In 1938, the term “borderline” was first used by A. Stern to describe individuals “on the border” of psychosis (Koerner and Linehan, 2000). Individuals afflicted by Borderline Personality Disorder, BPD, have unstable sense of relationship, mood, and identity. They exhibit low confidence on professional, sexual, and family relations and frequently experience depression, disappointments, and anxiety.
In connection to these, BPD patients are inclined to substance abuse, antisocial acts, erratic lifestyles, suicidal attempts, and self-mutilation. Specifically, BPD patients of ages below than 18 years are commonly diagnosed with identity confusion. The BPD cases have a prevalence of about 0. 2-4 percent in the general public and approximately 15-25 percent among the hospitalized psychiatric cases with co-occurrence of eating disorder and substance abuse (Koerner and Linehan, 2000).
Different hypotheses offer a possible etiology for BPD. Some of which ascribed it to the brain’s constitutional defects in different neurotransmitter systems like in the serotonergic, andrenergic, dopaminergic, and cholinergic systems while other hypotheses associated it to the history of learning disabilities, encephalitis, head trauma, severe hyperactivity, and epilepsy (Koerner and Linehan, 2000).
On the other hand, in terms of developmental perspective, the excessive frustrations during childhood, physical-sexual abuse, constitutional predisposition, early parental loss, arrest in normal development, traumatic separation from parental figure and post-traumatic stress disorder are considered as contributing factors in the BPD development (Koerner and Linehan, 2000). Meanwhile, a long term psychotherapy involving reality-oriented or analytic techniques along with drug medications which include mood stabilizers, antipsychotic, and antidepressants is the therapeutic mainstay.
Borderline Personality Disorder and Marital Relations Borderline Personality Disorder is a mental illness which causes unstable behavior, self-image, moods, and interpersonal relationships to the affected individuals. Eventually, these instabilities will result to disruption of self-identity, family life, long-term planning, and work performance (Sholevar and Schwoeri, 2003). As well, a BPD patient may experience anxiety, violent bouts of anger, and depression for several hours or even a day leading to substance abuse, aggression, and self-injury.
About two percent of adults, mostly women, affected by BPD suffer from instability of emotion regulation which often leads to self-injury and suicidal attempts (Sholevar and Schwoeri, 2003). Consequently, the disruptions of self-identity and cognition of the affected individual cause distortion on his or her gender identity, long-term goals, jobs, values, jobs, and career plans and in the long run may result to unworthy or bad perception about his or her self.
As such, the afflicted individuals, more often than not, feel low self-esteem, empty, mistreated, bored, and misunderstood. In severe cases, BPD patients tend to feel lack of social support and isolated which may lead to impulsive avoidance of perceived abandonment. In relation to these, individuals with BPD are susceptible to turbulent social relationships (Sholevar and Schwoeri, 2003). They are prone to frequently agitated relationships and tend to abrupt shifting of attitude from love and admiration to anger and hate towards their family and friends.
Hence, they easily idealize and develop attachment to other person; however, in the occurrence of conflict, their attitudes suddenly shift to anger and hate the person they are formerly attached to. In addition, even to their family circles, BPD patients are sensitive to rejection and separation issues. They tend to exhibit other behavioral problems such as risky sex, excessive eating, and extraneous spending (Sholevar and Schwoeri, 2003).
The American Psychiatric Association (2000) postulated that a BPD patient most probably may have a chaotic and unstable marital relation which is attributed to the distortions in his or her affects, thoughts, and behaviors. Since, children in this kind of marriage are negatively affected by the behavioral exchanges between the couple, BPD treatment in terms of its cost and mandated implementation became a significant issue. Moreover, the study of Daley, Burge, and Hammen (2000) suggested that the presence and the degree of a personality disorder largely predict the impairment of an intimate relationship.
As such, the results of their study fundamentally supported the significance of BPD perspective as not merely just a categorical diagnosis but as a continuum of severity. Whereas every woman in their study was diagnosed with BPD potential, women with more subclinical BPD characteristics tended to practice maladaptive romantic lives (Daley, Burge, and Hammen, 2000). This observation generally implied that the utilization of categorical approach in BPD assessment through systematic diagnostic threshold in inadequate in the detection of variations in the relationship behavior among individuals.
Nonetheless, at subclinical levels, the BPD symptoms were not directly linked with dysfunctional marital relationships (Daley, Burge, and Hammen, 2000). Even though every personality disorder has an association with romantic dysfunction, the BPD symptoms failed to generate significant contributions beyond the other Axis II pathology (Daley, Burge, and Hammen, 2000). This signified the crucial role of a factor which underlies every personality disorder under the Axis II pathology for the determination of relationship adjustment. Borderline Personality Disorder and Dysfunctional Marriage
In 1938, the relationship between personality disorder and dysfunctional marriage was first noted by Terman, Wilson, Johnson, Buttenweiser, and Ferguson (South, Turkheimer, and Oltmanns, 2008). They hypothesized that the unique attributes of every individual impart them the possibility for relationship dissatisfaction. In 1995, the vulnerability-stress-adaptation model for marital relations was proposed by Karney and Bradburry (South, Turkheimer, and Oltmanns, 2008). This model illustrates the role of individual differences along with interpersonal processes in the achievement of marital satisfaction.
