Borderline States

Borderline Personality Disorder is a psychiatric label developed for the Diagnostic and Statistical Manual of Mental Disorders many years ago. The term was thought to describe individuals who had “persistent maladaptive character traits” that were “enduring” and “long standing.” In particular, dysregulation and poor relationships were at the center of this “disorder.” The term “borderline” was derived from a belief that a person manifesting these symptoms and behaviors was on the border between psychosis and neurosis, a concept that we now know is inaccurate. In recent years, many clinicians have changed their thinking, finding the term to be misleading, unreliable diagnostically and pejorative and stigmatizing. Furthermore, the idea that this is a “lifelong disorder” is damaging and untrue.

At PCH Treatment Center, we avoid this diagnosis as we do not believe in the construct of Borderline Personality Disorder. Furthermore, we find the entire diagnostic category of Personality Disorders to be an inadequate way to describe complex personality traits and issues. We see dysregulation and attachment difficulties, which are at the center of what is called Borderline Personality Disorder, to actually be the result of complex psychological trauma. This trauma manifests as instability of mood (issues with regulating thoughts and emotions), behavior (recklessness and impulsivity), and relationships (intense relationships that cycle between idealization and devaluation). When people find themselves triggered and become dysregulated and highly reactive, we see that as a “Borderline State”, which reflects the contextual nature in which we view all psychological issues. We do not believe in the concept of personality disorders as a persistent and consistent trait (which is inferred in the term “Personality Disorder”). Rather, we find that by treating dysregulation and attachment from a trauma perspective, and recognizing the context of relational triggers, we are able to improve insight as well as emotional regulation. By using multiple treatment modalities, we provide tools to help our clients better regulate and navigate the attachment issues that cause such difficulties. Because anxiety, depression and stress exacerbate these symptoms and behaviors, we teach our clients to identify and manage these issues so they can maximize their well-being.

In short, we are less interested in what is “wrong” with you and more in what happened to you to trigger these difficult relational states.

Letter from Dr. Jeff Ball

At PCH Treatment Center, we see our clients as partners in their own treatment. We view our clients as adults who have experienced difficulties in life, rather than seeing them as “ill” or “sick” as is common in the medical model of psychopathology. Many of our younger clients, (who range between 18-30 years of age) have difficulties in emotionally self-regulating and difficulties with attachment. They have been repeatedly mislabeled as having “Borderline Personality Disorder.” Over the years, I have questioned the meaning of “Borderline” and “BPD” and even the concept of “Personality Disorder.” Every person has particular aspects of their personalities that are sometimes problematic, particularly within relationships. Unfortunately, the field has tended to pathologize and create pejorative terms for those that they deem as “difficult” or resistant to the clinician’s interventions.

At PCH, we have rejected both conceptually and practically the usefulness of the personality disorder concept. We have instead chosen to focus on the causes of the person’s symptoms and their behaviors, placed within the context of psychological and emotional trauma. Over the past nine years of PCH’s existence, we have treated hundreds of clients who were or would be misdiagnosed with “Borderline Personality Disorder” and treated within that context in other treatment programs. PCH has had tremendous success in addressing underlying trauma and attachment issues while avoiding these labels and all of the negative connotations. Furthermore, we do not believe in the narrative of a lifelong “disorder.” We find we can mitigate suffering and eliminate maladaptive behaviors through insight and skills learning within a healthy and supportive milieu. This allows our clients to better function in their lives and relationships with emotional regulation and the ability to tolerate intimacy.

PCH Treatment Center was designed to fill a gap between outpatient treatment and psychiatric hospitalization. We provide a safe and more humane setting for healing than a hospital or most treatment centers. Psychiatric hospitals, with treatment predicated upon a medical model and a strong emphasis on medicating, are sometimes necessary for containment when someone feels particularly out of control or they are a danger to themselves or others. Hospitals are not a place for psychological growth and development. Accordingly, we created a psychological and social milieu treatment model in which insight, peer support, and experiential treatments are best utilized. We created a hybrid between primary and transitional care, where the client practices their new insights and skills within the community while maintaining the support and structure of a strong psychological treatment team and program. The population that benefits from our services includes persons with depression and other mood symptoms (such as bipolar states), anxious clients, and clients with complex trauma that have been mis-labeled with “AXIS II Disorders,” Borderline Personlaity Disorder,” Cluster B Disorders” or “Personality Disorders.”

Complex or Developmental PTSD*

Defined as multiple social and/or interpersonal traumatic episodes, usually beginning in early development, and spanning multiple developmental stages.

With complex trauma, the patient presents additional symptoms and dimensional problems beyond the basic symptoms of PTSD.

