Chapter 4
A Reflection of Our Times: The Borderline Society
Psychological theories reflect their cultural context-Freud's sexual repression theories emerged from Victorian society, while today's more open yet confused social structures create different psychological challenges. Social factors interact with BPD in several ways: changing family structures affect child development; society's lack of structure exacerbates borderlines' difficulties with self-organization; and personality disorders may represent natural responses to contemporary culture.
Post-WWII society has become increasingly fragmented, with traditional family structures replaced by diverse patterns amid rising divorce rates, substance abuse, and economic uncertainty. Society fails to achieve "social rapprochement"-just as infants need to venture from and return to maternal security, people need stable social anchors. The need for dual incomes forces parents to relinquish childcare duties, while job mobility uproots families from stabilizing networks.
Our society's devaluation of the past has broken our sense of historical continuity, leaving us disconnected from both our predecessors and posterity. Time becomes perceived as isolated points rather than a continuous string influenced by past, present, and future. The constant threat of catastrophe-nuclear war, terrorism, environmental destruction-contributes to widespread hopelessness, especially among youth. The borderline personifies this "now" orientation, living without comforting memories to sustain them through difficult times, doomed to repeat mistakes.
The landscape of interpersonal relationships has transformed dramatically-from the sexual repression of the 1950s through the sexual revolution to today's digital dating world where relationships begin with keystrokes. Personal relationships have taken on "the character of combat," a battlefield where borderlines paradoxically thrive. Their masochistic tendencies fit well with narcissistic partners, creating dysfunctional dynamics where pain becomes equated with love.
Modern society has fractured once-integrated social roles, forcing individuals to juggle multiple, often conflicting identities. Women face particularly bewildering role expectations-from career woman to traditional mother to "supermom"-which may explain their higher rates of BPD diagnosis. The price of increased social options for women has been agonizing life decisions, strained relationships, and profound identity confusion-all central components of borderline personality disorder.
With fragmenting society and dissolving families, "faux families" or virtual communities have emerged to replace real communities. People seek tribal affiliation through sports fandom ("Raider Nation"), television voting (American Idol), or social networks (Facebook, Twitter). This reflects growing American narcissism documented since the 1970s, manifesting through reality TV, plastic surgery, celebrity worship, and social networking's "Look at me!" mentality.
Chapter 5
Speaking the Borderline Language: The SET-UP System
The borderline shifts personality like a kaleidoscope, transforming into whatever shape might please the viewer. Their explosions of anger, mood swings, suspiciousness, and unpredictable outbursts frustrate everyone around them. Effective communication requires understanding the SET-UP system-a structured method for family, friends, and therapists to use during borderline crises.
"SET" stands for Support, Empathy, and Truth-a three-part communication system for confrontations with borderlines. Support involves personal "I" statements of concern ("I am sincerely worried about how you are feeling"). Empathy acknowledges the borderline's feelings with "You" statements ("How awful you must be feeling"), avoiding sympathetic condescension. Truth emphasizes the borderline's ultimate accountability ("What are you going to do about it?").
Communication should include all three elements, as predictable problems arise when any part is missing or not "heard." When Support is bypassed, the borderline accuses others of not caring. Without Empathy, they feel misunderstood. Most dangerously, when Truth is missing, the borderline develops unrealistic expectations that eventually collapse in anger and disappointment.
SET-UP principles can defuse unstable situations involving borderlines, who often create no-win scenarios through contradictory messages. In the case of Gloria threatening suicide while forbidding her husband Alex from seeking help, she creates a double-bind: if he ignores her, he's uncaring; if he argues against suicide, he doesn't understand; if he calls authorities, he's untrustworthy. Using SET principles, Alex should express Support ("I love you and want to help"), Empathy ("The pressure must be unbearable"), and Truth ("Your alerting me shows part of you wants help, and I must respond to that part").
