Borderline Personality Disorder
According to DSM-IV-TR (the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) personality disorders are defined by maladaptive personality characteristics which begin during early years of life and have serious and consistent effects on functioning (Diagnostic and statistical manual of mental disorders, 2000). Borderline personality disorder (BPD) is a common reason to visit a psychiatrist (Skodol, Gunderson, Pfohl, Widiger, Livesley & Siever, 2002). BPD affects 2 percent of adults (mostly young women) (Swartz, Blazer, George & Winfield, 1990). Patients with BPD present a high rate of self-injury (without intent of suicide) and a significant rate of suicide attempts and completed suicide (Soloff, Lis, Kelly, Cornelius & Ulrich, 1994).
The patients of BPD are many times in need of mental health services and approximately 20 percent of hospitalizations in the psychiatric department are of BPD patients (Zanarini, Frankenburg, Khera &. Bleichmar, 2001). A patient with depression or bipolar disorder mostly endures the same mood for weeks while a patient with BPD may experience angers (intense bouts), anxiety and depression that may endure for only hours or at the most for a day (Zanarini, Frankenburg, DeLuca, Hennen, Khera & Gunderson, 1998). A study performed by Zanarini & Frankenburg (1997) showed that most of the patients with BPD report a history of neglect, separation (as young children) or abuse. Another study performed by Zanarini (2000) concluded that 40 % to 71% of Borderline Personality Disorder & Attachment Theory.
Origin of Borderline Personality Disorder
Children who have been exposed to psychological and physical neglect, sexual and physical abuse and maltreatment are at risk of developing BPD. The mental trauma faced by these children is due to neglect and abuse by a primary caregiver. This trauma disrupts the normal and healthy development of secure attachment. And as a result these children develop disorganized attachment (anxiety and depression). The children who are neglected are at risk of social rejection, incompetence feeling and social withdrawal. Neurobiological dysfunction can be caused because of abuse and neglect by primary caregiver. In order to develop a capacity of regulating emotions and developing a coherent sense of self the child has a requirement of attachment from the primary caregiver.
Attachment Theory and Borderline Personality Disorder
As per the ethological perspective of John Bowlby (1977, 1980, 1991) BPD can be considered as a condition of significant insecure attachment (with significant oscillations between detachment and attachment & between yearning and longing). The working models present in affect regulation and a lack of coherence (mainly in relationships with others) (Bowlby, 1973). The sorrow of detachment faced in early childhood negatively impacts the psychology of the person and this result in heightened sensitivity to loss and separation. It is also important to note here that since these feelings and thoughts are disconnected to the happenings in early childhood these individuals are unable to understand the reason behind their reaction. Research scholars (Melges & Swartz, 1989) have compared the fluctuations in the behaviour of BPD patients to prickly porcupines – they are of the opinion that patients with BPD are in need of someone but when someone comes close to them they drive themselves away as a result of fear. Thus BPD patients are looking for secure attachment but they fear rejection, anxiety and anger that could result (Bowlby, 1979). Melges and Swartz (1989) are also of the opinion that patients with BPD are preoccupied with regulating space. They do not feel the “invisible elastic” of attachment (Bowlby, 1969, p. 45). Also they are unable to protect themselves from anxiety of separation (Adler & Buie, 1979). The influence of certain types of experiences as related to family can be the cause of separation anxiety (Bowlby, 1988). John Bowlby’s “The seminal developmental theory” for treatment of BPD patients (Bowlby, 1969; Bowlby, 1973; Bowlby, 1980) has gained great attention. Bowlby proposed that human beings face pressures of natural selection in order to evolve behavioural patterns (example, clinging, smiling and proximity seeking ), that evoke in adults the caretaking behaviour (example, soothing, holding and touching).
These behaviours are reciprocal and encourage the development of an affective and enduring tie between caregiver and infant, which forms attachment. It is the result of these parental responses that internal models of the self and others are developed in infants which act as templates in the functioning of relationships later in life (Bowlby, 1973).
The Findings and Proposals of Bowlby the Following Is True In Case Of Attachment (Bowlby, 1973)
1. Model Of Self: The Internal Working Of It Is Related To The Degree Of Acceptance And Love One Has In The Eyes Of Primary Attachment Figures.
2. Model Of Others: The Internal Working Of It Is Related To How Available And Responsive Attachment Figures Are Expected To Be.
