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A Person-Centered Approach to
Borderline Personality Disorder
Jan van Blarikom
Emergis Zeeuws Vlaanderen, Terneuzen, The Netherlands
Abstract
Working with people who suffer from a serious mental disorder should fill us with modesty.
Borderline personality disorder is no exception to this. Outcome studies do not confirm the claim that
person-centered therapy is universally effective. A balanced approach to the borderline patient is required.
In this paper the author searches for common ground between the person-centered approach and general
psychiatry with respect to borderline personality disorder. Acknowledging pathological aspects of the
person is not necessarily in conflict with the basic principles of the person-centered approach. New
developments in person-centered therapy open up perspectives to work with people with a borderline
personality disorder. This paper is the second in a series of three concerning the person-centered approach
to severe mental illness.
Keywords:
borderline personality disorder, person-centered approach, diagnosis, mental disorders,
treatment, moral imperative
Ein personzentrieiter Ansatz zur Borderline-Persönlichkeitsstörung
Mit Menschen zu arbeiten, die an einer ernsthaften seelischen Erkrankung leiden, sollte uns bescheiden
sein lassen. Eine
Boräerline-Persönlichkeitsstörungist
dabei keine Ausnahme. Outcome-Studien bestätigen
den Anspruch nicht, dass Personzentrierte Psychotherapie universell effektiv sei. Eine ausgewogene
Herangehensweise an den Borderline-Patienten tut Not. In diesem Artikel sucht der Autor nach
Gemeinsamkeiten von Personzentriertem Ansatz und der allgemeinen Psychiatrie fur den Bereich der
Borderline-Persönlichkeitsstörung. Pathologische Aspekte der Person anzuerkennen, steht nicht
automatisch in Konflikt mit den Grundprinzipien des Personzentrierten Ansatzes. Neue Entwicklungen
innerhalb der Personzentrienen Psychotherapie eröffnen Möglichkeiten, mit Menschen mit einer
Borderltne-Persönlichkeitsstörung zu arbeiten. Dieser Artikel ist der zweite in einer Serie von dreien, die
sich mit dem Personzentrierten Ansatz bei schwerer psychischer Erkrankung beschäftigt.
Author Note. Address for editorial correspondence: Jan van Blarikom, Emergis Zeeuws Vlaanderen, De Jongestraat
3, NL- 4531 GL, Trrneuzen, The Netherlands. Email:< ¡anvanblarikom@gmail.com>.
© van Blarikom 1477-9757/08/0120-17
van Bíarikom
Un enfoque centrado en !a persona de un desorden borderline de personalidad
Trabajar con personas que sufren un desorden mental serio nos debería llenar de modestia.
El desorden
borderline de la personalidad no
es la excepción. Los resultados de los estudios no confirman la afirmación
de que la terapia centrada en la persona es efectiva universal mente. Se requiere un enfoque equilibrado
para
m\
paciente borderline. En este escrito el autor busca un campo en común entre el enfoque centrado
en la persona
y
la psiquiatría general con respecto al desorden borderline de personalidad. Reconocer los
aspectos patológicos de la persona no necesariamente está en conflicto con los principios básicos del
enfoque centrado en la persona. Nuevos desarrollos en la terapia centrada en la persona abren nuevas
perspectivas para trabajar con personas que sufren un desorden borderline de la personalidad. Este es el
segundo de una serie de tres escritos acerca de un eníbque centrado en la persona para enfermedades
mentales severas.
Une approche centrée sur la personne du trouble de la personnalité borderline
Nous devrions rester bumbie quand nous travaillons avec des personnes qui soufirent de troubles mentaux
sérieux. Le trouble de personnalité "borderline" en fait partie. Les recherches sur l'efficacité de telles
thérapies infirment l'affirmation qui dit que la thérapie centrée sur la personne est efficace de manière
universelle. Le patient borderline a besoin d'une apptoche équilibrée. Dans cet article l'auteur cherche
un terrain d'entente entre l'ACP et la psychiatrie générale, en rapport avec les troubles de la personnalité
borderline. Le fait de tenir compte des aspects pathologiques de la personne n'est pas nécessairement en
conflit avec les principes fondamentaux de l'ACP. Des développements nouveaux dans la thérapie ACP
ouvrent
àçs
perspeaives pour le travail avec les personnes souffrant de troubles de la personnalité bordedine.
Cet anide est le deuxième dans une série de trois articles qui aborde l'approche AC? dans le travail avec
la maladie mentale grave.
Abordagem centrada na pessoa e perturbaçâo
borderline
da personaÜdade
O trabalho com pessoas que padecem de perturbaçâo mental grave devia encher-nos de modestia. A
perturbaçâo
borderline
da personalidade nao é uma excepçâo. Os estudos realizados nao confirmam a
reivindicacáo de que a terapia centrada na pessoa seja universamente eflcaz. É necessária uma abord^em
equilibrada perante o paciente
borderline.