Borderlines often spiral downward by feeling bad about feeling bad. Their perfectionism and black-and-white thinking leads them to attempt to eliminate unpleasant emotions rather than cope with them. When unsuccessful, they layer guilt and frustration atop the original feelings, creating a bottomless descent. The solution lies in SET-UP communication that helps the borderline accept negative emotions as real and appropriate without self-condemnation.
For borderlines living in a world of inconsistencies, idle threats about unenforced consequences are worse than allowing inappropriate behaviors to continue. Intentions must be backed by clear, predictable actions. Parents or therapists who don't follow through on stated boundaries invite increased testing. Beyond SET principles, Understanding and Perseverance are essential-having a consistent, unflappable figure who provides a model of constancy may be one of the most important requirements for healing.
Chapter 6
Living with the Borderline: Practical Strategies
BPD is an illness, not a willful attempt to get attention. The borderline lacks the metaphorical bootstraps to pull himself up, making anger or pleading useless. However, this doesn't mean borderlines shouldn't be held responsible for their conduct. Like someone in a wheelchair, they deserve sympathy but must still accept the consequences of their actions and find ways to navigate their challenges.
Borderline rage erupts without warning and appears disproportionate to the situation. The best approach is to remain calm as the borderline escalates-the quieter and more composed you become, the more it highlights the unreasonable intensity of their anger. Leave immediately if physical violence seems possible. Don't attempt to reason with borderline rage; instead, acknowledge differences and agree to disagree, saving further discussion for calmer moments.
Rapid mood shifts confound both borderlines and those around them. Meredith could swing from joy to despair without warning, leaving her husband Ben in a "damned if you do, damned if you don't" dilemma-confronting her depression triggered withdrawal, but ignoring it seemed uncaring. Using SET-UP principles helped by involving Meredith in determining appropriate responses to her moods. For Meredith, recognizing her mood shifts, taking responsibility for them, and developing compensatory strategies became crucial.
When involved with a borderline, you'll experience powerful emotions-especially guilt, fear, and anger. Borderlines often project responsibility for their self-destructive behaviors onto others who readily accept it. Guilt inhibits honest confrontation, fear of harm prevents interaction, and anger emerges from feeling manipulated. Only by extracting yourself from this pattern can you break the cycle and force the borderline toward healthier self-sufficiency.
Parents should recognize that adolescence and BPD share striking similarities: struggles for individuality and separation from parents, seeking peer bonds and group identification, avoiding solitude, dramatic mood changes, and impulsivity. However, while normal teens may listen to gloomy music, write pessimistic poetry, and dramatically threaten, they don't cut wrists, binge and purge repeatedly, become addicted to drugs, or attack parents. All threats of self-harm must be taken seriously, as even "attention-seeking" attempts can go tragically wrong.
In workplace settings, borderlines can be exceptionally creative, dedicated employees who function best in well-defined environments with clear expectations. Coworkers should recognize the borderline's black-or-white thinking, avoid teasing or mockery, offer frequent compliments for good work, and provide matter-of-fact feedback about mistakes.
With age, many borderlines "mellow out" as impulsivity, mood swings, and self-destructive behaviors diminish in intensity. This improvement may reflect actual change, observers becoming desensitized to erratic behavior, the borderline settling into more routine lifestyles, or simply diminished energy for maintaining borderline intensity. Most borderlines improve over time, with or without treatment, eventually no longer meeting the diagnostic criteria. Long-term prognosis is hopeful, as borderlines gradually learn healthier ways to love and be loved.
Chapter 7
The Healing Journey: Therapeutic Approaches
Treating borderline personality places immense strain on therapists' professional abilities and patience. Sessions are often stormy and unpredictable, with progress painfully slow and many patients dropping out within months. The difficulty stems from borderlines approaching therapy like other relationships-viewing the therapist as alternately caring or deceitful. They can be extremely demanding, calling constantly between sessions, appearing unexpectedly with threats of self-harm, and skillfully provoking therapists into frustration and self-doubt.
