I Have Borderline Personality Disorder — Will I be in Therapy Forever?

There are treatments available that offer hope for those with BPD and don’t require a lifetime of therapy.

This morning I read an article by Keith Gottschalk called Yeah that’s Me: Accepting the Diagnosis of Borderline Personality Disorder where the author made the statement,

“In the end, basically, you land up in therapy. Forever.”

This troubled me, as I’ve heard similar comments from others diagnosed with BPD. Some of this is due to common misconceptions and misunderstandings related to the disorder, many of which have originated from the media in t.v. and movies such as, “Fatal Attraction”. Some of it comes from reading articles online which are either incorrect or not fully understood. While the internet has given us many amazing and wonderful things, the ability for anyone to publish pretty much anything has not been one of them. Yet there are also other reasons someone with BPD may believe they need to continue therapy forever.

The Ineffective Therapist

Upon hearing that their disorder was likely the result of genetics and childhood traumatic experiences, many feel justified in the belief that their symptoms will never go away completely, and at best, can only be reduced with long term therapy to manage them. Sometimes this message is given by an ineffective therapist.

When people learn I have a Ph.D. in clinical psychology, they often tell me stories about their experiences in therapy. I would hear tales of people in therapy for years with a therapist who other than nodding and making noises of sympathy offered little to no actual feedback or advice. In other cases, I heard about people whose therapist would tell them that unless they kept coming in, they would get worse and never recover. While at first I thought these stories to be the exception rather than the rule, over time I came to the troubling conclusion that ineffective therapy is disturbingly common.

We know that there are self fulfilling prophecies, and when proclamations are made by those who are believed to be experts or are seen as holding a position of power, they are even more likely to be made to come true. Thus the idea that without the therapist the person will be lost can become internalized such that they never think to leave therapy.

The perhaps well-meaning but unhelpful old school psychodynamic practitioner who nods but says nothing will not be able to help a patient with BPD effect the change that will improve their life. This can also lead to the person believing they have to continue therapy since they aren’t feeling better yet and their life seems exactly the same.

Yet when someone with BPD finds the right therapist, they can improve and though it will take time, this does not mean that they have to be in therapy for the rest of their life. It may take more time when therapy isn’t begun until later in life, but this still doesn’t mean that there is no hope of recovery. A provider who is trained and skilled in providing treatment for BPD can help the person develop new skills to cope with difficulties and establish meaningful relationships in their life.

Reluctance to Give Up Familiar Behaviors

It is common for those with BPD to engage in therapy interfering behaviors. This may be anything from changing the subject to self injurious behavior to excessive intrusions into the therapist’s private life. There are a variety of reasons for these behaviors.

Sometimes it is because the person feels that they cannot tolerate thinking or speaking about the topic and wish to avoid it. Other times it may be a way of pushing the therapist away because the person has begun to trust them and fears betrayal or abandonment. Still other times it may just be a manifestation of the disorder as the individual attempts to make sure the therapist is there for them albeit in inappropriate ways such as countless calls to their home number or even showing up in places the therapist is known to go.

Therapy interfering behaviors may also be an indication that the person is reluctant to give up what has become familiar to them, even though the recognize that the behaviors have cost them everything important in their life. While they are terrified of being abandoned, when they act in a way that causes someone to no longer want to be part of their life, as painful as it is, it’s something they know. Learning new ways to act that will help the establish and maintain new relationships is frightening. It means coming to care about someone and trust them which risks the possibility that they will also leave. Since they’ve never experienced such a relationship before which was characterized by adaptive, functional, positive and real responses, this makes them feel very vulnerable.

Thus, many of the problematic behaviors those with BPD evidence, may be due to fear of leaving familiar ways of acting behind while not knowing if the new behaviors will provide them with what they want and need. Likewise, the idea that they will need to be in therapy forever, may be a form of reassurance. It may provide a sense of security through the belief that they aren’t going to have to change in ways that leave them defenseless and unprotected.

This is why I often speak of not taking well established coping strategies or behaviors away from someone without first giving them new options that serve the same function. When they develop new skills that they have successfully used to handle small then larger difficulties, they will be more likely to abandon other less adaptive ways of behaving.

Takeaway

While there are several understandable reasons that someone with BPD may come to believe they need therapy for life just to not spiral out of control though not necessarily improve significantly, this is not the case.

It’s up to the individual to take responsibility for finding the correct therapist to help them. Not every therapist is right for every person. This does not have to mean that they aren’t skilled at what they do. It just means the practitioner has to be a good fit for the person seeking therapy. Just because someone is rated as one of the top therapists in the city or the like, doesn’t mean they will work well with everyone.

Making sure that the therapist selected is trained in providing treatment for BPD and is skilled in doing so, is the first step. They should have specialized training specific to BPD and have seen a number of patients with the disorder successfully. Just because someone has a doctorate doesn’t mean they can treat everything.

Also given the nature of the disorder and importance of interpersonal factors, the relationship between the therapist and patient is a large part of what makes therapy effective. While maintaining control over the sessions, it is crucial for the patient to know that the therapist won’t betray them or abandon them, no matter what they do. Learning that it’s possible to have such a connection to someone else, establishes the belief that this is something that the person can have outside of therapy as well.

A well-trained skilled therapist should be able to help the person learn to regulate and tolerate extreme emotions, develop new coping skills and social skills, and work through and accept the environmental factors that helped cause it within a validating therapeutic relationship. With the right therapist and the commitment to working towards recovery even when it’s difficult or frightening, a person with Borderline Personality Disorder can improve and live a satisfying, happy life complete with healthy relationships without the need for a lifetime of therapy.

Thanks to Keith Gottschalk for the inspiration for this piece.

Natalie Frank has a Ph.D. in Clinical Psychology. She specializes in Pediatrics and Behavioral Medicine.

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