How Effectively and Ethically is Borderline Personality Disorder Treated, and How Can it

be Improved?

Cayley Geddes
2021
Introduction:
 Borderline Personality Disorder (BPD) is a mental health condition that affects between
0.9% and 5.9% of the general United States population. It is characterized by a pattern of
unstable relationships, turbulent emotions- frequently triggered by external environmental
factors, frequent self-destructive and/or self-harming behaviour, and a lack of a clear sense of
identity. Symptoms typically present themselves in late adolescence or early adulthood. People
with BPD frequently suffer abuse or neglect of some form during their childhood. It is
hypothesized that a lack of meeting the child’s emotional needs can lead to the development of
BPD.
However, very few people are diagnosed and are instead, frequently misdiagnosed with
other disorders. The majority of diagnoses occur during a time of crisis at which the afflicted
person is either admitted to the hospital or psychiatric ward, usually for self-harm or suicide
attempts, or ideations. In clinical settings, BPD affects women more than men. To be diagnosed
with BPD a person must possess at least five of the nine criteria listed in the DSM-5. An
interview can also be completed that may take between thirty minutes to an hour and requires
training to conduct. It can be very difficult to get a diagnosis. This is likely due to a combination
of factors, including, the stigma surrounding the disorder, the complexity of getting a diagnosis,
and the comorbidity of the symptoms with other mood disorders as well as the lack of biological
indications.
BPD can not typically be treated with antidepressants, mood stabilizers, or antipsychotic
medications. It is most effectively treated with psychotherapy. Psychotherapy is a form of
treatment for mental health that occurs with a mental health professional. The patient learns
about their condition, moods, feelings, thoughts, and behaviours. They may also learn skills to
combat maladaptive behaviours. Symptoms of BPD can also worsen in therapy.
Most people diagnosed with BPD outgrow their symptoms by age twenty-seven. Yet,
those with BPD have a suicide rate that is twenty times that of the general population’s, so the
chance of living until twenty-seven is significantly lower. It is important to note that different
treatments will have different levels of effectiveness depending on the symptoms and
experiences of the patient. There are a possible two hundred and fifty-six symptom combinations
that result in a BPD diagnosis. BPD is also often comorbid with other disorders and conditions;
meaning that BPD exists frequently in conjunction with other conditions such as Substance Use
Disorder (SUD), depression, and ADHD. Therefore, BPD can manifest in a very diverse manner.
Hence, the varying levels of effectiveness in treatment.

Symptoms of BPD
The symptoms of BPD typically become present in late adolescence or early adulthood.
There are four domains that the disorder occurs in. The four domains are affectivity,
interpersonal functioning, impulse control, and cognitive.
Affectivity refers to mood fluctuations present in BPD. They often occur for short periods
with negative emotions felt more intensely and frequently for longer durations of time. The
fluctuations are typically triggered by external factors such as feelings of rejection or failure.
Secondly, intense or inappropriate anger is an effect of affectivity. Finally, patients with BPD
describe a chronic feeling of emptiness.
The second domain is interpersonal functioning. Interpersonal functioning refers to a
pattern of unstable relationships. Persons with BPD often go through patterns of idealizing and
devaluing people close to them. Another indication is efforts that are made to avoid
abandonment; some people may become socially isolated to avoid abandonment. Many people
with BPD frequently feel abandoned by those close to them. This abandonment may be real or
imagined. Moreover, there may be a lack of identity, often present in changing goals or life
plans, frequently changing sexual orientation, as well as a general sense of lack of identity.
Those with BPD may often feel as if they are taking on the identity of those close to them.
Impulse control is frequently lacking in those with BPD. This can be frequently exhibited
as a pattern of self-destructive behaviours. Including, frequent gambling, unreasonable spending,
substance abuse, and sexual promiscuity. The combination of substance abuse and dependency
and common suicidal ideation increases completed suicide and self-harming behaviours that
result in emergency room visits. “Between 60% and 78% of patients with the disorder have
shown suicidal behaviours, with more than 90% engaging in self-harm.” (NCBI Diagnosing
Borderline Personality Disorder. Biskin, R., Paris, J., 2012)
Lastly, the cognitive symptoms. Approximately, half of those affected by BPD
experience psychotic episodes. These symptoms present themselves in auditory hallucinations or
delusions that are simply a misperception of the existing environment or stimuli. Periods of
frequent or severe dissociation, derealization, or depersonalization may also occur.
Depersonalization refers to the feeling that one’s self is unreal or unusual. Derealization is the
sense that the real world is unreal or altered in a strange way.
Below are the nine criteria indicative of Borderline Personality Disorder, as found in the
“Diagnosing borderline personality disorder” article from the National Center for Biotechnology
Information from the US National Library of Medicine1.

