Is Borderline Personality Disorder Treatment Resistant?

A Reader brought this situation to my attention and I feel that it’s important enough to address in its own post because it is a problem in the clinical community concerning Borderline Personality Disorder. The Reader stated…
“I put this question to a psychotherapist from the Community Mental Health agency who came to evaluate my teen BPD  at the residential treatment center. She said that in her 20 years of practice, she had not seen BPD patients get better with age. Many stayed the same, but some got worse. She said the problem came from not being able to challenge or push them to improve. They cannot handle the challenge, and just wanted to come in and whine to her and seek justification and validation for their actions and emotions. Even when confronting them with this observation, they continued on with the same behavior. Often she would be the one to say “don’t come back if you don’t want to work on pathways to improvement.” It amazed her to see patients in their 60s coming in and dealing with the exact same issues she read in their charts from 30-40 years earlier.”
It sounds like your psychotherapist that you spoke to was not equipped to handle someone with Borderline Personality Disorder. This is quite common. When someone does not have the right tools to understand and work with the problem they easily become frustrated with their patients. It’s a failing on the part of both the patient and the practitioner. However it is not an accurate opinion to say that someone with BPD will never get better. If she has not seen any progress in a BPD patient I would 1.) question how many BPD patients she’s treated for an extended period of time (not just a couple months, I mean a couple years), and 2.) I would question whether she’s had any actual training that focuses on the specific issues of Borderline Personality Disorder. Not all psychotherapist have the same fields of study and are therefore not as qualified to deal with some kinds of people.
We can handle challenges, but because of the nature of our disorder it takes a different approach than someone who does not have BPD. It’s true that many people with BPD do seek therapy because they need validation, but a good therapist that understands the treatment of BPD is willing to take the time and put in the effort to help these people see through their actions and overcome their behaviors while building a more productive set of life skills.
You also can’t ‘merely confront’ someone with BPD and expect them to be able to change. Characterological problems, personality disorders, are deeply ingrained issues. Basic cognitive behavioral techniques are  not enough to correct deep psychological issues. It’s akin to slapping a band-aid on an amputation. As I spoke about previously, the very nature of personality disorders means that the way we perceive the world, how we interact with the world, how we experience emotion and our very selves is quite different than your average Joe. By extension, how we are capable of utilizing, dealing with, and incorporating therapeutic technique is also going to be different. That’s not to say that we don’t want to work through things, obviously this may not be the case, but since our base functioning is different, we need to approach these problems from a different point of view.
There are many faulty Assumptions made by clinicians regarding Borderline Personality Disorder (Click here to read them all).
Assumption: With brief training, patients can access their cognitions and emotions and report them to the therapist.
Cue the broken record. Someone with a Borderline Personality Disorder does not experience emotions the way a normal person does, by definition. Sometimes the buildup of emotion is so frustrating and such a jumble of so many different things that it’s impossible to distinguish individual thoughts or feelings. Or patients may block disturbing thoughts and images in a cognitive or affective avoidance of disturbing memories and negative feelings. When you learn that by avoiding negative stimuli you reduce your susceptibility to pain, it becomes ingrained into your habits and lifestyle. Breaking an instinctive pattern that you’ve developed as a maladaptive coping strategy isn’t easy. To first face those things that hurt you in order to finally move past them takes courage and time to reach that place of strength. Or you have someone like me that is dissociative on top of my other issues. Where something should inspire intense emotions all I can describe is…. A blank. A void of feeling like speeding to the pinnacle of Mount Everest with emotions ramping up higher and faster only to divert into a dark cave before you hit the top and, stop. How do you navigate the void? 
Assumption:   Patients can change their problematic cognitions and behaviors through such practices as empirical analysis, logical discourse, experimentation, gradual steps, and repetition.
The problem here is that our problems are rarely so straight forward. Our issues have issues.  “Because characterological patients usually lack psychological flexibility, they are much less responsive to CB techniques and frequently do not make meaningful changes in a short period of time. Rather, they are psychologically rigid. Rigidity is a hallmark of personality disorders. These patients tend toward hopelessness about changing. Their characterological problems are ego-syntonic: Their self-destructive patterns seem to be so much a part of who they are that they cannot imagine altering them. Their problems are central to their sense of identity, and to give them up can seem like a form of death – a death of a part of the self.” Do you know what it’s like to want to be rid of something, to despise it so much, and fear the losing of it in the same breath? Or to feel in your bones that something is so, despite all evidence to the contrary? I do.
Assumption: The patient is presumed to have problems that are readily discernible as targets of treatment.
Fill my emptiness please. What? You don’t have a prescription for that? No definitive list of reasons why this may be? It’s hard to treat a problem when you don’t have a clear idea of what the problem even is. Vague senses are difficult to discern for anyone, especially someone who has trouble connecting with how they feel in the first place.
If she’s actually saying “don’t come back if you don’t want to work on pathways to improvement,” that’s a huge red flag that this woman does not have a fundamental understanding of what Borderline Personality Disorder is. And frankly does not sound like a good therapist. A therapist should never give ultimatums to their patients. This is an outright statement of rejection and abandonment which will only make the Borderline patient more confused and hurt. It’s insensitive and hurtful.
It’s a huge stigma in the clinical community that believes BPD is treatment resistant. This is often a problem in the therapeutic technique, not that someone with BPD is resistant. Some styles of therapy are not conducive to treating Borderline Personality Disorder or one technique is simply not enough. It’s often difficult for us to internalize some concepts because the nature of BPD is so transient. What may work for someone without BPD probably won’t work the same for us. Or what does work for us one minute, may not work for us in another because our moods shift so rapidly. All this means though, is that we need to focus on changing our overall mentality, not just on techniques to get us through a situational development (though these can be helpful!). We can’t just record, talk through, and repeat new behaviors and expect them to work right away because these are things that are ingrained in our character, not a learned behavior that we’re just trying to reverse. It might take a variety of integrated techniques, not just one, but treatment is absolutely possible!
Another clinical stigma is that someone with BPD will never get better. With this attitude many clinicians adopt an attitude of hopelessness for someone with a Borderline Personality Disorder. They won’t even bother to treat someone with BPD because they don’t have the knowledge of current treatments and options for the patient. Because it requires more effort to change characterological problems many won’t read updated information and therefore remain stuck in outdated modes of thinking. This is not the patients fault. This is the failing of the clinician.
Whoever this psychotherapist you talked to was, I would seriously take her opinions with a big grain of salt and seek out someone who is specifically equipped to handle Borderline Personality Disorder. Talk to a clinician that specializes in Schema Therapy or Dialectical Behavioral Therapy. In recent years there have been HUGE steps made towards progressively treating Borderline Personality Disorder. It’s not a quick fix. There is no quick fix. It does take time and effort, but it is absolutely possible to learn to deal with and overcome this disorder.

