Borderline personality disorder is characterized by instability in self-image, interpersonal relationships, and emotions; and impulsive behaviour.
“What loneliness is more lonely than distrust?”
– from Middlemarch, by George Eliot
She frowned.
“I’m just nothing!”
I was surprised. When I’d seen Geraldine the week before, she’d seemed vibrant, funny, intelligent, and accomplished.
But now she suddenly sounded bitter, her voice filled with sharp self-contempt.
“Seriously… I’m nothing!” she repeated. I asked her about these feelings, and she said they stemmed from a row she’d had that morning with her boyfriend. But it was alright, she assured me – she often felt this way, but it would go soon.
Then she told me something else.
“I’m borderline!”
Over recent years I’ve had increasing numbers of clients tell me they’ve been diagnosed with borderline personality disorder (BPD). Geraldine was one of them.
Some people are quite enthusiastic about a diagnosis, seeing it as a neat explanation for why their life has gone the way it has. They may see it as destigmatizing, or even as a kind of status. Some may use it as a way of abrogating responsibility and accountability. After all, if I can blame my behaviour on a diagnosis I am let off the hook.
Another risk is that once labelled we may come to believe we are helpless to change because ‘our brain chemicals are all wrong‘.
Diagnosed cases of BPD seem to be on the rise. Whether this is indicative of a true increase in the condition or a widening and looser diagnostic ‘net’ is up for debate.
But some people do seem to exhibit the characteristics of borderline personality disorder. Many clients don’t neatly fit into one diagnostic category, but still, BPD is a useful category.
A useful definition
Borderline personality disorder is a psychiatric diagnosis characterized by instability in self-image, interpersonal relationships, and emotions; and impulsive behaviour. BPD encompasses a wide range of symptoms that significantly impact an individual’s daily life.
It is crucial to recognize that BPD arises from a complex interplay of genetic, environmental, and neurological factors. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines the following diagnostic criteria for BPD:
- Frantic efforts to avoid real or imagined abandonment.
- Unstable and intense interpersonal relationships.
- Identity disturbance: markedly and persistently unstable self-image.
- Impulsivity in potentially self-damaging behaviours.
- Recurrent suicidal behavior, gestures, or threats.
- Emotional instability due to a marked reactivity of mood.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger.
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
Traits I’ve noticed in some clients include:
- Proneness to jealousy and strong feelings of emotional insecurity
- Propensity for self-harm
- Distrust alternating with gullibility
- Proneness to attempt to emotionally manipulate others in order to feel more in control
- Inability sometimes to control behaviour
- Propensity to exalt people or ideas then devalue them in cycles
- Diminished empathy sometimes
- Lability – very sudden mood swings, which tend to be reactive to stress and vacillate between depression, anxiety, anger, enthusiasm, and sometimes nothing much at all
- A history of having ‘burnt bridges’ with people because of fits of rage and/or general emotional instability
- All-or-nothing thinking
- A shifting self-image and sense of identity – feelings of worthlessness and self-devaluation, alternating sometimes with feelings of grandiosity
- Proneness to misinterpret the intentions or facial expressions of others, feeling offended or insulted where no offence was meant or is discernible.
A question many ask is: Where does borderline personality disorder come from?
It’s 50/50
Geraldine’s diagnosis seemed to correspond to many of the features from the BPD checklist. As with many so-called personality disorders, BPD and its manifestation always come down to a combination of environmental causes and genetic ones.
For example, someone with an antisocial personality disorder such as psychopathy will tend to fare quite differently if they come from a stable, loving family as compared to if they were maltreated and abused.
American neurosurgeon James Fallon writes about how nurture and nature interact to modulate personality disorders in his interesting book The Psychopath Inside: A Neuroscientist’s Personal Journey into the Dark Side of the Brain.
Working with a client with BPD may feel difficult, but if we are clear and focused we certainly can help such people.
At its heart, BPD entails a dysregulation of emotions, which blocks the client, and sometimes those close to them, from adequately meeting their emotional needs and disrupts their life.