Diagnostic criteria of borderline personality disorder *

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and

marked impulsivity beginning by early adulthood and present in a variety of contexts, as
indicated by 5 (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or
self-mutilating behaviour covered in criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

1 Biskin, R. S., & Paris, J. (2012, November 6). Diagnosing borderline personality disorder. CMAJ :
Canadian Medical Association journal = journal de l'Association medicale canadienne.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3494330/.
 4. Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-
mutilating behaviour covered in criterion 5.
5. Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

*Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision.11 Copyright © 2000 American Psychiatric Association.

Treatment of Borderline Personality Disorder:

The most common forms of psychotherapy used for BPD are Cognitive Behavioural
Therapies (CBT) - specifically: Dialectical Behaviour Therapy (DBT), Transference Focused
Psychotherapy (TFP), Schema-Focused Therapy, Mentalization-Based Treatment, and Cognitive
Analytic Therapy. For this paper, only DBT, TFP, and schema-focused therapy are investigated.
Outlined in “Personality disorder” Vol. 347, No. 7924 of the British Medical Journal are the
“Basic Principles of Managing Personality Disorders.” The treatment should be explored in an
environment of hope and optimism. The mental health professional must be focused on building
a trusting, open-minded relationship in an open and non-judgemental manner; the patient and the
therapist should work in partnership. The resources and services should be consistent, reliable,
and accessible to the patient. Patients should learn to develop autonomy throughout their therapy
and be involved in working towards a solution.
Dialectical Behaviour Therapy is a modified CBT approach. DBT was formulated for the
treatment of persons with BPD. It is rooted in the Buddhism practices of meditation and
mindfulness. Patients will work one-on-one with their therapist and will have homework outside
of their session. Homework may include actions such as journaling and practicing new skills.
There will also be group sessions. These sessions allow patients to interact with others. In this
controlled environment, participants can practice their new skills. Their therapist will also be
available to call for immediate advice. Patients with BPD can put a large emotional strain on
other types of therapists, therefore, DBT therapists work in groups of professionals that they can
consult with. This allows them to minimize the impact on their patients- leading to optimal
patient success.
Many people with BPD struggle to mentalize and remain ‘in their bodies.’ Mentalizing is
essentially the ability to understand one’s own and others’ mental state(s) and intent(s). This
form of therapy teaches the patient that all things in life are interconnected and that change is
constant and inevitable, opposites can be integrated to get closer to the truth. For example, one
may recognize and accept their current state, while also striving to improve. DBT is a highly
structured form of therapy that teaches skills to patients to improve their ability to cope. DBT is
taught through four main modules. The modules are core mindfulness, distress tolerance,
interpersonal effectiveness, and emotion regulation.
 Firstly, core mindfulness. Core mindfulness is the component most rooted in Buddhism
as it focuses on being more aware of the present moment. The patient can focus on only one
problem at a time, without judgment.
Secondly, distress tolerance. The skills taught to the patient in this module allow them to
use constructive, at the moment, alternatives to self-destructive or self-harming dangerous
alternatives. It teaches the utilization of distraction and self-soothing techniques such as deep
breathing, going walks, listening to music, or taking a hot bath. Patients will learn to accept
uncontrollable problems
The next module is interpersonal effectiveness. One of the biggest struggles for patients
with BPD is a trend of unhealthy and inconsistent relationships. Therefore, they must be taught
how to maintain healthy relationships while also caring for themselves. The skills of this module
allow them to work through conflict, develop good listening skills, and be able to ask for their
needs and wants.
Lastly, emotional regulation is taught. Patients will learn to label their emotions without
judgement. Throughout the analysis of themselves and their lives, they are taught how emotions
shape their behaviour and any obstacles that may prevent them from managing their emotions
effectively. Furthermore, they are taught what events might trigger a negative response and how
they can avoid those settings, while also increasing positive emotional events.
The main goal of DBT is for the patient to live a good feeling, fulfilling life. This goal is
accomplished through the assessment of life-threatening behaviours such as suicide attempts,
suicidal thoughts, and self-harm. As well as, addressing behaviour that may be preventing
progress in the results of the therapy, like not attending sessions or not completing homework.
Many people with BPD do not respond well to typical forms of therapy, their symptoms
may even worsen in therapy. The manifestations of symptoms associated with BPD make this
therapy more effective. People with BPD frequently struggle to label their emotions, and they are
often very turbulent which can make it difficult to consistently attend therapy and even more
