach
A BPD diagnosis is common for clients attending the Bower Place Complex Needs Clinic. An approach which addresses ownership, the proper exercise of authority and responsibility, over difficulties and their resolution, has been useful. This dynamic is explored both within the family and the wider system with the intent of empowering all who interact with the client and giving them the possibility of becoming agents of change in their own lives.
Choi,H. (2018) Family Systemic Approaches for Borderline Personality Disorder in Acute Adult Mental Health Care Settings Australian and New Zealand Journal of Family Therapy 39, 155-168
Access Bower Knowledge