Attachment plays a very crucial role in the development of an external environment from which the child develops a safe and secure internal model of the self. Security on the grounds of attachment as perceived by the child results in his or her exploration of the world with confidence; this confidence springs by the availability of the caregiver. Security in attachment thus promises consistent, coherent and positive self-image. It also provides a feeling of being worthy of love and expectation that the important ones to him or her will be responsive and accepting. We here note that Bowlby has presented to the scientific mind the importance and need of attachment as essential to infants and children. Thus, attachment can be considered as an essential ingredient in the production of a psychologically healthy life. Now let us consider BPD patients, it is a case where the security in attachment is absent and there is a split and malevolent representation of self and others (Kernberg, 1967). In the life of BPD patients we usually observe angry, manipulative and needy relationships (Benjamin, 1993).
A number of scientific studies and intellectual thoughts have considered that intolerance of aloneness is the main defining characteristic of BPD and it is essential to note here that the descriptive criteria of DSM are also of the same opinion (Adler & Buie, 1979). Thus, the concepts and theories of attachment in many ways relate to DSM diagnostic criteria. Gunderson (1996) proposed that the early attachment failures actually constitute the cause of intolerance. He noted that in times of distress and sorrow patients with BPD are unable to invoke a “soothing interject” and this is due to unstable and inconsistent attachments to early caregivers. The above proposed scientific thoughts of Gunderson (1996) are same as that of Bowlby’s concept of insecure attachment.
The Scientific Observations Of Gunderson (1996) The Following Points Are True In Case Of Patients With Borderline Personality Disorder:
A Feeling of Insecurity on Grounds Of Attachment, Especially Pertinent To:
- Plea for Attention
- Pleas for Help
- Checking For Proximity
A Feeling of the Following in Borderline Personality Disorder Patients:
- Denial Of
- Dependency Needs
- Fearfulness About
Based on the comparison of theories of object relations and attachment (Lyons-Ruth & Jacobvitz 1999) distinguished between normal processes (in early development) of separation individualization from the disorganized conflict behaviour (for attachment figures) by toddlers who are at significant risk for development of psychopathology. She identified that in infants the disorganized insecure attachment as a risk factor in the later development of BPD. Thus, we can state that as per the findings of Lycos-Ruth those infants who are victims of insecure attachments during the early years of life are at risk of developing BPD during later years of their life.
In 1990, ATTACh (Association for Treatment and Training in the Attachment of children) was created in order to address the need of society and families to deal with critical attachment and bonding issues. ATTACh has cited important principles of attachment therapy and this includes the following:
1. Attachment therapy can be defined as a therapeutic process that is designed with the aim to define, develop and promote reciprocal attachment relationship and that which completely meets the criteria of that therapeutic process as defined and developed by ATTACh.
2. The aim of treatment by attachment therapy is to address the attachment problems and enable patients with healthy attachment relationships.
3. The emphasis in attachment therapy is laid on touch, physical and emotional closeness, reciprocal behaviours, empathy, atonement, communication, playfulness and humour. The attachment and bonding therapists are therefore required to treat with attention to the physical and psychological safety and wellbeing of the children and adults.
4. Family systems approach is of prime importance in attachment therapy. Thus there is need to correct child’s relationship with his or her primary caregiver.
5. It is essential to assess and study the following;
- Psychological history
- Educational history
- Treatment history
- Medical history
- Attachment & Social history (including breaks in attachment)
- Developmental history (including prenatal and birth)
- Intellectual and Cognitive skills and deficits
- Family functioning
- Differential diagnosis (including DSM and ICD diagnoses)
6. Parents and children form the most active group of treatment regimen. Attempts are made to develop healthier patterns of interaction and communication.
7. To assist parents to develop parenting strategies in order to support positive attachments.
8. Description of any shortcomings attachment therapy might have for treating this issue and what else could be fused with attachment therapy to meet these needs.
Criticisms of Attachment Therapy
1) The application of attachment therapy for treatment of patients with BPD is equated with rebirthing or holding therapy and the techniques used to achieve the results are dangerous.
2) During the treatment of patients with BPD the attachment therapists make use of criteria that are even beyond those provided by the DSM-IV-TR (Zeanah 1996; Boris et al 2004). The strong correlation between insecure attachment and pathological parent-child interaction as shown by attachment therapy are beyond the symptoms listed in the DSM criteria (Bowlby 1944, 1973).
3) The attachment therapists many times over diagnose BPD.
- Almost 87% to 96% of the children, who experience abuse, neglect or both, show an insecure attachment (Crittenden, 1988).
- Between 50% and 80% of the adopted children have attachment disorder symptoms (Carlson, Cicchetti, Barnett & Braunwald, 1989).
- Approximately 20% of children living in homeless shelter and nearly two thirds in foster care are identified with attachment disorders (Boris, Wheeler, Heller & Zeanah, 2000).
