Did you know that Borderline Personality Disorder affects approximately 1-2% of the general population?
We would like to introduce you to the psychiatrist and psychotherapist Dr. Vanni Giovanna who coordinates the Psychology Service at the Centro Casa di Cura San Benedetto Menni in Albese Con Cassano, in the Province of Italy. For several years she has been working with the team of psychologists on Borderline Personality Disorder.
What is Borderline Personality Disorder and what are its symptoms?
Borderline Personality Disorder (BPD) is characterised by permanent instability of mood, self-image, interpersonal relationships and impulsivity. It is one of the most studied personality disorders and accounts for more than 20% of the psychiatric outpatient population. The age of onset is usually early adulthood, but increasingly, adolescents are exhibiting features of this disorder that alarm both families and clinicians.
People with BPD often have an intense fear of abandonment and may overreact to situations of loss or rejection. Interpersonal relationships tend to be turbulent and unstable, oscillating between extremes of idealisation and devaluation. This dichotomous ‘black/white’ mode is also directed towards themselves, conferring instability also on their sense of identity. People with BPD show very fast and intense emotional fluctuations and often act impulsively without regard for long-term consequences. These behaviours can manifest themselves in various areas of life, such as overspending, substance abuse, promiscuous sexual activity, self-harm and reckless driving. They are often put into practice to (dysfunctionally) regulate intensely painful emotions, such as anger, but not only that. They may experience a persistent sense of emotional emptiness and transient episodes of paranoia or dissociation, during which they may perceive the world around them in a distorted way or feel detached from reality. Unfortunately, their distress may be so intense that it leads to suicide.
What are the most common challenges faced by people with Borderline Personality Disorder in their daily lives?
Symptoms can vary in intensity from one individual to another and can significantly affect a person’s ability to function effectively in everyday life.
The challenges of everyday life are manifold. In times when crises are more frequent, even just staying alive is a daily challenge. These are people who are in constant pain, as if they are burnt and every gust of wind renews a sharp pain. It is difficult, therefore, to maintain consistency in interpersonal relationships and at work, which is inevitably reflected in their self-image.
How can family and friends best support someone living with this disorder?
Family members need to avoid blaming those with the disorder, but this is not easy. Families need to be informed and educated about the disorder.
Internationally, the National Education Alliance for Borderline Personality Disorders has launched an evidence-based treatment to support family members and ease their emotional and physical burden called ‘Family Connections’ which consists of 12 information sessions, education about the disorder and the practice of some techniques of Dialectical Behavioural Therapy, one of the most effective treatments for this disorder and the most studied with research programmes. Family members of people with BPD have a greater family burden than family members of other people with mental disorders.
What are some of the most effective therapies you have found in your work with patients with Borderline Personality Disorder?
There are several effective therapies for this disorder but, from my point of view, Dialectical Behavioural Therapy (DBT) is the most comprehensive, as well as the most studied. It was implemented by Marsha Linehan specifically for this type of person and is based on the biosocial model.
The characteristics of extreme sensitivity to environmental stimulation are present in these people from birth. The environment (family, work, among others) does not recognise this way of perceiving the surrounding environment and sets in motion invalidating relational modalities (the person’s emotions are not recognised as understandable and natural in relation to the stimuli that generated them, as they react first and very intensely and find it difficult to calm down). From the failure of the encounter between these two factors, Borderline Personality Disorder develops over time. In our centre we use DBT on an outpatient basis and on the rehabilitation ward (we use a form of DBT adapted to the 30 days of hospitalisation). For family members we use Family Connections.
It is also important to remember the use of pharmacological therapy. Although there is no specific drug, the literature points out how beneficial it is to use them when coding with another psychiatric disorder. In my clinical experience, pharmacological therapy is essential in addition to psychotherapy.
What are some common myths about this disorder that you would like to demystify?
For a long time these people have been considered untreatable by psychiatrists themselves, but this is not the case. It is necessary to receive an accurate diagnostic assessment in order to access appropriate and effective treatment. People with BPD, when they stop suffering, often put their wonderful empathy and sensitivity at the service of others and are altruistic people. Marsha Linehan herself suffered from this disorder and devoted her whole life to seeking treatment and succeeded fully.
What advice would you have for someone who has just been diagnosed with Borderline Personality Disorder and is looking for help and support?
My advice is not to get discouraged because you may be fine. Look for the right therapy, i.e. ask your therapists what treatment they use and what level of scientific evidence it has. Besides that, the relationship you develop with your therapist is important, be honest with them and tell them if you don’t like something about the way they do or are. Therapy is the right ‘gym’ where you learn new ways to be better with yourself and others.
How is hospitaller charisma reflected in the treatment approach of the Psychological Service towards patients with Borderline Personality Disorder?
Hospitaller charisma, which is also embodied in the total hospitality of the person with Borderline Personality Disorder, is central to the approach to care. Hospitality, listening, compassion, are factors of care, as well as strategies that lead to behavioural changes. The entire psychiatric rehabilitation team, which includes social and health workers, nurses, educators, psychologists and doctors, has received specialised basic training on the disorder, from its aetiopathogenic origins to the modalities of relating to people with BPD. This modality corresponds to the acronym G.I.V.E (one of the skills taught in DBT) which stands for being gentle, interested, validating and polite. Each of these factors is important for the well-being of everyone (as science has amply demonstrated) but for this particular type of person. Studies have shown that being validating is necessary for the treatment of these people who would not be able to make use of change-only techniques. Validating the other person’s emotions, seeing from their point of view, welcoming, non-judgmental, listening with an open heart and mind, combined with science, are the essence of the charisma of the centre I work for. Every new psychiatric rehabilitation worker receives training.
Can you share an example of how the hospitaller charisma has had a positive impact on the emotional and mental well-being of a patient during his or her treatment?
In particular, I remember a patient who was treated on an outpatient basis and who presented with a complete symptomatology of the disorder, therefore very severe. She had to be admitted several times to the Rehabilitation Service. Her life was very deteriorated. She was highly validated by the team and attended to on both a personal and family level (family members were introduced to the Family Connections itinerary). She is now totally free of the disorder, has a stable relational and working life, is married and is a mother. Her sensitivity can now only be expressed in fruitful self-care, but she makes herself available to others by practising a helping profession herself.
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