I don’t think there is any diagnosis that evokes stronger emotional reactions and judgments from counselors than that of Borderline Personality Disorder. I have been consistently surprised by the number of therapists I have seen rolling their eyes and throwing up their hands, dismissing these clients saying, “She’s Borderline.” I have not seen these types of strong responses with any other diagnosis or problem.
I can’t help but think that when we dismiss these clients as hopeless and incurable, this must grieve the heart of God.
According to the DSM-V, Borderline Personality Disorder is defined as, a pervasive disorder of the emotion regulation system. It is characterized by profound instability in interpersonal relationships, self-image, and affects, and marked impulsivity (DSM-V, 2013).
In the therapist’s office, individual’s struggling with these vulnerabilities tend to display extreme emotional deregulation, therapy-interfering behaviors, co-occurring substance abuse problems, eating disorders and other high-risk behaviors (like suicidal ideation, suicide attempts and self-mutilating behavior such as cutting).
It is true that clients with these types of difficulties often present in a way that challenges the therapist. They are frequently given the title, “bad patient” or “treatment resistant”. I wonder if this is precisely the reason why we are tempted to dismiss them. They challenge us and therefore it can bring out our own frustrations, vulnerabilities, defenses and weaknesses as individuals. I would like to suggest that this is a great place for us to be…out of our comfort zone and in need of help!
But he said to me, “My grace is sufficient for you, for my power is made perfect in weakness. Therefore I will boast all the more gladly about my weaknesses, so that Christ’s power may rest on me.” 2 Corinthians 12:9
In our own power, we are incapable of moving our clients with Borderline Personality Disorder forward toward true healing and wholeness. It is God who does the work and we are but a vessel. We need to have the Holy Spirit help us to bring the love and compassion of Jesus to relieve and heal the physical, emotional and spiritual suffering in our clients.
It is true that some of our clients are easy to love and some of our clients are more difficult to love. Yet, aren’t we called to love those who are difficult to love?
“If you love those who love you, what reward will you get? Are not even the tax collectors doing that?” Matthew 5:46
God wants us to love our Borderline clients and do our best to help them find healing. This often takes humility, patience and a willingness to draw God down into the therapy session when we may feel weak and powerless to move these clients toward true healing and wholeness.
When I think of the deep suffering that clients with Borderline Personality often endure, it makes me think of Mark 5: 25-34. In this passage, we read the story of how Jesus brings healing and wholeness to a woman who had been suffering for a very long time. Many people had given up on her dismissing her as irredeemable. She had struggled for 12 painful years with hemorrhaging and was unable to find any relief. Although this appears to be a physical illness, it is not hard to imagine that she must have suffered socially, emotionally and spiritually too as her bleeding would have made her unfit for the company of others. She would have been someone that others avoided, as she was an outcast and one who was considered ‘unclean’.
This woman had looked for healing, and ended up going to see many, many doctors and spending all that she had. We are told:
“She had suffered a great deal under the care of many doctors and had spent all she had, yet instead of getting better she grew worse.” Mark 5:26
At some point, even the doctors had given up on her, seeing her as incurable. She must have felt isolated, alone, ashamed and perhaps even dejected, depressed and nearly hopeless….
Until she heard that Jesus was nearby, and then everything changed…
She moved swiftly and desperately, pressing herself toward Jesus in the crowd. She thought to herself, “If I just touch his clothes, I will be healed” (Verse 29). When she reached Him she touched the tip of His robe. Immediately, she felt in her body that she was freed from her deep suffering. Jesus then asked who had touched Him and He looked for her. She came to Him trembling and fell at his feet. Jesus commended her for her faith saying, “Daughter, your faith has healed you. Go in peace and be freed from your suffering”.
In my work as a counselor, the majority of my clients struggle with Substance Use Disorders, Eating Disorders, Mood Disorders, Trauma and Personality Disorders. I have personally seen a look in the eyes of many of my clients that I imagine the woman in this passage of Scripture must have had with each doctor she went to see. After seeing many other therapists before me, theirs is the gaze that seems to inquire, ‘Will you be the one who can help me? Will you be the one that can free me from this physical and mental prison? ‘
In the United States alone, it is estimated that 18 million individuals suffer from Borderline Personality Disorder (NIMH website, 2015). Unfortunately, it is often underdiagnosed or misdiagnosed. Borderline clients often endure great suffering on a daily basis and receive constant messages from their body and brain that their inner state is aversive or painful.