The American Psychiatric Association identifies psychotherapy as primary, complemented by targeted medications. While strict behavior modification and classical psychoanalysis are typically avoided, most approaches share the goal of helping patients function more effectively in a less threatening world. The therapeutic relationship forms the foundation for developing trust, object constancy, and emotional intimacy. Through this relationship, the borderline learns to extend appropriate expectations and trust to others.
Most therapeutic approaches derive from two orientations: psychodynamic therapy (examining past and present patterns to forge a better future) and cognitive-behavioral therapy (changing current thinking and behaviors without dwelling on the past). Regardless of approach, effective therapy requires structure and clear goals while maintaining flexibility.
Borderline Personality Disorder is unique among major psychiatric illnesses in having more evidence supporting psychosocial therapies than pharmacological treatments. Two primary therapeutic schools have emerged-cognitive-behavioral and psychodynamic approaches-each with distinct strategies.
Cognitive-behavioral approaches focus on changing current disruptive thinking processes and behaviors rather than exploring the past. Dialectical Behavioral Therapy (DBT), developed by Marsha Linehan, has the most evidence supporting its effectiveness. The "dialectic" refers to resolving the borderline's contradictory states-loving then hating the same person, or trying hard while needing to do better. DBT views BPD as resulting from biological vulnerability to emotional over-reactivity combined with an invalidating environment.
Schema-Focused Therapy (SFT) combines cognitive, Gestalt, and psychodynamic theories to address maladaptive schemas-worldviews developed by vulnerable children facing unstable parenting. Treatment identifies five schema modes in borderlines: Abandoned Child, Angry Child, Punitive Parent, Detached Protector, and Healthy Adult. Therapists employ "re-parenting" to supply unmet childhood needs, using warmth and openness while teaching new coping mechanisms.
Psychodynamic approaches include Mentalization-Based Therapy (MBT), which focuses on "mentalization"-how people understand themselves, others, and their environment. Fonagy theorizes that disruption in early childhood mentalization development leads to BPD. When children cannot bond appropriately with parents, they struggle to understand emotions and develop abandonment fears or detachment.
Transference-Focused Psychotherapy (TFP) focuses on "identity diffusion" (distorted self-perception) and "splitting" (black-and-white thinking) as core BPD features. The therapy involves twice-weekly sessions examining the patient-therapist relationship as a laboratory for understanding splitting patterns. By experiencing and analyzing these dynamics in a safe environment, patients can develop healthier identity integration and more nuanced perceptions of others.
All these standardized treatments have demonstrated superiority over non-specific "treatment as usual." Comparative studies show different approaches excel in different areas: DBT and TFP reduce suicidal thinking; TFP and supportive therapy better reduce anger and impulsivity; TFP performs best for irritability and assault behaviors. However, the key finding isn't which treatment works best, but that psychotherapy itself works for BPD.
Chapter 8
Beyond Talk: Medications and the Biological Dimension
While psychotherapy remains the primary BPD treatment, most plans include medications. No single medication treats all aspects of BPD, but medications help manage associated symptoms like depression and reduce problematic traits like impulsivity. New discoveries in genetics and neurobiology are improving understanding of medication effectiveness.
Twin studies show that when one identical twin has BPD, the other has a 35-70% chance of also developing it, even when raised in different environments. Specific borderline traits like anxiety, emotional instability, suicidality, impulsivity, and relationship problems show high heritability. Molecular genetics has identified specific gene alterations affecting neurotransmitters (serotonin, norepinephrine, dopamine) associated with mood disorders, impulse dysregulation, dissociation, and pain sensitivity.
Advanced brain imaging techniques like fMRI, CT, PET, and SPECT have revealed anatomical and physiological deviations in BPD, showing overactivity in emotional response areas (limbic system) and underactivity in executive thinking regions (prefrontal cortex). Chronic stress disrupts neuroendocrine balance by activating the hypothalamic-pituitary-adrenal axis, which, when constantly triggered, causes brain shrinkage patterns observed in BPD, PTSD, and major depression.