7 comments on “Is Borderline Personality Disorder Treatment Resistant?

  1. Apparently I have a good karma: I was lucky to find a therapist who is equipped to handle BPD.Frankly, in my relationship with my therapist I feel like I have met the first human being on Earth, for the first time in my life, like all the people I have ever met before – were aliens, or robots. It is scaring, to feel this difference. Therapy can be very triggering and the attachment gets very scaring, it can be very painful because of the abandonment issues etc., but the therapist also helps to deal with those fears, pain and flashbacks (nobody helped me to deal with my fears and intense feelings before, not really, ever). At least it's worth it, because it works, and has sense. Thinking about all the pain and terror I experienced before that was not worth it, that had no sense and had no positive results (except for: here we go, I learned another thing that definitely does not work for me, what's next?), at least now I know where I am heading, and I am aware of what is going on with me. And now (as first signs of progress probably), life also gives me it's gifts in form of joy, not toxic joy, but pure joy – a thing I was not very familiar with before.

  2. Hand on your heart:Just by being borderline you are automatically a “horrible person”. You are a predator. That is your very nature. The only really effective treatment for borderlines/monsters is euthanasia.

  3. You are such a great writer and you are so very educated. I write in my blog about my own experiences with BPD, but nothing as amazing as you. I went through DBT for over a year and have been out for about the same amount of time and just last month i started to slip and times have been tough. I am thankful for my therapist who understands me and knows DBT skills and is educated in BPD, but growing up I had many therapist who had no clue and didn't help at all.Some days i feel like this is a never ending fight and there is really no point… no matter how hard i try and how much i work at it, i always end up in the same spot later down the road. You give me hope. Thank you!

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