For people with borderline personality disorder (BPD), relationships can be a struggle. The people close to these individuals themselves face significant challenges. With symptoms of the disorder that include difficulties with boundaries, instability of self-concept, inability to regulate emotions, and frequent attempts at self-harm, the individuals who meet this diagnosis may expect too much out of their relationship partners, react with outrage when they feel they’re being rejected, and be demanding of excessive reassurance and attention. Treatment for people with borderline personalitydisorder is generally given only to the individual instead of to the individual and close relationship partners. Such an approach not only leaves those partners out of the therapy loop, but also may fail to take advantage of the “data” a relationship partner can provide about the individual’s behavior outside of the therapy context.
According to new research by Rutgers University’s Skye Fitzpatrick and colleagues (2019), early childhood relationships are important factors in the development of this disorder. However, theorists and researchers may pay less attention than they should to adult relationships. A biopsychosocial perspective to BPD emphasizes how the disorder is maintained within the close relationships that people have in adulthood. As the authors note, “When emotional intensity increases in people with BPD, SOs (significant others) attempt to escape the intense emotion rather than engage in effective problem-solving, emotional validation, or emotional tolerance” (p. 2). As a result, the SOs become less supportive and more judgmental, and can become demanding, critical, attacking, and withholding of affection. A downward spiral ensues, only exacerbating the individual with BPD’s distress and hence, dysfunctional behaviors within the relationship.
Fitzpatrick and her colleagues note that SO’s are involved in many other types of treatments for a range of other disorders from depression to post-traumatic stress disorder. BPD would be an area particularly suitable for such interventions, given that the symptoms are so closely linked to relationship factors. Although some studies have included relationships with family members, they do not take into account the very important contributions of nonfamilial relationships. There are, Fitzpatrick et al. note, a number of potential targets of treatment if close intimate partners are involved in the process. These include reducing BPD symptoms in the individual but also reducing the distress of the SO, and thereby reducing the general distress in the relationship. SOs could also be used in therapy as “coaches,” as targets of education about the disorder, and to help the couple work on reducing their relationship distress in general.
Using this as a background, the Rutgers University researchers examined the existing literature on the most well-established approaches to BPD therapy that fall into these three categories. The first, are those coachinginterventions in which the SO actively participates in treatment. In what is called “Systems Training for Emotional Predictability and Problem-Solving (STEPPS),” clients themselves learn about such well-established therapeutic approaches as cognitive-behavioral therapy and dialectical behavior therapy, which encourage clients to challenge their thoughts, learn to manage their emotions, communicate effectively, and manage their behaviors. SOs are brought in for one 2-hour session so that they can learn about these techniques. They can bring the therapy home by asking the individual with BPD such questions as “Have you tried a skill?” when they are distressed. STEPPS was shown, in two well-controlled randomized trial interventions, to show improvement in BPD symptoms that persisted past the end of therapy.
The second way of involving family in treating people with BPD uses education and family-based interventions. In “Family Connections,” family members of people with BPD participate in 12 weeks of group therapy in which they receive information and support. They also are taught some skills from dialectical behavior therapy to learn how to build healthier relationships with the individual with BPD. The tests of this approach were mixed, and compared to STEPPS, did not appear to provide substantial improvement, and it therefore appears to work more as a support group than as a therapeutic intervention. One variant of this approach involves family skills training in methods shown to work for individuals with BPD in traditional therapy, but there are no empirical studies demonstrating its effectiveness. Small positive effects of treatment were shown in what’s called “Staying Connected,” that focuses on the SO’s distress rather than on the partner with BPD. However, there were not enough studies to support this approach’s effectiveness.
Disorder-specific therapies involve SOs in forms of therapy ordinarily used for individuals alone. In couple dialectical behavior therapy, couples are seen as trapped together in a cycle of “high emotional arousal, inaccurate expression of emotion, and invalidation” (p. 7). Therapy attempts to reduce suicidal, self-injurious, and aggressive behavior. The couple then goes on to learn how to reactivate their relationship by engaging mindfully in joint activities. They learn how to identify and express their emotions in an accurate manner, and acknowledge the feelings of their partners. The couple also learns how to manage conflict in ways that reduces destructive communication and helps to restore feelings of closeness. Couple dialectical behavior therapy, although tested only in one randomized study, showed positive effects on relationship quality as well as the SO’s levels of passion.
The next BPD-specific therapy tested in the context of couples counseling was “couple emotion dysregulation treatment.” Across 3 phases of a 16-week treatment, couples learn methods of dialectical behavior and couples cognitive behavioral treatment with the goal of reducing the couple’s levels of distress. In the couples cognitive behavior phase of the treatment, for example, couples learn to differentiate between sharing and problem-solving, and in the process learn to soothe each other and express emotion. Unfortunately, the one study testing this approach was an uncontrolled pilot study, but the results suggested that the method did yield some positive effects on relationship satisfaction that persisted beyond the end of active treatment.
Given that these studies are just a beginning, the authors believe that the involvement of SOs in treatment of people with BPD shows promise. One common feature of all these approaches is their focus on training in emotion regulation skills. Using skills taught to the individual’s partner, such an approach helps to provide consistency outside the therapy session and in the home, both in terms of the feedback the individual receives from the partner as well as through modeling. Another positive feature of this approach is that the SO learns to regulate his or her own emotions, helping to break the destructive cycle in communication that can result when their anger and frustration start to get out of control.
As noted by the Rutgers researchers, the studies that incorporate SOs have additional limitations in that most of the individuals with BPD were female. Furthermore, other theoretical underpinnings in the causes and maintenance of the disorder were not tested in the intervention context. The other major limitation, of course, is that couples treatment was not compared to treatment involving individuals alone.
To sum up, Fitzpatrick and her collaborators have laid the groundwork for a potentially crucial area of intervention research with individuals who have BPD. Taking into account the relationships that make up such an important context for the lives of people with this disorder should help advance not only the theories of BPD in adulthood, but also the everyday contexts in which this disorder affects people’s lives.