4) Attachment therapy is not supported with “empirical evidence” While attachment therapy can provide treatment of BPD, studies have revealed the effectiveness of other therapeutic methods as well. These methods have been briefly described below:
Randomized controlled studies have presented the efficacy of dialectical behaviour therapy and psychodynamic / psychoanalytic therapy (Bateman & Fonagy, 2001). The treatment provided in these trials comprises of three key features;
- Meetings with an individual therapist (once a week)
- Group sessions (one or more in a week)
- Meetings of therapists for supervision or consultation
The psychotherapist’s approaches include a building of a strong therapeutic alliance and monitoring the suicidal or self-destructive behaviours. Other essential component of effective treatment plan for patients with BPD includes managing feelings, promoting reflection action (and not impulsive action), reducing patient’s splitting tendency, and limiting the behaviours related to self-destruction. There is some empirical data that supports individual psychodynamic psychotherapy.
2. Group Therapy
Group therapy for BPD patients is supported with research findings that indicate that it can be helpful (Greene & Cole 1991). Note: However, the benefit of family therapy in the treatment of BPD patients is not evaluated yet with research studies.
Descriptions of how dimensions of cultural context impact the issue you are discussing. How might this inform your treatment? I strongly believe that psychologists should not be racists. Today we are required to treat patients of different ethnic groups and countries during our clinical practice. Even an expression of detachment or neglect can hurt hard the patients with BPD. As discussed above the patients with BPD are in need of love and acceptance, care and attachment, understanding and touch, soothing approach and closeness. If a psychologist will distinguish on the grounds of colour, race, region and country then s/he won’t be able to perform well because for the treatment of BPD patients with attachment therapy it is essential to shower true attachment. Roentsch (1985) defines racism as: “Let there be no misunderstanding. A racist is anyone who accepts the existence of racial collectives”. Amongst doctors there is a belief in the a priori inferiority of non-white (Eysenck, 1990: pp. 215-220). The facts on racism reveal that we divide the world into ‘in-group and out-group’ or ‘us and them’ (Baron and Byrne, 1994: pp. 228-229). An important study first conducted by Clark and Clark (1947, in Baron and Byrne, 1994: 256) showed that a significant proportion of non-white children had internalized the attitudes of white racist. Thus the reaction of non-white adolescents towards white psychologists can be considered to be different from the reaction towards non-white psychologists. These racists’ feelings need to be addressed with maturity and patience. The dealings, behaviour and communication need to be such monitored that the feeling of racism is absent.
Self-issues that may impact a clinician’s conceptualization and treatment of this issue from an attachment perspective. How might one’s cultural context inform what they see and how they see it? What should clinicians be cautious of? Bonus points for examination of your own “self” in relation to treating this issue from an attachment perspective.
During my school times I lost my best friend because of racial differentiation attitude of a teacher. I was very much in harmony with my non-white friend. We had a high level of understanding and we loved spending time together. We were best friends for 3 years. However, my teacher did not like us being friends. She was white and disliked non-white people. Though she did not show it openly but it was obvious by some of her remarks at different times about non-white people. My teacher asked me to quit my friendship with the non-white girl. At first I was very much hurt by my teacher’s approach but then I agreed to it. This is because my teacher said that she will assure that I will get better grades in school if I agreed to what she said. My friend was very much hurt when I broke friendship with her. And after doing this I felt guilty for doing something really wrong. Even several years after quitting friendship with her, I feel sorry for my decision. Actually for some part of my life I had started thinking the way my teacher thought. I use to respect my teachers and had a feeling that they are always right. This is the reason why I started feeling that my teacher’s attitude towards non-white people was right. However, my thoughts have changed to good after leaving school. Now, I am equally friendly towards both non-white and white. I have both non-white and white as my friends. But sometimes the thought that I was once a racist makes me feel guilty. When I recollect that I was once a racist, I lose confidence in dealing with non-white people. I noted this when I was working on the treatment of a BPD patient who was non-white. I need to be more confident in my dealing with non-white people. I need to feel sure that I no more differentiate between non-white and white. I think I will gain this confidence when as a result of my sincere work several non-white BPD patients will get healed.