No presente artigo, o autor procura pontos de concordancia
entre a abordagem centrada na pessoa e a psiquiatria geral no que concerne a pemirbaçâo
borderline.
O
reconhecimento de aspectos patológicos da pessoa nao entra necessariamente em conflito com os
fundamentos de base da abordagem centrada na pessoa. Desenvolvimentos recentes na terapia centrada
na pessoa abrem novas perspectivas ao trabalho com pessoas com perturbaçâo
borderline
da personalidade.
Este é o segundo de uma série de très artigos referentes à aplicabilidade da abordí^em centrada na pessoa
em casos de perturbaçâo mental grave.
Person-Centered and Experiential Psychotherapies, Volume 7, Number î
21
A Person-Centered
Approach to Borderline Personality Disorder
Een persoonsgerichte benadering van de borderlinepersoonlijkheidsstoornis
Het werk met mensen die lijden aan een ernstige psychiatrische stoornis vraagt om de nodige
bescheidenheid. Dat geldt in het bijzonder voor de borderline persoonlijkheidsstoornis. In onderzoek
wordt niet bevestigd dat de persoonsgerichte thérapie bij om het even welke stoornis efFectief is. De
borderline patient vraagt om een genuanceerde benadering. In dit artíkel wordt gezocht naar het
raakvlak tussen de persoonsgerichte benadering en de algemene psychiatrie in verband met de
borderline persoonlijkheidsstoornis. De pathologische aspecten van een persoon onder ogen zien,
hoeft niet in strijd te zijn met de uitgangspunten van de persoonsgerichte benadering. Nieuwe
ontwikkelingen binnen de persoonsgerichte thérapie bieden een perspectief op het werken met
mensen met een borderline persoonlijkheidsstoornis. Dir artikel vormt het tweede deel in een
driedelige serie over de persoonsgerichte benadering van ernstige psychiatrische stoornissen.
INTRODUCTION: A MORAL IMPERATIVE
She was only sixteen when she was referred to the borderline ward of the psychiatric hospital
Mishna had become a nightmare to the nurses of the youth clinic. She cut deep wounds in
her arms, belly and legs. Later on, she knotted small ropes around her neck, subsequently
lost consciousness and had to be resuscitated several times. The working staff became divieied
into two camps. Some of them pointed to the parents'apparent reluctance to engage in their
daughter's education. They had delivered her to the youth clinic when she was twelve and
since then there had been hardly any contact. Others stressed the manipulative traits of the
girl who seemed to select certain staff members especially to perform her suicidal acts in
front of Nurses were traumatized by the self inficted deep wounds, the suffocation and the
personal impact of her suicidal acts.
This paper is the seœnd in a series of three concerning the person-centered approach to
severe mental illness. The borderline patient is perceived as diffictilt to handle, especially in
the context of a psychiatric hospital. About 15% of all inpatients receive the diagnosis borderline
personality disorder (Widiger
&i
Weissman, 1991). Intensive psychiatric care often makes
the borderline symptomatology worse. The staff and patient are caught in a destructive
relationship. "Do not harm" shotild be the leading principle in the "management" of the
borderline patient (Dawson, 1988). Tbe patient must be treated as an autonomous, responsible
human being even when they are not behaving like one.
In the preparation of this article one reviewer commented that there is a "moral
imperative" implied that traditional client-centered therapy should modify itself to the
treatnnent of a specific disorder. I am not sure about this modifying—I would leave that up
to the traditional client-centered therapists. But the moral imperative is indeed hidden in
this series: I fmd that person-centered therapy
should
look after people with a serious
mental disorder. Client-centered therapy originated in an era where the focus was on the
individual emancipating themself from traditional values. Now, fifty years later, we see not
only the fruits but also the complicated aspects of individualization. The emphasis on the
individual took its toll with vulnerable people.
22
Person-Centered and Experiential Psychotherapies, Volume 7, Number 1
van Blarikom
Traditional client-centered therapy was very optimistic about the healing capacity of the
actualizing tendency even with respect to severe psychiatric disorders (if these disorders were
acknowledged at all). In borderline personality disorder we meet a human being in a modern
world where traditional bonds have lost their meaning and individual capacities to live one's
own life fall short. In this article I will look for an answer to the question of in what way the
person-centered approach can contribute to a better life for persons whose functioning is
severely impaired because of a borderline personality disorder.
WHAT IS BORDERLINE?
Borderline personality disorder is a "serious mental disorder," {Lieb, Zanarini, Schmahl,
Linehan, & Bohus, 2004, p. 453) with a pattern of instability in affect regulation, identity
and relations, often accompanied by severe acts of self-mutilation, suicidal behavior, severe
psychosocia] impairment and a high (10%) mortality rate due to suicide. In contrast with
other severe mental disorders such as schizophrenia and mood disorders, which are described
in the language of the
Diagnostic and Statistical Manual of Mental Disoreiers {DSM)
as Axis I
disorders characterized by an acute exacerbation of symptoms, borderline personality disorder
is an Axis II disorder characterized by a
''pervasive pattern
of instability" (American Psychiatric
Association, 1994, p. 654). Like schizophrenia and mood disorders, borderline personality
disorder shows very different levels of psychosocial ftinctioning and a large variety in its
course over the long term. Zanarini, Frankenburg, Hennen, and Silk, (2003) demonstrated
that 75% of the patients achieved remission after a period of six years.