The model postulated that personality traits and couple’s vulnerability directly determine the couple’s endurance and their behavioral exchanges with respect to the stressful circumstances in their marriage. In relation to these, the symptoms of personality disorder have been tied up with serious couple’s conflict and marriage violence. Specifically, the partner-violence studies through behavioral analogue and factor-analytic techniques found that borderline personality and antisocial traits of individuals are predictors of the occurrence of violence in married life.
Nevertheless, through developmental research, the relationship of personality traits during childhood and adolescent years with temperament and abusive behaviors in an intimate relationship has been reported (South, Turkheimer, and Oltmanns, 2008). For someone married to a partner with BPD, the frequent turmoil in their relationship can either make their bond stronger or at worst, result to hatred and divorce. More often than not, dealing with the love-hate nature of marital relations is exasperating for every couple.
In particular, an individual can hardly understand a partner who at one time offers love and adorations then all of a sudden will just lose temperament and fall into horrific rages. This scenario would make the spouse of the BPD patient dumbfounded for the hastily anger may seem came from nowhere at all. The relatives of a BPD patient may experience stress and feel helpless as they witness their loved one suffering from self-destructive BPD symptoms (Sholevar and Schwoeri, 2003).
The immediate caregivers, the parents or the spouse are more susceptible to chronic stress due to the pitiful condition of the patient which at worst may even lead to psychological trauma especially for the patient’s children. For instance, as the patient engages into self-destructive behaviors like self-injury, burning, or suicidal attempts, the immediate caregivers are vulnerable to post-traumatic stress disorder because they directly observe the patient’s high-risks behaviors as they respond for help.
In line with this, the spouse of the patient may experience guilt as he or she tries to figure out the cause or his or her liability in the BPD development of the patient. Meanwhile, close relatives may want to support the patient but are afraid to do so because of the harm they may possibly beget from the self-harm behaviors of the patient. As well, family members may become impatient due to the patient’s disruptive behaviors. Nonetheless, family members, friends, and relatives may have inadequate knowledge about BPD; thus, they can hardly understand and give empathy to the patient.
In the long run, the relationship turmoil between the couple along with the stress and guilt of the patient’s spouse cause impatience, hatred and may even lead to divorce. Still, the atmosphere at home has a great impact on the personalities of the couple’s children. For example, the eldest among the siblings are often tasked to look after the needs of the patient while the youngsters are instructed to keep away from the patient to avoid emotional trauma or the possible physical harm they may beget.
Moreover, the extended family like uncles, grandparents, and close friends can also be affected as they relay aegis to the patient’s family. Couple’s Therapy An individual with a spouse afflicted with BPD can adapt to the behavioral problems of his wife or her husband by understanding the nature of BPD. Along with drug medications, therapeutic counseling is widely used to save marital relations from the consequences of BPD behaviors. Both Lachkar and McCormack in 1998 and 2000 respectively, suggested the creation of “holding environment” for couples with one partner having BPD (Oliver, Perry, and Cade, 2008).
In this approach, each partner, rather than withdrawing or projecting, is conditioned for the recognition of his or her subjective experiences. In particular, Lachkar proposed three fundamental functions: containment, empathy versus containment, and self-object (Oliver, Perry, and Cade, 2008). In containment, the counselor mirror and defuse the negative affects and projections in order to provide new means of images and experiences to the couple. On the other hand, the empathy or mirroring versus containment is necessary for the containment balance.
The couple also needs to experience empathy and mirror-back their statements and behavior to them. Thus, the counselor must know how to employ either one or the other so as to facilitate the effective relationship functioning and the healing process of traumatic experiences. Lastly, the self-object functions are designed for the structural repair of the self. In 2003, Fruzzetti and Fruzzetti identified the five functions for a complete dialectical behavioral therapy (Oliver, Perry, and Cade, 2008). Skill acquisition or enhancement is the first function in which specific skills are taught to individuals in every session.
Next in line is the skill generalization wherein the learned skills are applied to real life setting through planning and telephone advising. The client motivation or behavior change is the third function which requires the collaborative effort of the client and the counselor in identifying and changing the dysfunctional patterns. Then, the crucial skills and high level of motivation are the required functions in the development of enhancement and motivation capabilities of the counselor. Finally, the environment structuring is a required function to ensure the desired outcomes.
Gottman’s Approach In 1999, Gottman proposed the different levels for a sound relational house which include: marital friendship foundation which consists of admiration and fondness, cognitive space for one’s spouse, and turning toward versus turning away; override of positive sentiment versus the override of negative sentiments; conflict regulation which involves dialogue establishment and physiological soothing; and the creation of shared system of meaning such as meshing narratives, dreams, metaphors, and rituals (Oliver, Perry, and Cade, 2008).