Describe what the early, middle and ending phases of therapy might look like for treating this issue based on what you have learned. Please also include some possible interventions and assessment methods. Attachment theory has been applied to both children and adults suffering from detachment. Bowlby (1969) formed a lifelong attachment behavioural system which encourages secure attachment. The attachment thus begins with the child’s requirement of secure attachment from the primary caregiver. The behaviour of attachment is organized and revolves around primary care giver. The feelings of attachment are elicited during the period of mental or physical discomfort or stress (1969). As per Bowlby’s (1969) perspective BPD can be considered as a condition of significant insecure attachment. There exists number of oscillations between detachment and attachment. The early childhood experiences of BPD patients are that of detachment, neglect, abuse, separation and loneliness. Thus the systems that mediate the feelings of attachment and positive behaviour are distorted and deactivated. In addition to this BPD patients have intense fear linked with loss and separation. However, since BPD patients do not remember their childhood time when they were neglected and abused they are unable to understand the reason behind their behaviour. I think a therapist is required to develop a secure and genuine attachment relationship with the BPD patients. The patient should feel completely secure in his or her relationship with the therapist. S/he should have no fear of loss or separation as related to relationship with the therapist. Development of a ‘secure’ attachment can help establish happiness in the life of the patient.
BPD patients are in need of love but the fear of loss and separation drives them away from people. It is therefore crucial that this fear of loss and separation should be dealt in the first phase of treatment. The patient with BPD should be counselled in such a manner that s/he starts gaining confidence in building secure relationships. The approach of the therapist should be driven by ‘attachment’ and ‘love’. Thus, while attempting to heal the BPD patient of the fear of separation, the therapist should try to build his or her own place in the heart of the patient. The approach should not only aim to heal the fear but also to open ways for love and attachment. The therapist should make the patient feel that s/he really cares for him. That it is not just a routine responsibility or duty to address the need of the patient. The therapist should show that s/he has started loving the patient and has become attached with him. S/he has started caring for the needs and essential requirements of the patient. A feeling of attachment should spring from within the heart of the therapist and should touch the emotions of the patient. Parents of the patient should be educated on the basics of attachment.
They should be taught the need of touch, eye contact, motion, love, compassion, care and attachment. The issues related to behaviour should be addressed and the pitfalls should be examined. The treatment should include a review of the attachment issues of the parents’. The parents should be educated on good ways to bring up the child. The attachment from parents and primary care taker are essential for answering the need of BPD patients. Gregory C. Keck states that holding the child or adolescent gives rise in an emotional response and intensity that cannot be achieved by any other medicine or therapeutic regimen. Therapist should educate the parents or the primary caretaker to hold the child or adolescent. The therapist should work to build in attachment between the child/adolescent and the parents/primary caretaker. Building of relationship and providing security and affection from parents or primary caretaker should be assured.
The therapist should also spend time to build in attachment between the child/adolescent and himself
The therapist should also work to repair the relationship that has been broken. S/he should try to develop more peaceful and lovable feelings between the child/adolescent and the parents/primary caretaker. The therapist can also do the holding of the child/adolescent and then s/he can transfer the responsibility to the parent or primary caretaker. The therapist is also required to make an important clinical judgment with regard to the suitability of the primary caretaker or parent for such an attachment. Guidance and education as related to the attachment should be provided by the therapist. In addition to holding ‘eye contact’ is an important part of attachment therapy. Eye contact opens the door to the heart of the person and builds attachment.
In conclusion, the therapist should believe in building relationships of attachment. A feeling of security should be the base of such attachments. Broken attachments should be repaired and new attachments should be built-in. The therapist should form attachment of the patient with himself or herself. In addition to this attachment should be built between the parent/primary caretaker and the child or adolescent. Education should be imparted on developing attachment. Today, in the modern days parents find little time for their children. Many times they forget to care for their own child. The child gets hurt each moment by a lot of anxiety, depression, neglect and loneliness. The child loses the charm of attachment and feels that s/he won’t get attachment from anyone. I believe that in order to begin with attachment therapy it is essential for the therapist to first build attachment between himself and the child/adolescent. Therapist should also build in attachment between himself and the parents of the child/adolescent. This is because the parents who feel attachment from the therapist will be more responsive and agreeable to treatment.
Attachment Can Create Wonders in the World of Therapy and Therapeutics
Attachment speaks to the heart and touches the emotions to bring forth a feeling of recovery. I strongly believe that attachment therapy is the best suit for patients with BPD. This is because attachment can repair the broken hearts, the fading hopes, the dying relationships and the detached home. I would strongly recommend attachment therapy as a method of choice for the treatment of patients with BPD. Children and adolescents want someone to speak to their heart, someone who understands their need of attachment and addresses to their requirement of love, touch, care and affection. During all the phases of treatment this should be kept in mind and should be reflected in approach and practice of the therapist.
Attachment theory is a good addition to the knowledge of psychology and its application can be beneficial for the treatment of BPD patients. While dealing with patients of BPD the psychologist should not have racist attitude and his or her approach should be confident.
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