Borderline Personality Treatment Goals - Regulating Emotions, Relationships, Self-Image

Understanding Borderline Personality Disorder

Borderline personality disorder (BPD) is a complex mental health condition characterized by difficulties with emotional regulation, unstable interpersonal relationships, and a distorted self-image. People with BPD often experience intense and fluctuating emotions, impulsive behavior, and chronic feelings of emptiness or boredom.

While the causes of BPD are not fully understood, research suggests that genetic, environmental, and social factors play a role. Childhood trauma, inconsistent parenting, and neurological differences are thought to contribute to the development of BPD symptoms.

BPD affects 1-2% of the general population and occurs more frequently in women. The disorder often emerges during adolescence or early adulthood, although symptoms may not be recognized until later. BPD can significantly impact relationships, work or school performance, and quality of life.

With appropriate treatment and support, many people with BPD can find relief from their symptoms and improve their overall functioning. However, BPD is often misunderstood and stigmatized. Raising awareness and providing compassionate care are essential for those struggling with this condition.

Goals of BPD Treatment

The main goals of BPD treatment are to:

• Reduce dysfunctional emotional responses
• Improve impulse control and decision-making abilities
• Foster healthy relationships
• Enhance self-image and identity
• Promote emotional stability and positive coping skills

Achieving these goals can relieve painful BPD symptoms, prevent self-harm and suicidal behavior, and allow individuals to pursue meaningful life activities like work, education, and relationships.

Regulating Emotions

People with BPD often struggle with intense and rapidly fluctuating emotions that feel out of control. Goals include learning to identify, accept, and express feelings in healthy ways. This may involve:

• Increasing awareness of emotions
• Developing distress tolerance techniques
• Practicing mindfulness and relaxation skills
• Reducing emotional reactivity and mood swings

Improving Impulse Control

Acting impulsively without consideration of consequences is common in BPD. Treatment aims to enhance contemplative decision-making abilities. Goals involve:

• Slowing down to evaluate options before acting
• Considering long-term impacts of behavior
• Resisting urges to self-harm or attempt suicide
• Making rational choices despite emotional distress

Developing Healthy Relationships

Unstable interpersonal relationships frequently occur with BPD. Treatment strives to build relationship skills like:

• Communicating needs and boundaries assertively
• Managing fears of abandonment or engulfment
• Compromising instead of splitting people as "all good" or "all bad"
• Practicing empathy and consideration of others' perspectives

Improving Self-Image

People with BPD often feel inadequate or have shifting beliefs about themselves. Goals involve:

• Developing a stable, positive identity
• Building self-confidence and self-efficacy
• Cultivating self-acceptance, self-compassion, and self-respect
• Recognizing personal strengths and talents

Promoting Emotional Stability

Finally, an overarching treatment goal is to enhance overall emotional stability. This means:

• Reducing mood swings and emotional extremes
• Coping effectively with stressors without crisis
• Experiencing emotional balance most of the time
• Feeling resilience in the face of setbacks or triggers

Therapeutic Approaches for BPD

Various types of psychotherapy can help individuals work toward treatment goals for BPD. Common approaches include:

Dialectical Behavior Therapy (DBT)

DBT is considered the gold standard treatment for BPD. It uses cognitive-behavioral techniques within a validating framework. Goals include:

• Building emotion regulation, distress tolerance, and interpersonal effectiveness skills
• Encouraging acceptance of the self and life circumstances
• Balancing change and acceptance strategies

DBT is often conducted in group and individual therapy over 6-12 months. Skills training, diary cards, mindfulness practice, and phone coaching help reinforce learning.

Mentalization-Based Therapy (MBT)

MBT aims to enhance mentalization or understanding one's own and others' behaviors in terms of thoughts, feelings, and intentions. Goals involve:

• Increasing capacity to mentalize during emotional interactions
• Understanding impact of behavior on relationships
• Regulating emotions through improved mentalization

Treatment takes place in group and individual settings over 12-18 months. Role playing, exploring past relationships, and focusing on the therapeutic relationship help develop mentalization skills.

Transference-Focused Therapy (TFP)

TFP uses the relationship between client and therapist to gain insights into relationship patterns. Goals include:

• Exploring client's experience of therapist
• Identifying maladaptive interpersonal patterns
• Developing more flexible, reality-based perceptions of self and others

TWP involves twice weekly individual sessions over a year or more. The therapist adopts a neutral but inquisitive stance, allowing transference to emerge and be explored.

Schema Therapy

Schema therapy focuses on unmet childhood needs that create lifelong maladaptive schemas. Treatment aims to:

• Identify self-defeating schemas like defectiveness or abandonment
• Change schemas by understanding their origin and meeting unmet needs
• Develop healthier coping styles and emotion regulation abilities

Schema therapy integrates CBT, gestalt, and psychodynamic techniques over approximately 50 sessions. Imagery, dialogues, empathy, and psychoeducation help modify schemas.

Systems Training for Emotional Predictability and Problem Solving (STEPPS)

STEPPS provides group skills training on:

• Identifying and managing emotions
• Building relationships
• Communicating effectively
• Regulating intense emotions
• Responding to problems in healthy ways

The 20-week program uses cognitive-behavioral methods. Role plays, discussions, and exercises strengthen skills. Support groups and booster sessions help maintain gains.

Psychodynamic Therapy

Psychodynamic approaches explore the unconscious roots of BPD. Goals include:

• Gaining insight into subconscious themes driving behavior
• Working through inner conflicts related to childhood experiences
• Transferring repeating relationship patterns to the therapeutic relationship

Long-term therapy focusing on interpreting resistance, transference, and dreams can modify entrenched patterns developed in childhood.