Discoveries in genetics and brain physiology have led to new drugs for many conditions. While no medication targets BPD specifically, research shows three primary classes of medicines effectively treat many borderline behaviors:
1. Antidepressants: Most research has examined serotonin reuptake inhibitors (SSRIs), including Prozac, Zoloft, and Lexapro. These effectively treat mood instability, emptiness, rejection sensitivity, and anxiety. They also decrease inappropriate anger, aggression, and self-mutilation, even without depressive symptoms.
2. Mood Stabilizers: This group includes Lithium and antiseizure drugs like Depakote and Lamictal. These medications help stabilize mood, decrease anxiety, and control impulsivity, aggression, and anger at typical doses.
3. Neuroleptics: These drugs are recommended for initial treatment of cognitive-perceptual distortions in borderline patients. They target paranoia, dissociation, and feelings of unreality. Combined with SSRIs, they relieve anger and aggressiveness, stabilize mood, and decrease anxiety and interpersonal sensitivity.
Professional opinion about BPD prognosis has shifted dramatically. In the 1980s, personality disorders were considered enduring and stable, with suicide rates approaching 10 percent. Recent longer-term studies show significant improvement over time, with up to two-thirds of patients no longer meeting BPD criteria after ten years. Improvement occurs with or without treatment, though treated patients achieve remission sooner. While acute symptoms like self-harm and impulsivity respond more quickly to treatment, temperamental symptoms like fear of abandonment and emptiness often persist longer.
Chapter 9
Finding the Middle Path: The Journey to Integration
Change for borderlines is exceptionally difficult because it disrupts established psychological equilibrium. Borderlines particularly fear change because they distrust their psychological "brakes," believing they'll slide uncontrollably from one extreme to another without the ability to stop in the middle ground. Successful change requires consciously resisting unproductive automatic reflexes and gradually choosing alternative responses.
Personality can be visualized as intersecting lines representing character traits, with extremes at each end and middle ground at the center. The ideal is to have these traits balanced like spokes in a wheel, intersecting near their midpoints. Change becomes a process of identifying where one falls on each trait line and deliberately moving toward the adaptive middle ground, not because any position is inherently "better" but because balance is most adaptive.
The borderline's healing journey begins with learning to "limp"-putting just enough weight on their psychological injuries to build strength gradually without causing reinjury. They must break out of an impossible catch-22: to accept themselves and others, they must learn to trust, but trusting others means first trusting their own perceptions.
Borderlines experience the world through a child's intense emotions and perspective, unable to separate from their family of origin or see their world through adult eyes. Change comes when they learn to review past memories through adult "lenses"-like watching a once-frightening horror film years later and wondering why it seemed so scary.
The borderline's greatest obstacle is evaluating in absolute extremes-either total perfection or complete failure. Rather than playing the hand they're dealt, they keep folding, waiting for four aces. Improvement comes when they learn to accept their circumstances and play skillfully despite imperfections. As they mature, choices become less frightening and more empowering.
A primary goal for borderlines is establishing a separate identity and overcoming the tendency to merge with others-evolving from parasitic dependence to symbiosis and eventually independence. The borderline's demanding dependence can destroy relationships, but learning collaborative connections benefits everyone.
As borderlines develop a distinct identity, they learn to appreciate others as independent persons with their own flaws and struggles. They must integrate positive and negative aspects of others rather than splitting them into all-good or all-bad. The healing borderline develops constancy about themselves and others, learning to be dependent in comfortable rather than desperate ways.
When borderlines change, others in their relationships must adjust to maintain equilibrium. If these readjustments don't occur, relationships may shatter. Those who overcome the illness develop greater capacity to trust and establish satisfactory relationships, with clearer purpose and more stable self-understanding. Like mountain climbing, the fullest experience comes from appreciating all perspectives: looking up toward goals, looking down to recognize progress, and pausing to appreciate the present moment.
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