Furthermore, Gottman argued that resistance can hardly be avoided in the therapy because it resulted from the disruptions in the various level components of a sound relational house of the relationships’ internal working model (Oliver, Perry, and Cade, 2008). Hence, BPD patients suffer from the distortions of internal working models with respect to relationships and the self.
Gottman further believed that the resistance due to the psychopathology of the individual is brought by his or her stable steady state, characterized by high negativity, and by the disruptions in the individual’s means of influencing and influence acceptance (Oliver, Perry, and Cade, 2008). Dialectic Behavioral Therapy In 1980s, at the University of Washington, Marsha Linehan developed the Dialectic Behavioral Therapy or DBT after the failure of the standard behavioral therapies she has employed in treating women with chronic suicidal attempts (Koerner and Linehan, 2000).
The DBT is an intensive and multimodal approach in the treatment of BPD. This form of therapy incorporated the cognitive-behavioral techniques with the time-tested Western contemplative and Eastern meditative medication approaches. These approaches with opposing notions, acceptance, and change were all integrated by means of a dialectical framework which can serve as a guide in the formulation and implementation of medication strategies. Since then, DBT has been utilized in the treatment of parasuicidal behavior among BPD cases and in other psychotic disorders.
On the basis of biosocial maintenance and etiology of BPD, the DBT was developed in order to provide a plausible explanation for the BPD attributes with consistency on behavioral theory and empirical research findings (Koerner and Linehan, 2000). As posited by the biosocial theory, the BPD development is triggered by a dysfunction in the emotion regulation system during childhood brought by the interaction of the emotionally susceptible child to the invalidating environment.
The immediate individuals in the child’s environment, either unknowingly or intentionally, invalidate the child’s emotional experiences which in turn result to the elevation of the child’s emotional responses which aggravate the environmental invalidating responses. Further, the biosocial theory argued that the child and the environment have biodirectional relationship; thus, both influence the continuous elevation and deescalation of the borderline behaviors. The DBT treats BPD behaviors as spontaneous products of dysregulated and maladaptive attempts of emotions regulations (Koerner and Linehan, 2000).
This model illustrated the characteristics of both individual and environment wherein the latter inhibits the development of the capabilities and potentials of the former. As such, BPD patients have low distress tolerance, interpersonal, and self-regulation skills. Hence, for any treatment approach, the development and enhancement of skills, capabilities, and motivation of every patient must be given prime importance. On the other hand, the therapeutic relationship between the BPD patient and the therapist poses a dialectic tension in which they can find themselves at the opposite sites of a particular issue.
The therapeutic process then attempts to synthesize these opposing views resulting to a new dialectical tension. For instance, the therapist may perceive that the suicidal tendency of the patient is the root cause of the problem while the patient may take this behavior as the solution. The possible synthesis of these positions may result to the notion that committing suicide is a maladaptive solution to the problem at hand. Then, this new position may necessitate the learning of new skills so as to smoothly adapt the patient into the present state of life.
DBT Treatment Stages Since DBT is a multimodal approach, the treatment is categorized into several stages, each of which has its own goals (Koerner and Linehan, 2000). In Stage I, the behavior is out of control as the individual possesses debilitating and pervasive problems. The first stage aims to facilitate the achievement of action control and stability as well as the natural life expectancy by preventing suicidal behavior, the development of the capability of helping individuals in reducing severe impediments, and the achievement of necessary skills for such tasks.
In the following stage, the individuals have attained reasonable action control. The Stage II then intends to gain understanding and at the same time to reduce the impact of early traumatic experiences, and to strengthen the individual’s endurance in emotional experiences in the absence of psychological trauma. In the third stage, the focus of treatment is on the resolution of residual problem behavior which hinders the attainment of personal goals. The BPD patient, with self-trust and respect, takes a pivotal role.
Finally, Stage IV aims for the sustenance of personal freedom and goals. This last treatment stage facilitates the patient’s achievement of spiritual fulfillment, vast awareness, and connection to the universe. Empirical Findings The randomized controlled DBT trials proved its efficacy on BPD behaviors such as suicidal tendency, substance abuse, depression, binge eating, anxiety, and other personality disorders across various populations (Koerner and Linehan, 2000).
In addition, a substantial number of nonrandomized controlled DBT trials have shown efficacy similar to the randomized controlled. Thus, in general, the results of DBT studies indicated its superiority against non-DBT controlled trials in the prevention and reduction of problem behaviors like substance abuse and suicidal behavior as well as treatment dropout and hospitalization, and the improvement of the general and social functioning of the BPD patients. References American Psychiatric Association. (2000).
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Arlington, VA: APA. Daley, S. E. , Burge, D. , and Hammen, C. (2000). Borderline Personality Disorder Symptoms as Predictors of 4-Year Romantic Relationship Dysfunction in Young Women Addressing Issues of Specificity. Journal of Abnormal Psychology, 109 (3), 451-460. Koerner, K. and Linehan, M. M. (2000). Research on Dialectical Behavior Therapy for Borderline Personality Disorder. The Psychiatric Clinics of North America, 23 (1), 151–167.