Interactions, Pt. 3 (we're on a roll here!): Borderline *What*?

This week's papers caught me by the most pleasant surprise of any we're read so far. I admittedly embarked on these readings with dread and apprehension, colored by my general ambivalence and uncertainty about the elusive Axis II diagnoses (which I've thus far regarded as far more slippery and confusing and unconvincing in their claims to "category" status than even the Axis I's). Granted, I've liked what I've read of the theoretical framework for DBT thus far, but usually these were bits and snatches from articles that identified certain radical behavioral principles at large or therapeutic principles at large and didn't go into any rigorous detail about the specific nature of "Borderline" Personality Disorder (other than some vague reference to emotion dysregulation, which, let's face it - what psychological disorder doesn't involve *some* degree of emotion dysregulation?), which led me to tacitly conclude that the principles of DBT were simply very effective at treating patients who had major psychological problems and were generally regarded by therapists as very hard to treat.  In fact, it's funny, but according to the Linehan paper, one of the features that psychoanalysts proposed at one time as a defining characteristic of Borderline PD was "intense anger and helplessness on the part of the treatment personnel dealing with them" - which is consistent with the impression I've always gotten to date that "Borderline" is just a keyword for "oh no, red flag, it's another one of those patients!" I think it's sadly telling that in all the time I've heard the term "Borderline" being flung about, I never thought for a second to wonder what it was that those patients were thought to be on the "borderline" of; in my mind I think it implicitly stood as "borderline-crazy" or something of that sort (which, apparently, is also not too far off from some of the older definitions, with the "border" between "neurosis" and "psychosis" as one of the early conceptions).

But alas, I was happily disabused of my expectations as I read Linehan's paper - which presented an actually theoretical, not to mention compassionate rather than dismissively pejorative, account of what basic interactive processes underlie and are common across the myriad cases of at least one common subtype of Borderline Personality (namely the type that includes parasuicidal self-injury) but that very likely generalizes to BPD more broadly. My favorite part, perhaps unsurprisingly given what my favorite parts of all the other papers we've read by the founders of various theory-based therapeutic treatments, was the part in which Linehan recounts the process of clinical observation and logic that led her to formulate her theory (which, in turn, she proceeded to test empirically): for instance, the whole section debunking the commonly held view that Borderline patients are "manipulative" in their self-injury and suicidal behavior, meaning they are motivated by some conniving, underhanded intention to pressure you into protecting or saving or attending to them (her argument, in a nut-shell: 1. just because a given behavior - in this case, self-injury and crying out for help - tends to solicit a certain response, such as increased attention or help from the therapist, doesn't mean it was originally motivated by the desire to get that response; 2. her clinical observations belie the "manipulation" hypothesis and lead her to alternate explanations, such as that patients are attempting to reduce their anxiety or otherwise escape the very real (and often largely externally imposed) misery in their lives. I also loved the section in which she identifies the seeming opposites of extreme, intense outbursts of anger in some and "overcontrolled," rarely expressed anger in other patients; tracing them both to a common cause - an underlying difficulty at regulating and perceiving themselves as in control of their anger - that explains each "extreme" once you add certain interacting factors.

And above all, of course, I loved Linehan's account of the actual nature of the "dialectic" in "dialectic behavior therapy": the striking of a fine balance between “acceptance” and “change." Even more so than the last time we ran across this account (in much less thorough, summary form, as part of a larger article on third-wave behavioral therapies), I realized how much this idea of the "dialectic" is aligned with and clarifies my intuitions about “unconditional positive regard” as being “conditional” in a sense and also “unconditional” in a deeper sense--in that you never dismiss a person on the basis of individual patterns of behavior or particular unlikeable traits or habits, but rather you respect them fundamentally for their humanity and act as their advocate when you collaborately work with them toward certain changes. It is out of genuine caring for them, the living, emoting human being underneath all the particular behaviors, who is both capable and worthy of growth and progress toward a happier life and who is worthy of our empathy and compassion in the meantime, that you engage in efforts to change particular maladaptive behaviors with them and to help them improve their lives.

And now I'm out of time to comment on the similar features of the Moffitt article that demystified and lent a conceptual, theoretical framework to Antisocial Personality Disorder, which had previously stood in my mind as a mishmash of symptoms that could only be collectively described as the "bad person syndrome"; but suffice it to say (for now) that the article's quest for underlying etiological differences and interactive relationships between biology, environment, and stress had a great deal to do with it. And so we once again come around to the same theme: Interactions, interactions, interactions!