difficult to recognize emotions. Since BPD is frequently considered a developmental disorder,
there are traits and coping mechanisms developed to compensate for a common childhood
environment that was invalidating. One such example is polar opposite behaviours, perhaps to
achieve emotional validation or recognition, as a child, they may have either showed no
emotions or had intense expressions of emotion. Therefore, DBT helps them to recognize this
heavier problem, find a better strategy, and implement it. Therefore, their ability to mentalize is
improved and their emotional outputs and relationships are healthier. The grounding and
mindfulness techniques taught can also improve cognitive symptoms and impulsive behaviours.
Patients will learn to be more grounded and can't calm themselves in times of crisis. These skills
will lend themselves to patients reducing the build-up of BPD episodes and impulsive behaviours
that often lead to hospitalization from suicide attempts or ideation and self-harm (impulsive
behaviours). The process can also lead to desensitizing patients from the pain associated with
fluctuating emotions.
Essentially, DBT teaches patients skills and tools to manage their symptoms of BPD.
They learn to be more independent and practice these skills in a safe environment. It also
recognizes the limits of the therapist and ensures their health is maintained. DBT therapy can be
used in conjunction with other forms of psychotherapy.
 The approach of transference-focused psychotherapy has similarities and differences to
DBT. TFP is rooted in contemporary psychoanalytic theory. Simply put, psychoanalytic theory
investigates the impact that the ego (sense of self and identity) has on a person’s behaviour and
development. The goal of TFP therapy is for the patient to be able to better understand
themselves.
Both TFP and DBT aim to help the patient understand their emotions and reactions.
However, where DBT teaches skills to combat maladaptive behavior, the main focus of TFP is to
understand the patient. The symptoms of BPD, in this instance, any observable or manifested
behavior of the disorder that is caused by an internal, mental, or environmental factor are given
attention. As the patient and therapist meet, they pay close attention to the patient’s behaviors
and emotional responses and learn to understand them. They will meet twice a week and TFP
follows the Guidelines for Treatment of Borderline Personality Disorder from the American
Psychiatric Association.
There are two rough phases of TFP therapy. The first is the setting of limits. Self-
destructive and self-harming behaviours are limited and restricted. The second phase is to
explore the patient’s mind and identity. These phases are likely to overlap due to the high ain't
that they overlap. Patients are also taught to identify the factors that inhibit their ability to
progress in treatment which increases their responsibility and autonomy.
The high emotional focus and understanding of this form of therapy make it extremely
relevant to the relationships of those with BPD. By learning to understand their emotions and
responses they are improving the ability to mentalize. Because mentalization includes the
understanding of other people’s mental states, TFP can aid those with BPD in the stability and
health of their relationships.
Schema Focused therapy is very similar to TFP. It is rooted in schema theory. Schema
can apply to all aspects of life. It can be described as the brain’s use of pre-existing knowledge
and experience to fill in missing information, categorize and remember information, as well as
respond to it. In schema-focused therapy, the schema is the manifestation of learned responses
and behaviours to frequently invalidating behaviours. For example, if a child’s character was
frequently criticized they may often feel judged or unwanted by others as an adult. In response to
this schema, they might become socially withdrawn. In schema therapy, if one or more schema is
activated, it may lead to an emotional response or state. This state is referred to as a mode.
Mode’s are identified by behaviours and emotional states. The focus of schema therapy is to
recognize unhelpful patterns of thinking which is how it is similar to TFA - the analysis and
understanding of thought patterns linked to behaviour.
Schema-focused therapy may address the core needs. The core needs include a sense of
safety and secure attachment to the caregiver(s), a sense of self-identity and autonomy, freedom
to express needs and feelings, the ability to play and be spontaneous, safe, and age-appropriate
limits and boundaries. These core needs are considered what triggers negative schema
development in childhood if they are not met.
Effectiveness in Treatment of BPD:
There are a variety of methods available to treat BPD. Due to the diversity in the
expression of BPD symptoms, this can improve the effectiveness of treatment. There are also
limitations to the treatment of BPD due to its comorbidity with other disorders and complex
treatment. However, people with BPD are more likely to seek treatment than those with other
personality disorders. To a large extent, psychotherapy is seen as an effective way to treat those
with BPD. Analyzed in this paper are DBT, TFP, and Schema-focused therapy. These methods
were chosen due to their high use and effectiveness.
The use of DBT to treat BPD typically results in lower rates of self-harm and suicidal
ideations or attempts, reduction in anger, improved interpersonal functioning, improved overall
well-being, reduction in dissociation, reduction in symptoms, and improved impulsive
behaviours. These results are found in a plethora of studies that investigate the effectiveness of
