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Why Doesn't Therapy Work For Borderline Personality Disorder?

Updated on January 30, 2016

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Why Therapy is So Difficult For Borderline Patients

This should be prefaced by stating right away that many people suffering from BPD find therapy works very well for them. That's wonderful but unfortunately, it is not that way for everybody. This article looks at some of the reasons why therapy can be so difficult for some borderline patients.

Therapy requires a commitment to wellness and an understanding of their disorder from the patient. Because personality disorders are so thoroughly entrenched in the way a person thinks and perceives things, people suffering from BPD often cannot see their disorder. To them, it literally looks like everybody else is the problem. They truly believe that things did happen the way they think they did and they truly believe they are a victim. In fact they are a victim but not in the way they imagine: they are a victim of their illness, not somebody else’s perceived cruelty or indifference. They are often master liars and manipulators and even the most astute observer cannot detect their lies. Why? There is no lie to detect. They really believe what they are saying.

One of the biggest issues you find dealing with people with BPD is misperception. They often will not remember things the way you do at all, especially when it comes to stressful situations. They will accuse you of saying things you didn’t say or doing things you didn’t do. There is no talking them out of it; they truly remember it that way. The best explanation for this is that most “normal” people fit their emotions to the facts but people with BPD fit the facts to their emotions. In other words, a “normal” person will see that you have been cruel to them and they will emotionally react accordingly with hurt feelings, anger, etc. A person with BPD is already angry or hurt so they perceive that you have been cruel to them, even if you haven’t. This is extremely difficult to deal with because nothing you say or do (or don’t say or don’t do) makes any difference at all. They see rejection and abandonment in everything you say.

There is no reasoning with this, because this is not reasonable or rational. The problem is that when a person with BPD gets close to someone emotionally, the other person is automatically seen as a threat, as an enemy. They expect they will be hurt and react as such, punishing their partner for things they have not done and would never do. This translates to therapists, too and it is one of the reasons that therapy often does not work. Therapy will never work when the patient sees the therapist as an enemy or as someone who is trying to hurt or trick them.

Another barrier to treatment is that many therapists and doctors will just not treat people with BPD because these patients are so difficult. Other well-meaning but misguided therapists diagnose a less-stigmatized illness and treat that, which results in less-effective treatment. Still others believe it is not a real illness at all, that it is a "catch-all" diagnosis with no real definition, or that it only occurs in women. None of these things help or make therapy any easier.

It is also very difficult for therapy to work when so much of what the borderline says is lies, misunderstandings and skewed perceptions. They routinely misunderstand things others have said and attribute the misperceived meaning to the person. People with BPD may also lie outright and they often cannot see any of their own wrongdoing, especially if the BPD diagnosis is complicated with other personality disorders like Narcissistic Personality Disorder. A therapist who does not understand BPD and who relies on the patient to self-report may get completely wrong information and this is very dangerous, both for the patient and the people in the patient's life.

Complicating therapy even further is the fact that there is no such thing as "pure" BPD. Borderline Personality Disorder always occurs co-morbidly with other things: eating disorders, substance abuse problems, depression and more. It's not uncommon to find that a borderline patient has other personality disorders as well, often more than one. Narcissistic Personality Disorder, Histrionic Personality Disorder and Antisocial Personality Disorder often occur in tandem with BPD, and the presence of these disorders make any treatment significantly more difficult. The presence of Narcissistic Personality Disorder in particular can make successful therapy almost totally impossible.

Perhaps the biggest obstacle for therapy is that therapists just don't see the borderline patient the way they really are. Therapists see them in a very controlled environment for a very short period of time where all the attention is focused on the borderline patient. Since borderline patients have the most difficulty when they feel abandoned or rejected, a therapy session where 100% of the focus and attention is on them is not an environment where they will be triggered. Since therapists do not see the borderline patient act out, they often inadvertantly reinforce the borderline patient's belief that there is nothing wrong, that what the patient claims is wrong with them is exagerrated, or that it really is everybody else who has the problem. Validating these beliefs is extremely counter-productive, because one of the biggest hurdles in treating BPD is getting the patient to understand that their perception is distorted. If this distorted perception is validated, it becomes even harder to address.

Overall, the outlook for therapy for BPD patients can be very positive if it is handled correctly and if the borderline patient truly wants to get help. The selection of a therapist is crucial to the success of therapy, perhaps more with BPD than other illnesses. There are a lot of excellent therapists out there, but there are also many therapists who do not understand BPD or personality disorders very well. These therapists can inadvertantly make the disorder harder to treat, especially if they are unaware of the manipulative aspects of BPD and the other cluster B personality disorders that often exist with it.

If the therapist your family is working with does not listen to you, does not take your concerns seriously, does not seem to believe what is being said about the borderline patient, takes sides or in any way seems to make things worse, find a new one. There are many therapists out there, and with a little patience you can find one who can help you and your loved ones.

© 2015 The Little Shaman


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      Lisa 20 months ago

      I have BPD and since this disorder, as it's name implies, Borders on other disorders, it often comes with additional, unwanted problems. This means, that while there is a pretty definitive set of symptoms, some people will have "Borderlining" symptoms of others problems or Co-morbidities. I personally, can logically understand that others see my feelings about a situation as being over reactive at times. However, the emotion my brain and body are experiencing are very real, they're not imaginary, manufactured to bother you, nor are they a means of attention. It's not a reaction to a hallucination. It is very real, intense and extremely upsetting. Some people with BPD experience delusions or hallucinations (which SEEM real but are in fact NOT real). This is sometimes a symptom for some (but not all) BPD people. Therefore, imagine how difficult it is for them to understand your perception of a situation when you see Purple and they see Green? Lots of people might break their leg but the severity and level of healing can be different for each one of them. There are some with Schizophrenia that can take meds and function fairly well, have a successful marriage, family and career and others that spend most of their life in a mental ward. It's very misleading to say a person has such and such illness and expect ALL of them to fit into the same size box equally perfect. It's also a shame on any medical professionals friends, family or strangers to then blame the person suffering the most for his or her illness.