Borderline Personality Disorder (BPD)is one of the hardest disorders of all to treat. It can be improved with some therapies, but the road is long and hard. Many seem to go on for years or decades with little or no improvement. There are reports of cures, and I am familiar with a woman whose BPD cleared up at age 55 after having come on in childhood. That’s probably a typical cure. Decades of nasty illness followed by a lifting of the illness in middle age.
Many mental disorders improve in middle age, and even many personality disorders improve during this age period.
Schizophrenia often ‘burns out” in middle age, and florid positive symptoms are replaced by more negative symptoms.
Many anxiety disorders attentuate in middle age.
Even psychopaths often get better or at least less destructive in middle age, as many of them also burn out in a similar fashion as schizophrenics. A number of highly antisocial psychopathic men get better in middle age as the antisocial behavior attentuates. It is often replaced by depression, heavy drinking and a pessimistic, cynical, imbittered and misanthropic person who nonetheless does little damage to society anymore.
It should be noted the clients with BPD vary widely in their symptom pathology. Some are much more functional than others. Quite a few can even function well at their jobs all day, but when they come home from work, they fall apart and shift into full BPD pathology.
However, some people with BPD are so ill that they seem nearly untreatable. It is these people who will be the subject of this post, not BPD’s in general. These people seem so far gone and broken that one wonders how anyone could ever even begin to put them back together again. I suppose some progress could be made, but the damage is so severe that I have a hard time seeing how even the best therapist could possibly fix these people in any significant way.
A typical case might be a young woman who, only in her late 20’s to early 30’s, already has 8 -13 suicide attempts and many hospitalizations behind her. She goes into the hospital on a regular basis. Therapy seems to do nothing but feed her pathology as she manipulates gullible new therapists to believe her lies, nonsense, and projections as the new therapist confuses symptom pathology with the truth. Drugs do almost nothing.
Diagnosis itself is often difficult because the BPD is so severe that the person often appears psychotic/delusional. One wonders what are delusions and what are not. Even the delusions do not seem to last for long, as they are dropped, changed around, added to or substituted in a wildly chaotic fashion.
Usually there is a lot of combativeness and involvement with the court system, as the extreme rage leads a litigious person.
Splitting is severe and textbook.
Self-image is so unstable that the person almost literally adopts the full personality and even persona of whomever is on their radar at the moment. The clinician needs to be prepared that this person will so identify with the clinician that they will adopt the therapist’s image and persona as their own. Boundaries nearly do not exist for these people, and they often fall in love with their therapists, try to seduce them, or on the other hand become furious at them to where sessions became rage attacks at the therapist, and the therapists is at odds of how to respond without violating ethics.
The client can become overtly suicidal even during sessions, and infatuation with the therapist can quickly split to where the therapist is the source of all evil. Homicidal threats and homicidal-suicidal threats against the therapist may now appear. The client then hospitalizes themselves due the “horrible trauma from the evil, incompetent therapist” and soon finds sympathetic new therapist, typically a feminist woman, to unload her story on. The new female therapist forms an alliance with the client against the “evil male” former therapist and accuses him of damaging the client.
Commonly, the therapist gets angry and tells off the client. This leads to abandonment and a vengeance agenda against the therapist, who has now “irreparably damaged” the BPD and “caused them to spiral out of control.” Be prepared to get accused of abandonment, causing severe trauma in the client and making them dramatically worse. The client may become hospitalized due to allegations of damage from an incompetent therapist.
These people are so difficult and chaotic that many clinicians refuse to see Borderline patients. Some are on the record as saying that when they say a Borderline client coming their way, they hide under their desk until they go away. For a lot of therapists, these clients are nothing but trouble, and endless parade of drama and chaos. Therapy itself is chaotic, mercurial, and wild with severe splitting and often extreme idealization of the therapist for good or ill or both, interrupted by fairly regular hospitalizations. The therapist begins to wonder what’s in it for them and thinks you could not pay them enough to suffer through such clients. These clients make an excellent argument that therapeutic abandonment is the proper choice with some clients.