DBT as a treatment of BPD.
DBT works as an effective treatment because it allows patients to better understand
themselves and provide them with the skills they need to manage their symptoms of BPD. They
can become more independent and also experience a healthy relationship with their therapist. It
also improves their ability to mentalize, in turn, improving their ability to cope. Moreover, DBT
can be used to treat a variety of mental illnesses such as eating disorders, depressive disorder,
substance abuse disorder, and substance abuse disorder comorbid with BPD. Due to the high
number of people with BPD who have comorbid diagnoses with other mental illnesses, DBT can
be even more effective. The duality of DBT can help the patient manage symptoms of other
disorders that may share similar symptoms to their BPD. Therefore, their overall health is
improved alongside the effectiveness of the treatment. In contrast, the use of DBT might not
benefit symptoms of other disorders, such as ADHD, at all. This could lead to patients still
experiencing negative symptoms and not knowing how to cope, lending way to hopelessness and
frustration in treatment. DBT is also not completely effective. Some participants may not
improve their symptoms and many drop out. In conclusion, DBT is an effective treatment for
BPD but there may be complications that result from the nature of the disorder that decrease its
effectiveness.
Transference-focused therapy has also been demonstrative of its improvement in the lives
of those with BPD. In comparison to Experienced Community Psychotherapy (ECT), TFP
resulted in a significantly lower dropout rate, more reduction of borderline symptoms, improved
psychosocial functioning, improved personality organization, improved attachment styles, and
improved reflective skills. Transference Focused Therapy’s focus on the understanding of the
patient also improves their ability to mentalize. Its large focus on reducing dangerous behaviors
also helps to manage BPD. However, TFP does not teach skills to manage BPD. This could limit
its effectiveness in treatment. Its biggest benefit is its relationship improvement. To conclude,
TFP is an effective treatment of BPD especially in its improvement of mentalization and
relationships. It can be made more effective with the use of a behavioural improvement therapy
such as DBT.
Lastly, schema-focused therapy is also an effective treatment of BPD. Schema-focused
therapy has been shown to improve the core symptoms of BPD, improve psychological
functioning and quality of life. Schema-focused therapy is effective for the same reasons as TFP
and DBT; it improves the mentalization of patients as well as their awareness of their emotions
and the impacts they may have on their behavior. It can also help patients to manage these large
feelings. The dual-use of awareness and skills makes it more effective. Similar to DBT, it can
also be used to treat different disorders which improve its effectiveness. Unique to schema
therapy, is its focus on the impacts of childhood. BPD is likely developed as a result of
childhood therefore a focus on it will allow the patient to better understand themselves.
Essentially, schema-focused therapy is a very useful form of psychotherapy. However, as with
all forms of psychotherapy, it is not perfect and will not eliminate BPD.
All forms of psychotherapy are shown to be significantly beneficial in the treatment of
BPD. However, they will not work for everybody. Much of the data ineffectiveness does not
include those who have dropped out of treatment. It should be taken into consideration that those
who do not complete treatment are unable to determine its effectiveness and therefore, it could
be more or less effective than is exhibited in the results. Different psychotherapies can target a
variety of symptoms of BPD making them more or less effective depending on the person. When
used in conjunction they can also be more effective. Due to the diverse nature of BPD, finding
the best form of treatment can be challenging and patients may then become hopeless and in
turn, decrease the effectiveness of their treatments. Psychotherapy is the most effective treatment
of BPD but that does not make it completely effective.
The use of medication is not beneficial in the treatment of BPD. However, the majority of
people diagnosed with BPD are on some form of medication such as antidepressants,
antipsychotics, and mood stabilizers. The frequent prescription of medications that serve little to
no benefit to the patient indicates an ineffectiveness in the clinical treatment of BPD. Treatment
for BPD is not always accessible. The treatment is specialized and therefore harder to find and
often expensive. If treatments cannot be accessed then they cannot be accessible.
Overall, BPD can be treated with a variety of different forms of psychotherapy. When
and if that therapy is accessed it is often effective in treatment. However, in practice, patients are
regularly given medications that do not help or are misdiagnosed. A misdiagnosis is unlikely to
lead to effective treatment of BPD. In theory, it can be treated effectively, in practice, it usually
is not.
Ethics in the Treatment of BPD:
The treatment of BPD is entirely ethical. In the sense of scientific ethics (briefing and
debriefing, confidentiality, informed consent, right to withdrawal, and protection from mental
and physical hardship), the treatment of patients with BPD, in practice, is entirely ethical. Before
beginning therapy, patients fill out a consent form and discuss with their therapist the process
that will occur throughout their therapy. There is no deception or intentional harm. However, that
