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May 31, 2019

Written by Theresa Hasting, LMHC

I remember my first job out of graduate school, working in a psychiatric inpatient facility, and listening intently as nurses and doctors spoke about the patients with whom we were working.  A patient in particular sticks in my mind, a young adult female who had been in and out of our facility ten times in the past two months, who loudly exclaimed her self-harm for all to see and hear.  The stigma of Borderline Personality Disorder (BPD) that I witnessed some twenty years ago is still with me. Since that time, I have revised how I think of people who present with these symptoms and with this diagnosis, realizing how these behaviors do not define them, but rather how they are an expression of fear, of pain, of vulnerability, and of anxiety.

An article, that many of you may have seen, recently floated across Facebook: “We need to treat borderline personality disorder for what it really it is – a response to trauma.”  I was intrigued and as I read through the comments posted prior to the reading the actual article, I realized just how much the stigma of BPD hasn’t actually changed in the past twenty years.  I still hear parents gasp with shock and fear at the mention of BPD traits.

Let’s forget the Facebook article, that while true and accurate, isn’t actually a credible source and instead examine scholarly research.  A study by Bandelow, et al, (2005) indicated that those diagnosed with BPD had a statistically higher rate of early childhood trauma than the control sample.  These traumas ranged from abuse and neglect, parental separation, childhood illnesses, medical trauma, unhealthy family systems, etc. Premature birth was also noted as statistically higher for those diagnosed with this disorder.  This is one of many research articles making this link.

In practice with adolescents and their parents, those presenting with borderline traits consistently have a history of trauma and as they describe the symptoms we are so familiar with (poor ego strength, instability in functioning and achieving goals, impairment in relationships, frequent mood changes, separation insecurity, anxiety, impulsivity and/or risk-taking, and hostility), they talk about really wanting connection, to feel safe in relation to others, fearing rejection and abandonment, and having big emotional responses to small situations that they don’t understand any more than the next person.  Sometimes, I hear stories of a big Trauma and other times I hear stories of little traumas that accumulated over time. It may be that there were dozens, maybe hundreds of little emotional betrayals and hurts that added up and derailed a child’s ability to trust someone with their care. They described the need to be impenetrable and safe while simultaneously tormented by the human desire to feel closeness, created the push/pull dynamic that friends, families, and therapists are so acutely aware of.

The Facebook article is right…it is time we recognized BPD as a response to trauma.  Rather than focus on the very difficult symptoms to manage, recognize the strength being presented to you in their ability to survive.  Recognize that inside the layers of muck, there is a precious human being desperate for safe connection. With this new formulation of BPD at hand, we also have to look at how we treat BPD.  Ultimately, we have to approach treatment from a trauma-informed lens, one that aims at healing, providing reparative experiences, and teaching healthy attachment. To do this, we must focus on emotional regulation, emotion tolerance, debating negative self talk, building ego strength and finding ways to celebrate success; all in the context of healthy relationships being role-modeled and the clinician providing a safe, non-judgemental space to hold what is present and return it back to the person in a form they can digest in order to heal the relational trauma of the past.  Only then, will a person be able to move to a place of accountability, examining unhealthy relational patterns, and work on their ensuing identity crisis as the “get better.”

Ultimately, what a client who presents with these symptoms needs from their treatment team is compassion and the unwavering ability to see through the unpleasant layers of protection they have covered themselves in.  Or, in the words of the late Dr. Karyn Purvis, who specialized in relational and developmental trauma: “It is powerful for [people] to know that they are loved and adored even in the midst of their worst behaviors.”