Symptoms include:

• Self-destructive and suicidal behaviors
• Mood and affect dysregulation
• Dissociation
• Identity problems
• Eating disorders
• Somatization
• Substance abuse

*Note that the symptoms of Complex PTSD are virtually identical to what is referred to in DSM-V as “Borderline Personality Disorder”

At PCH Treatment Center, we address emotional dysregulation and attachment issues in the context of Complex Psychological Trauma with our Trauma and Dysregulation track. We employ a combination of therapeutic modalities to address these issues. Relational psychoanalysis is an approach that emphasizes the role of interpersonal relationships in treating dysregulation and attachment issues, in particular within the therapeutic relationship. The PCH approach to psychotherapy and to managing our therapeutic milieu is based upon this relational approach. Our primary individual therapy modalities are two relational psychoanalytic approaches: Self Psychological/Intersubjective models and Mentalization-based therapy (MBT); we also employ variants of Object Relations Theory. These relational approaches address emotional dysregulation, abandonment, and trauma-related issues. The Trauma and Dysregulation Track includes clients who may have been previously diagnosed as “Borderline personality disorder” or “Cluster B Personality Disorders (BPD, Narcissistic, Histrionic, Antisocial).”

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, and further research aims to examine the links between genes associated with impulsiveness and focus upon the interactions within the therapeutic relationship, and strive to bring to light old patterns from past relationships into present day reality.

“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.

Several therapies have shown promising results for treating ‘Borderline Personality Disorder’. For instance, cognitive behavioral therapy, or CBT, aims to discover and modify the root of one’s distorted self-image and perceptions of others. Dialectical behavioral therapy, or DBT, is another useful instrument for treating ‘BPD’ and is featured at PCH Treatment Center. This approach emphasizes mindfulness, and can help with self-control, emotional regulation, and reduction of harmful behaviors.

Additionally, PCH offers many other therapeutic modalities to address the psychological trauma associated with ‘Personality Disorders’: anger management, process groups, psycho-education, and neurofeedback. Our family therapy sessions and family weekend program integrate family members or significant others into the client’s treatment environment. Holistic therapies including mindfulness meditation, acupuncture and massage therapy are also important for recovery and healing. In particular, research has shown the utility of yoga in helping those with trauma histories, and we offer multiple groups per week. In sum, our multiple treatment modalities for psychological trauma, attachment issues and dysregulation provide both insight-oriented approaches to increase the client’s understanding of the origins of their relational issues, and many therapeutic and experiential tools by which clients become more adept at coping with and managing the challenges of our complex and often conflictual world. Another 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 or ‘BPD’ often have unstable and intense relationships. They may be unable to recognize the effects their behavior has on other people and have trouble understanding other people’s emotional states and empathizing with them.

Trauma and Dysregulation Treatment

• Mentalization Based Therapy (Implicit and Explicit)
• SP
• Regulation Skills group
• Neurofeedback
• Trauma Phase I and Phase II groups
• SE
• DBT
• EMDR
• Trauma Releasing Exercises
• Seeking Safety group

Because ‘Borderline Personality Disorder’ was officially recognized in 1980 by the psychiatric community, research on the causes and risk factors for ‘BPD’ is over two decades behind when compared with other major psychiatric disorders. This preliminary data generally shows that genetic and environmental factors both play a role in the development of ‘borderline personality disorders’. Studies on twins have shown evidence that there are heritable factors involved. Additionally, social and cultural circumstances are also linked with the development of ‘BPD’, such as unstable home environments, neglect and trauma.

Personality Disorders are defined as consistently maladaptive ways of perceiving, thinking, and relating to the world that cause significant impairment. Unfortunately, personality disorders are not typically described as reactions to stress or manifestations of trauma. Persons with personality disorders are seen as “acting out” patterns of behavior rather than experiencing intra-psychic disturbance. A person with a personality problem behaves in ways that are contrary to social attitudes or expectations.

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 characteristics range from normal expressions to pathological exaggerations; pathologic features can be found on a smaller scale and less intensely expressed in many “normal” individuals. Clinicians’ own subjective experiences and tolerances of particular personality characteristics can also lead to poor diagnostic reliability, especially for Borderline Personality Disorder.

At PCH Treatment Center, we find that “personality disorder” inaccurately suggests a long-term or permanent state 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 Complex Trauma and incorrectly diagnosed as “Borderline Personality Disorder” are usually contextual, usually relational, and, when receiving the appropriate treatment, not enduring or permanent. We prefer to avoid utilizing labels that stigmatize a struggling individual and create additional problems from the original condition.

CH Treatment Center has worked with clients experiencing moderate to severe emotional dysregulation and psychological trauma since we opened in Los Angeles in 2009. Our clinicians and therapy teams are extremely experienced and qualified to treat the symptoms and behaviors associated with complex psychological trauma and related personality issues. We work with clients who may have carried the pejorative label of Borderline Personality Disorder for years; however, we choose to break the pattern and redirect their thinking to a more productive state. We are referred clients with the most challenging circumstances from hospitals and treatment centers all over the country. These referring facilities and clinicians feel comfortable knowing that PCH is very successful in treating clients with “Borderline Personality Disorder” and transitioning them to healthy, productive lives.

In sum, at PCH we believe the term “disorder” stems from an outdated medical model of psychological problems. While there is no “cure” for the human condition, we help our clients to understand and better deal with their psychological difficulties and give them the insight and the tools to manage their lives in a much more functional and contented way.