So anything we can do to help such clients gain some emotional stability and regulate their emotions will help.
Let’s get into it.
Tip one: Form clear goals
As with all clients, we need to form clear goals.
Geraldine had originally come to see me because she had been having problems controlling her anger and jealousy with her boyfriend. So her stated goal for our time together was to “chill out more” and not take things so personally.
We didn’t talk of “curing” BPD or completely changing who she was, but rather “working with it”. And there’s truth in that. We all tend towards certain characteristics and, while we can change and adapt hugely, we may always have those tendencies, though they may become fainter and more manageable.
Clients with borderline personality disorder will still have specific issues, just like anyone else.
When dealing with any troublesome emotions we need to calm the mind so it can, just like calm water, reflect reality more accurately.
Tip two: Help them develop mindful calm
Dialectical behavior therapy (DBT), developed by Marsha M. Linehan, has shown significant efficacy in treating BPD.1 It combines cognitive-behavioural techniques with mindfulness practices and emphasizes validation and acceptance. DBT helps individuals regulate emotions, manage self-destructive behaviours, and improve interpersonal skills.
I’d say this is a good approach as long as the client is taught to calm their feelings first before trying to influence their thoughts.
Using mindfulness techniques, we can help our BPD clients accept and observe their emotions and so begin to respond to life rather than just blindly react.
I taught Geraldine self-hypnosis and encouraged her to use it daily. In this way her general stress levels began to diminish.
We examined her most difficult feelings and the most common triggers for those feelings and, in mindful hypnosis, I helped her rehearse stepping aside from her habitual reactions and observing them as though they were lily pads floating by on a river – just accepting them and calmly letting them pass.
We need to help our BPD clients manage stress generally so they can more easily meet their innate emotional needs.
Once Geraldine’s emotional mind was calmer, we had greater access to deal with her troublesome thoughts – which, because she was calmer, were now less extremist anyway.
Strong emotion over and over can, bit by bit, form negative core beliefs. We need to deal with these too.
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Tip three: Help them examine their emotional assumptions
Clients with borderline personality disorder will invariably experience cognitive distortions, and we need to help them see these distortions for what they are and thereby start to overcome them.
But we must remember that it’s not always thoughts that drive feelings, but the other way around – especially when those feelings are very strong.2 So trying to get a highly emotional client to think differently in the midst of stormy feelings will be hard, if not impossible.
So we need to calm the client down first, then help them identify and challenge their cognitive distortions. But how do we do that?
There are two broad aspects to this approach. We need to help the client learn to:
- mindfully accept extremely strong emotions, and thereby calm and, to some extent, control them.
- examine assumptions and thinking styles in order to check them out for validity.
A mania for jumping to conclusions
Leaping to conclusions is almost a mania for some clients with BPD.
Many of Geraldine’s assumptions were based on an overactive threat response, especially socially.
She would “fly off the handle” when other people were just trying to relate to her in neutral or even kind ways. She would interpret their comments or behaviour as sarcastic and belittling. Many of her boyfriend’s actions were interpreted as indicating he was losing interest in her or lusting after another.
As with all emotional conditions in which conclusions are jumped at with all the speed of a cheetah running downhill on an oil spill, we can help our clients pause and sit calmly with not knowing the meaning of something.
The all-important meaning vacuum
Bit by bit I helped Geraldine develop the capacity to hold a ‘meaning vacuum’ in her mind by not immediately filling ambiguous or neutral words or actions from others with negative meaning.
She started to develop the skill of relaxing without knowing the meaning of things immediately and waiting to see reality rather than simply creating it imaginatively (and destructively), then assuming these imaginings must represent the true meaning.
Geraldine loved the idea of a ‘meaning vacuum’ and even visualized holding this vacuum in her mind where “wild emotions”, as she put it, would normally rage.
Because of an inability to hold meaning vacuums, many clients living with BPD have problems relating to other people. Working on these feelings and thoughts and developing the capacity for meaning vacuums will certainly help improve their relationships. But we can work on how these clients relate to others more directly, too.
