Borderline personality disorders

These patients form a significant proportion of the caseloads of many therapists. Working with them can pose difficult clinical problems based on their 'stable instability' including inability to form a stable therapeutic alliance, mood oscillations, poor impulse control, limited reflective ability, painful states of psychic emptiness followed by self-destructive acting-out, including self-destructive gestures and self-mutilation, violence, substance abuse, sexual acting-out, and eating disorders. Short-term hospital admissions are sometimes necessary. Some attempts at short-term group therapy combining cognitive behavioural and psychodynamic approaches have shown promise. Longer therapies in outpatient groups have been encouraging but have not been evaluated. (113) Good results have been reported with inpatient applications at, for example, the Henderson Hospital and other forensic settings (see below), and in day hospital group treatments followed by outpatient group therapy in a carefully monitored programme. (lJJ

Homogeneous outpatient groups do not do well because, with individuals functioning at the same level, there is insufficient diversity. The members of such a group, using similar 'primitive' defences of splitting, projection, and denial, will not have acquired a cohesive stable sense of identity. They will be suspicious of close interpersonal contact and will have little capacity to care for or be cared for by others. Such groups lack cohesion, are pervaded by a sense of pessimism, hostility, and rivalry, and easily fragment. Because therapeutic factors like cohesion, hopefulness, interpersonal learning, and reciprocity are weak, self-destructiveness is turned onto the group and its therapists who may experience intense countertransference feelings of frustration, despair, and anger.

These anti-group potentialities can be managed to good effect in the containing setting of closed or specialized institutions, and there is an increasing literature on different approaches of this kind. (115) It is generally better to place one or two borderline patients in otherwise well-functioning groups where there is a good therapeutic stance and the capacity to understand and care. Other members will not always respond to borderline pathology at the same primitive level. They may, like the adult carers of children, respond with understanding, find ways of setting limits, and expect co-operation with the task in hand. After sometimes lengthy periods in which borderline patients maintain a frustrating presence on the margins of the group or make themselves felt in aggravating terms at its very centre, they can acquire resources to take part in the group's work in more mature terms. This combination of borderline and neurotic members in a carefully composed group can benefit both parties. Borderline members will often have an unerring accuracy of perception about others; they can shake the group into more active interactions and may not collude with others' neurotic defences. The containing resources of the other members that set the norms and values of the group can slowly be internalized by the borderline members. As with many of these specialist areas, therapists working with these populations will need to acquaint themselves with the literature, have ongoing supervision, and initially may work more fruitfully in co-therapy.

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