An introduction to the concept of Complex Psychological Trauma as it relates to Borderline Personality Disorder and Personality Disorders in general.
Letter from Dr. Jeff Ball
PCH Treatment Center was designed in part to fill a gap between outpatient treatment and psychiatric hospitalization. The population that needs this type of service includes many bipolar and mood-disordered clients, anxious clients, and primarily clients that we’ve labeled with “AXIS II Disorders” or “Personality Disorders.”
But what does that mean? So many of our younger clients, who range between 18-30 (about 70% of our clients) tend to have major dysregulation and would fit the criteria, as written, of Borderline Personality Disorder. But they also have significant trauma histories and would also fit a definition of Complex Post-Traumatic Stress Disorder (PTSD).
Over the years, I have questioned the meaning of “Borderline.” Is the term really useful anymore? Is it now a pejorative term for difficult people? Is it even useful to use that label? At PCH Treatment Center, we have rethought the concept, asking a lot of questions about the utility of the personality disorder concept. We have instead chosen to focus on the etiologies of the person’s symptoms and behaviors in the context of psychological and emotional trauma.
What is a “Personality Disorder” as currently defined?
Personality Disorders are defined as consistently maladaptive ways of perceiving, thinking, and relating to the world that cause significant impairment, and that is typically not a reaction to stress or trauma. Persons with personality disorders are seen as “acting out” patterns of behavior rather than experiencing intra- psychic disturbance. Further, the person behaves in ways that are contrary to social attitudes or expectations of others rather than stifling such behavior and experiencing inner anxiety.
What are problems with using the label “Personality Disorder?”
Personality Disorders such as Borderline Personality Disorder, are not sharply defined with a clear set of diagnostic criteria. Thus, there are problems with validity and reliability in diagnosis. Diagnostic categories are not mutually exclusive and often clients show characteristics of more than one personality disorder. Furthermore, diagnosis is heavily subjective and context-based. Personality Disorders are defined by inferred traits rather than clearly observed behaviors. The dimensionality of personality characteristics ranges from normal expressions to pathological exaggerations and can be found on a smaller scale and less intensely expressed in many “normal” individuals. Diagnosticians’ own subjective experiences and tolerances of particular personality characteristics can also lead to poor inter-rater reliability particularly in cases like Borderline Personality Disorder.
At PCH Treatment Center, we find that the label “personality disorder” inaccurately suggests a longterm or permanent derangement of a person’s personality. We believe that persons suffer from personality states related to stress, trauma or relational difficulties. For example, symptoms related to “Borderline Personality Disorder” are usually contextual and not necessarily permanent.
What is Borderline Personality Disorder? Has the term outlived it’s usefulness? Is there a Better Alternative To Conceptualize these Issues and Symptoms?
At PCH Treatment Center Los Angeles, we believe that there is a serious need for a paradigm shift in how we conceptualize and treat behavioral health issues and the way in which mental health services are categorized and delivered. The term Borderline Personality Disorder has become pejorative and polarizing. While some centers encourage its usage, at PCH we find that the negative connotations of this term outweigh it’s appropriateness. In concert with our philosophy of avoiding stigmatizing labels, we prefer that our clients conceptualize their psychological issues in terms of trauma, emotional states and behaviors.
“When any label obscures more than illuminates, practitioners are better off discarding it and relying on common sense and human decency, like the lost sailor who throws away the useless navigational chart and prefers to orient by a few familiar stars” – Nancy McWilliams, Ph.D.
Many psychiatric diagnoses conform to the medical model of illness, in which the problem is seen to be residing within the person. We feel this model is not appropriate for conceptualizing all behavioral health issues. The medical model is reductionistic and convenient, as it provides a clear-cut approach to handling individual situations by diagnosing a mental health disorder (which can often be stigmatizing). These diagnoses are then increasingly used as a vehicle for prescribing psychotropic medications. At PCH, we feel there is a need to shift from a model in which psychotropic medication is seen as first line treatment for behavioral health issues toward psychosocial and holistic approaches with pharmaceuticals as adjunctive when necessary and appropriate.
How does PCH Treatment Center treat Complex Trauma and related Personality Issues?