In clinical practice we meet highly diverse levels of psychosocial ftinctioning of persons
with borderline personality disorder. There are young people who have attempted suicide,
had some intense conflicts in relationships and suffer from a very negative self-image, who
are able to start a new, healthy life after a few years of treatment. And we see, especially in
psychiatric hospitals, complicated cases where patients, for example, suffer simultaneously
ftom borderline personality disorder, severe recurrent depressions and diabetes. They might
neglect their physical condition deliberately as a form of self-destruction, sometimes with
fetal consequences. Other complicating faaors in the course of borderline personality disorder
are eating disorders, severe self-mutilation and addiction. Many borderline patients have a
long history in psychiatric treatment.
She was involuntarily committed afier she had parked her car with locked doors on a
railroad crossing. Bystanders hadtopush the car from the crossing. An interruptedpre^mncy
had brought Anna into this crisis. In her early thirties she already had a long history in
psychiatry. Brought up in a strict religious milieu, she never got along with her parents. She
had been sexually abused by a female teacher under whose care she had been placed by her
parents. When she told about it no one believed her. She got involved in a sadomasochistic
relationship with someone. Because she felt used in this relationship, she asked for money to
continue it. Subsequently she felt like a prostitute, a prediction about her future her parents
Person-Centered and Experiential Psychotherapies, Volume?, Number I
23
A Person-Centered Approach to Borderline Personality Disorder
had made many years ago. When she got prenant, she ended the relationship. Two months
later she suffered a miscarriage and her religions acquaintances strongly advised her to keep
silent about what had happened to her. A little later she came into this crisis.
There are many "pathways to the development of borderline personality disorder," Zanarini
and Frankenburg (1997) argue in an article of the same name. Recent research su^ests a
strong genetic component involved in the development of borderline personality disorder
(Skodol et al., 2002; Torgersen et al., 2000). Already known is that insecure attachment,
early separations and losses, disturbed relationsbips with one or both parents, and a history of
sexual abuse contribute to the development of borderline personality disorder (Zanarini &
Frankenburg, 1997). Early deprivations or physical and sexual abuse by primary caretakers
(Links, Steiner, Offord, & Eppel, 1988) and the severity of childhood sexual abuse (Zanarini
et al., 2002) may also be linked with the severity of the disorder and impaired psychosocial
functioning.
The best-fitting models for the genesis of borderline personality disorder (as for other
mental disorders) seem to be the diathesis-stress model (Stone, 1980) or the multifàctorial
model (21anarini oí Frankenburg, 1997). Three factors contribute, in each patient in a unique
way, to the development of borderline personality disorder. There is a constitutional
vulnerability in a negative interaaion with early life circumstances such as deprivation, abuse,
and disturbed relationships with the parents. The definite ciinicai manifestation of borderline
personality disorder might be caused by triggering events (Zanarini & Frankenburg, 1997)
in early adulthood such as rape or a series of adverse sexual events, a sudden ending of a
relationship, the death of a beloved one or the loss of a job.
The development of the concept of borderline personality disorder has always been
linked with difficulties in diagnosing and the patients treatment. The first phase of the
concept was the mentioning of borderline states (Knight, 1953). The borderline patient was
situated between the neurotic and psychotic patient. Knight (1954) remarked that borderline
patients in a clinical setting can cause many problems between the staff members. He
mentioned "the management of the borderline patient" which meant avoiding the patient
beginning to behave dependently and developing destructive behavior. Kernberg (1967)
coined the term
borderline personality organization,
a term still in use in psychoanalytic-
oriented psychotherapy. It refers to a stria separation of good and bad objects in the experience
of the borderline client. Grinker, Werble, and Drye (1968) were the first who tried to give a
description of the borderline syndrome using empirically based criteria.
In 1980 it became a D&W-///diagnosis. Discriminating features of borderline patients
(Gunderson & Kolb, 1978) were fused with criteria from Kernbergs borderline personality
organization. Almost all the criteria have been reinserted in the actual
DSM-FV
(American
Psychiatric Association, 1994) diagnosis. The diagnostic system of DÄVf received a considerable
amount of critique fi-om its start. Yet, in its ideal form, it is no more than the "objective-
descriptive sense" of phenomenology (Davidson & Strauss, 1995, p. 53). It might be true
that there is no such thing as an objective way to describe psychopathology, but still it is
important to try to distinguish between what we
think
and what we
see.
If we consult a
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Person-Centered and Experiential Psychotherapies, Volume 7, Number Î
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