Borderline clients are typically not helped by psycho-dynamically oriented therapists and tend to have been treated by 5-10 therapists, on average, yet to no avail (Dimeff, 2010). These clients often incur great expense as they seek healing, like the woman in Mark, and often require long-term solutions for care.
It may be useful for us to remember that research suggests that Borderline Personality Disorder is due, at least in part, to several brain abnormalities that result in cognitive impairment as well as problems regulating emotional responses. There is also evidence to suggest that problems with emotion regulation can be due to differences in the Central Nervous System in some patients due to genetics and events that occurred during fetal development or early life trauma (Dimeff, 2010).
In other words, individuals struggling with Borderline are not really “bad people with a bad personality”. Most often they are biologically vulnerable individuals who have deep-seated trauma and a history of growing up in an invalidating environment. Of course there is often great variability in clients with Borderline Personality Disorder and, as is true with other mental health diagnoses, there exists a continuum of behavioral and emotional deregulation.
We also need to remember that research suggests there is healing for Borderline Personality disorder. In fact, there is evidence to suggest an 84% remission rate over time for the illness (NIMH, 2015). With advances in neuroscience we now know that brain neuroplasticity profoundly effects the outcomes of treatment for individuals struggling with mental illness. Treatment can actually change the brain and this is certainly true for individual’s struggling with Borderline Personality Disorder symptomology.
One of my favorite therapies to use with individual’s experiencing deep emotional pain and deregulation is Dialectical Behavior Therapy (DBT). It is efficacious for treating Borderline Personality Disorder as well as treatment-resistant depression, substance use disorders, eating disorders and suicidal or at-risk adolescent clients (Linehan, 2015). I think it is also interesting to note that DBT is also now used in the treatment of complex PTSD, according to trauma experts (Dimeff & Koerner, 2007). In fact, our existing understanding of Complex PTSD actually comes from a reframing of the diagnosis of Borderline Personality Disorder where many, but certainly not all have experienced some type of trauma or are part of a history of intergenerational trauma or disorganized/disoriented attachment (Linda Curran in Dimeff & Koerner, 2007).
DBT is a therapy that balances the client’s need for acceptance and the client’s need for change. Part of this therapy is skills training where the therapist teaches the client; 1) Mindfulness to decrease identity confusion, emptiness and cognitive deregulation; 2) Interpersonal effectiveness to address interpersonal chaos and fears of abandonment 3) Emotion Regulation and Self-management to reduce changing affect and excessive anger; and 4) Distress Tolerance to help reduce impulsive behaviors, suicide threats and intentional self-injury. Often these skills give real-time relief from the inner turmoil experienced by these clients.
In terms of the therapist’s stance, these clients need us to offer them a compassionate, non-judgmental attitude of acceptance and validation. When we sit with them, we must attempt to enter in to the client’s reality and deep suffering. When we do, we realize that our Borderline client is really doing the best that he or she can with what she has been given. The behaviors the client is exhibiting are very often a maladaptive attempt at meeting unmet needs. We want to balance this out, however, and believe in the client’s desire and inherent ability and capacity to grow and change.
As someone who sits with those who are suffering day in and day out, I realize that true compassion is not seeing myself as ‘well ‘and the client as the one in need of healing. It is really a relationship between equals. Only when we know our own suffering and need for a Savior well can we have true compassion for the pain and suffering in others. Compassion becomes real when we acknowledge our own brokenness.
“Praise be to God, the Father of our Lord Jesus Christ and the God of all compassion, who comforts us in our distress so that we might comfort others with the same comfort God has given us”. 2 Corinthians 1: 3-5
Let us reach out our hands then and offer that comfort and hope for healing to all of our clients. We want to lead them to the feet of Jesus where they can touch His robe and be made fully whole. Yet, we do not want to leave them there alone. This is ultimately where we too should be sitting, trembling with thanksgiving. Indeed, it is the blood of Christ that cleanses us from all of our sin and leads us to true wholeness and freedom ourselves.
May God richly bless you and fill you with love and compassion as you minister to those who are hurting.
Dimeff, L. A. (2010). Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change. Oxford: University Press.
Dimeff, L. A. and Koerner, K. (2007). Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings. New York: The Guilford Press.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, (DSM-5). Washington, DC: American Psychiatric Publishing.
Holy Bible, New International Version (2006). Michigan: Zondervan.
Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets: Second Edition. London: The Guilford Press.