Tip four: Help them develop calm and optimism in their relationships
Intense idealization of others can switch with dizzying swiftness to profound contempt and devaluation of them. This was a pattern Geralidine experienced with relationship-corroding regularity.
Helping our BPD clients understand their own mental states can help them appreciate other people’s, too.
I talked with Geraldine about what all human beings need and how people suffer when they don’t meet these needs. We then related this specifically to what both she and her boyfriend needed from their relationship, and how they could both aid in that. For example, she needed reassurance, but tended to seek it so often that it impacted on her boyfriend’s needs for privacy and autonomy.
We talked calmly about what she would do and how she could carry on successfully even if the relationship did end. I wanted to build up within her a sense of confidence that ‘abandonment’ wasn’t the end of the world. In fact, she could not just survive it but eventually live meaningfully and happily beyond it. We even drew up steps of what would happen after a breakup and how she’d manage that.
I encouraged her to mentally rehearse feeling relaxed and calm in her relationships, and we developed strategies for her to communicate assertively rather than “going off the rails”, as she put it.
Bit by bit Geraldine began to feel secure in her relationships because she was less terrified of rejection and more able to resist old triggers for explosive emotional reactions.
All this helped with my final point.
Tip five: Help them stabilize a positive sense of self
Geraldine sometimes felt good about herself: confident, attractive, and able. But this sense of self was extremely unstable. She often talked of hating herself, being ugly or useless, or even not really having a sense of who she was at all.
Don’t misunderstand me here – we can all veer a bit in our sense of identity. Variant moods aren’t the sole preserve of people with borderline personality disorder!
But in those with BPD this instability of a sense of self can be extreme and distressing, not to say bewildering for the people in their lives.
Helping Geraldine generally feel calmer and more able to regulate her emotions went a long way towards stabilizing her sense of self, so that the dramatic swings in her sense of who she was happened less often.
I asked Geraldine to write out all her core values, such as honesty, kindness, and determination, and also many of her core strengths, such as intelligence, creativity, energy, humour, and kindness. I then had her hypnotically connect with each of these qualities by recalling times in which she had felt her strengths fully.
I also encouraged her to, whenever she felt herself losing or downgrading her sense of who she was, read her list of core values as she breathed calmly using the famous 7/11 technique.
Remembering their core values and regularly calling to mind their strengths and successes can help BPD clients regain a sense of positive identity when it starts to waver.
Of course, the flips and turns in emotions can happen dramatically and with lightning speed, but Geraldine found that, even if she couldn’t always catch a shift in feeling immediately, she could speed up the process of rebalancing herself by using these strategies.
Towards the end of the therapy, as Geraldine sat calm and relaxed, I said:
“That little voice in your head that sometimes tries to tell you you’re nothing?”
“Yes?”
“Ignore it!”
She smiled.
How to Be Artful With Your Language
As we all learnt as kids, it ain’t what you say, it’s the way that you say it.
Another way of saying that is the following Aesop’s fable about the Wind and the Sun.
The North Wind boasted of great strength. The Sun argued that there was great power in gentleness. “We shall have a contest,” said the Sun.
Far below, a man travelled a winding road. He was wearing a warm winter coat.
“As a test of strength,” said the Sun, “Let us see which of us can take the coat off of that man.”
“It will be quite simple for me to force him to remove his coat,” bragged the Wind.
The Wind blew so hard, the birds clung to the trees. The world was filled with dust and leaves. But the harder the Wind blew, the tighter the shivering man clung to his coat.
Then, the Sun came out from behind a cloud. The Sun warmed the air and the frosty ground. The man on the road unbuttoned his coat. The Sun grew slowly brighter and brighter. Soon the man felt so hot, he took off his coat and sat down in a shady spot.
“How did you do that?” said the Wind. “It was easy,” said the Sun, “I lit the day. Through gentleness I got my way.”
If you’d like to expand your abilities with language, consider Mark’s online course Conversational Reframing.
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About Mark Tyrrell
Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.
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