is not to say some individuals do not act unethically, simply, the patient is protected by law and
in the scripture of treatments.
The largest barrier to entirely ethical treatment of BPD is the stigma surrounding it. Many
people assume persons with BPD are manipulative and evil or ‘crazy.’ Unfortunately, this stigma
transfers into the mental health world and the world of medicine. Doctors who do not specialize
in BPD may tell patients (falsely) that there is no cure or effective treatment for BPD. Many will
also avoid diagnosing patients with BPD due to the stigma surrounding it. These actions can
prevent people with BPD from accessing the resources they need to help. They may feel more
rejected by society as well. The feeling of rejection can trigger an episode due to the sensitivity
many people with BPD harbor towards rejection. Furthermore, it could prevent them from
reaching out because they feel hopeless or burdensome.
 Outside of treatment, patients may also experience stigma in an organic environment.
Friends and family might treat them differently or poorly which can negatively impact their
sense of self. Moreover, the majority of people with BPD self-harm. There is also a large stigma
surrounding self-harm that can make people feel outcasted, unwanted, and insecure. These
stigmas are very harmful to those with BPD and make their lives harder and their transition into
therapies and healthy behaviors more challenging.
To summarize, the outline for treating people with BPD is ethical and in theory, they
should be treated ethically. However, the social stigmas surrounding BPD and the resulting lack
of education can lead to barriers that those with BPD must face getting diagnoses and treatment.
In society, many people with BPD are not treated fairly.
Strengths and Limitations of this Paper:
This paper utilizes a variety of sources and studies which increases its validity. The
researcher was able to access diverse amounts of information. Therefore, there is more data and
evidence to support the claims in this paper. Essentially, it has increased validity.
In contrast, the majority of the studies only examine women with BPD. The lack of
information surrounding men who have BPD makes drawing fully comprehensive conclusions
more difficult. It is possible that the treatments available only positively impact women and have
little to no benefit for men. There may also be other forms of therapy that are more beneficial to
men. With the data presented, it is difficult to determine. However, the effectiveness displayed is
beneficial to women with BPD.
Furthermore, this paper only analyzes three types of therapy. The three types investigated
are frequently used to treat those with BPD. Hence, their analysis is most applicable to the
general treatment of BPD (the focus of this paper). Yet, it is possible that some different types of
therapy may be more effective but are simply used less. Put simply, the relevancy of this paper is
great due to the studies and therapies chosen, but, it may be limited in comprehension due to the
limited scope.
Improving the Treatment of Those with BPD
1. Reducing Stigma.
The largest barrier to those with BPD accessing treatment and being treated fairly is the
stigma surrounding the disorder. The steps taken to decrease stigma should include the
following:
- Increased education
● During the education of mental health disorders in medical training, implement
BPD more comprehensively and fully. By doing this, healthcare professionals will
be less likely to dispel harmful and untrue stereotypes to patients, the public, and
their families.
● Educate the general public. Mental health and mental health awareness should be
taught in schools. If children are taught from a young age that mental health, in
any form, is not shameful, then they will continue that mindset and access to
mental health help will be easier
2. Increased Accessibility.
 Many people with BPD may lack access to treatment. This could be for financial or
availability reasons. Increasing accessibility to treatment for those with BPD will benefit the
effectiveness of their treatment. Improving accessibility can be done in two ways:
- Financial Support
● If financial reasons prevent the patient from receiving the treatment they should
be entitled to subsidize or free treatment. In an ideal world, all treatment would be
free. For now, patients should receive subsidies so they can afford all necessary
treatment. Mental health support should also be entirely covered by insurance and
health care plans. This will allow patients to access the support they need
consistently- improving the effectiveness of their treatment.
- Greater Availability
● The treatments available to those with BPD should be easily accessible. The
opportunity for these treatments should not be location-dependent. Those in
isolated areas should be able to access treatment easily or be subsidized to access
treatment at an equal rate. If the amount of treatment available is the issue, more
therapists and sessions should be run.
If these two factors are implemented, the treatment for those with BPD will be improved.
They will be more accepted by society, less feared by mental health professionals and they will
have access to beneficial treatments.
To fund this process the government can devote its health care spending more to mental
health. These funds can come from other sources such as building pipelines through Indigenous
land. Working to improve the health of the population will increase the revenue Canadians earn
and in turn the government makes more money. Therefore, it is a better long-term solution.

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