Good Psychiatric Management (GPM)

GPM integrates medical, psychological, and social interventions. Treatment aims to:

• Provide education about BPD
• Improve motivation for change
• Medicate conditions like depression that exacerbate BPD
• Coordinate care across treatment settings

GPM enhances motivation, forms a therapeutic alliance, and manages crises in a structured, goal-oriented approach.

Integrative Treatment Strategies

Given the complexities of BPD, integrated treatment combining multiple approaches is often most effective. This may mix:

• Individual, group, and family therapy
• Cognitive-behavioral and psychodynamic techniques
• Medication and psychological interventions
• Inpatient, outpatient, and community support

A team approach integrating psychiatric care, psychotherapy, and social services provides comprehensive treatment. Different levels of care are used over time as symptoms improve.

Addressing Acute Symptoms

In crisis situations with self-harm, suicidality, or psychosis, hospitalization may be needed to provide safety. Goals involve:

• Containing dangerous behaviors like self-injury
• Stabilizing moods, thinking, and behavior
• Adjusting medications to relieve symptoms
• Developing a post-discharge treatment plan

Building Community Supports

Ongoing community mental health services help maintain stability. These include:

• Assertive Community Treatment (ACT) teams
• Intensive Case Managers (ICMs)
• Clubhouse programs
• Drop-in centers and warm lines
• Peer support and shared living

Such supports reduce social isolation, provide advocacy, and give round-the-clock assistance to manage persistent symptoms.

Addressing Co-occurring Conditions

BPD often coincides with other mental health and substance use disorders. Concurrent treatment of conditions like trauma, eating disorders, or addiction supports overall goals like:

• Stabilizing moods
• Preventing self-medication of symptoms
• Improving impulse control
• Cultivating self-care and coping skills

An interdisciplinary team can address the biological, psychological and social aspects of co-occurring disorders.

The Role of Medications

While meds don't treat BPD itself, they may relieve accompanying symptoms or disorders. Medication goals include:

• Reducing depressed or anxious moods
• Controlling impulsive aggression
• Improving concentration and sleep
• Providing emotional stability

Medications like mood stabilizers, atypical antipsychotics, and antidepressants have demonstrated benefits. However, their role is viewed as subsidiary to psychotherapy in treating BPD.

Medication Challenges

Using meds for BPD poses some difficulties, including:

• No medications approved by the FDA specifically for BPD
• High placebo response rates in clinical trials
• Mixed evidence for efficacy of different drug classes
• Low compliance due to sensitivity to side effects
• Drug or alcohol use limiting medication effectiveness
• Risk of overdose when combined with impulsiveness

Careful monitoring, psychoeducation about medications, and preferred use of certain agents can help maximize benefits and safety.

Common Medications Used

While not definitive, medications for associated BPD symptoms may include:

• Antidepressants - SSRIs like Prozac to treat mood swings and depression
• Mood stabilizers - Lithium and Depakote to reduce extreme emotional highs and lows
• Antipsychotics - Abilify and Seroquel to control stress-induced paranoia or dissociation
• Sedative-hypnotics - Ativan or Klonopin for anxiety, insomnia, and impulse control

Low doses and slow titration minimize side effects. Polypharmacy or use of multiple medications may be required given multifaceted symptoms.

Psychoeducation as an Adjunctive Tool

Psychoeducation is crucial for improving BPD treatment compliance and outcomes. Goals include teaching clients and family members about:

• BPD symptoms, development, and course
• Relationship between thoughts, feelings, and behaviors
• Treatment options and self-help strategies
• Medication effects and side effects
• Developing a relapse prevention plan

Psychoeducation reduces stigma, empowers clients, enhances coping abilities, and allows early intervention for symptom flare-ups.

Methods of Psychoeducation

Psychoeducation can be provided through:

• Therapist consultations
• Informational brochures and workbooks
• Websites, videos, and podcasts
• Support groups and peer services
• Group therapy and classroom settings
• Conferences and seminars for clients and families

Multimedia tools and repetition of key concepts across settings helps reinforce learning.

Involving Family Members

Including family in psychoeducation:

• Improves home environment during and after treatment
• Teaches effective communication and coping strategies
• Provides skills to disengage from dysfunctional interactions
• Enhances social support and accountability
• Reduces enabling and adversarial relationships

Family education along with individual and group therapy can facilitate progress on BPD goals.

The Importance of Client Motivation

Client motivation represents a pivotal factor influencing BPD treatment success. Those who fully engage in the therapeutic process tend to have the best outcomes. Motivation can be enhanced by:

• Therapist empathy, warmth, and positive regard
• Rewarding steps made toward treatment goals
• Celebrating even small improvements in functioning
• Adopting a non-judgmental, collaborative approach
• Conveying hope and optimism about recovery

Motivational Interviewing techniques help clients resolve ambivalence about change. A supportive alliance boosts motivation to persevere through the ups and downs of therapy.

Overcoming Treatment Challenges

Clients with BPD may experience several obstacles that hamper motivation, including:

• Feelings of shame, failure, or pessimism
• Trouble recognizing how behaviors affect emotions
• Difficulty trusting therapists or authority figures
• Running away or avoiding problems
• Regressing after periods of progress

Patience, empathy, consistency, and praise of each positive step can help clients work through motivational barriers.

Utilizing Crisis Periods

Renewed desire for treatment often emerges after crises like:

• Job loss or divorce triggered by BPD symptoms
• Hospitalization due to self-harm or a suicide attempt
• Psychotic breakdown reflecting emotional overload
• Substance abuse relapse or overdose

Leveraging these pivotal moments to highlight the benefits of therapy can augment motivation for change.

Creating a Strong Therapeutic Alliance

The relationship between client and therapist significantly impacts BPD treatment. A strong therapeutic alliance provides social support, bolsters change, and models healthy relating. Key elements include:

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Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.