At PCH Treatment Center we avoid stigmatizing labels and diagnoses. Our approach to emotional dysregulation and trauma is to employ a combination of therapeutic modalities, including individual psychotherapy, yoga, DBT skills groups, and somatic approaches such as Somatic Experiencing therapy and Sensorimotor Psychotherapy. Our primary individual therapy modalities within the trauma and dysregulation track are two relational psychoanalytic approaches: Self Psychological/Intersubjective models and Mentalization-based therapy (MBT). Both relational approaches primarily treat dysregulation, abandonment, and trauma-related issues. The Trauma and Dysregulation Track includes clients who have been previously labeled with Borderline personality disorder or a Cluster B Personality Disorder (BPD, Narcissistic, Histrionic, Antisocial).
Relational psychoanalysis is an approach that emphasizes the role of relationships with others in treating dysregulation and attachment issues. The primary motivation of the psyche is to be in relationships with others. As a consequence, early relationships, usually with primary caregivers, shape one’s expectations about the way in which one’s needs are met. Therefore, desires and urges cannot be separated from the relational contexts in which they arise. Consequently, motivation is determined by the systemic interaction of a person and his or her relational world. The PCH approach to psychotherapy and to managing our therapeutic milieu is based upon this relational approach.
Intersubjective psychoanalysis suggests that all interactions must be considered contextually; interactions between the client/analyst or child/parent cannot be seen as separate from each other, but rather must be considered always as mutually influencing each other. The therapies focus upon the interactions within the therapeutic relationship, and strive to bring to light old patterns and constructs from past relationships into present day reality.
The other relational approach utilized at PCH is Mentalization-Based Therapy (MBT). Mentalization is a psychodynamic therapy that helps people understand their own and others behaviors and feelings in realistic and accurate mental state terms. People with trauma-related personality issues often have unstable and intense relationships. They may be unable to recognize the effects their behavior has on other people. They have trouble understanding other people’s emotional states and empathizing with them.
Both Relational Psychoanalytic Approaches tend to be less directive than cognitive-behavioral approaches, such as dialectical behavior therapy (DBT). DBT is another important modality to address trauma and personality issues, which is featured at PCH Treatment Center. We also offer anger management, process groups, psycho-education, and neurofeedback to further enhance each client’s treatment experience. Holistic therapies including yoga, mindfulness meditation, acupuncture and massage therapy are also important for recovery and healing. Family therapy groups and a family weekend program are available to integrate family members or significant others into the client’s treatment environment.
In sum, our multiple treatment modalities for Trauma and Dysregulation provide both insight-oriented approaches to increase the client’s understanding of the origins of their relational issues, as well as many therapeutic and experiential tools by which clients are then much more adept at coping and managing the challenges of our complex and often conflictual world.
Importance of Accuracy in Diagnosis and Issues and Dangers of Labeling
Labeling theory is the theory of how the self-identity and behavior of individuals may be determined or influenced by the terms used to describe or classify them. A stigma is defined as a powerfully negative label that changes a person’s self-concept and social identity. Primary Labeling Theory refers to how the label affects the person who is being labeled. Secondary Labeling Theory refers to how others see the labeled person. In both cases, incorrect or stigmatizing labels can have very negative effects on the person being labelled. Even when accurate, diagnostic labels may be stigmatizing and negatively impact self-esteem and openness for treatment. They also may result in the person isolating or being shunned. When inaccurate, diagnostic labels may create self-fulfilling prophecies in which the person adopts the characteristics of the psychiatric label. An incorrect label may also lead to inappropriate medicating with unnecessary side effects.
What are the pros and cons of using psychiatric labels?
- A necessary shorthand for communication between professionals
- Categorization as necessity for clinical research
- Provides an educative framework for the client (though the label may still be stigmatizing)
- Insurance Reimbursement (Personality Disorder Diagnoses, including BPD, are not reimbursable by insurance; PTSD IS Reimbursable)
- Self-fulfilling prophecies
- Misdiagnoses and inaccuracies leading to inappropriate treatment and medication
How is psychological trauma related to “Personality Disorders”?
Commonly accepted causes of personality issues are psychological trauma including physical or sexual abuse, an unstable family life as a child, or severe loss (such as death of parents or siblings). Marsha Linehan, the developer of Dialectical Behavior Therapy (DBT), believes it is caused by an interplay between biological factors and an “emotionally invalidating” childhood environment (where the child’s emotional needs are not met). Exposure to high levels of stress, substance abuse, self-medication, medical problems, and difficulties with family or other interpersonal relationships can all contribute to decreased functioning in someone with a history of psychological trauma. Furthermore, recent research indicates there may be disruption in the functioning of the brain’s limbic system, which regulates emotion.