Why Doesn't Therapy Work for Borderline Personality Disorder?
Why Therapy Is Difficult for BPD Patients
Many people suffering from borderline personality disorder (BPD) find that therapy works well for them. Unfortunately, however, this is not the case for everybody.
Therapy requires the patient's commitment to wellness and an understanding of their disorder. Because personality disorders heavily affect the way a person thinks about and perceives things, people suffering from BPD often cannot recognize their disorder. To them, it looks like everybody else is the problem. They truly believe that they are a victim.
The truth is that they are a victim—they are a victim of their illness, not of someone else’s cruelty or indifference. They are often master liars and manipulators; even the most astute observer cannot detect their lies. This is because there is no lie to detect—they truly believe what they are saying.
They Often Misperceive Reality
Borderline patients often misperceive reality. Patients will not remember things as they actually occurred, especially when it comes to stressful situations. They will accuse you of saying things you didn’t say or of doing things you didn’t do, and there is no convincing them otherwise.
While most people work their emotions into the facts, people with BPD work the facts into their emotions. Someone without BPD might see that you have been cruel to them, and they will react with hurt feelings, anger, etc. On the other hand, a person with BPD might already be angry or hurt, so they perceive that you have been cruel to them, even if you haven’t. Nothing you say or do will make any difference; they might see rejection and abandonment in anything you say.
There is no reasoning with this. When a person with BPD gets emotionally close to someone, the other person is automatically seen as a threat. They expect that they will be hurt and will react accordingly, punishing their partner for things that never happened.
This translates to therapists too, and it is one of the reasons that therapy often does not work: When the patient sees the therapist as an enemy, therapy is not an option.
Some Therapists May Refuse to Treat Borderline Personality Disorder
Because these patients are challenging, many therapists and doctors simply will not treat people with BPD. Other well-meaning—but misguided—therapists diagnose a less-stigmatized illness, which results in less-effective treatment. Still, others believe that it is not a real illness at all, that it is a "catch-all" diagnosis with no real definition, or that it only occurs in women.
It Is Hard to Identify Lies
Much of what the borderline patient says is lies, misunderstandings, and skewed perceptions. They routinely misunderstand things that others have said and attribute the misperceived meaning to the person.
People with BPD may also lie outright, and they often cannot see any of their own wrongdoing. This is especially true if the BPD diagnosis is complicated with other personality disorders, such as narcissistic personality disorder. A therapist who relies on the patient to self-report may receive the wrong information, and this is very dangerous—for both the patient and the people in the patient's life.
There Is No Such Thing as Pure BPD
Complicating therapy even further is the fact that there is no such thing as "pure" BPD. Borderline personality disorder always occurs alongside other disorders and health concerns, such as eating disorders, substance abuse, depression, and more.
It's not uncommon to find that a borderline patient has one or more other personality disorders as well. Narcissistic personality disorder, histrionic personality disorder, and antisocial personality disorder often occur in tandem with BPD, and the presence of these disorders makes treatment significantly more difficult. Narcissistic personality disorder, in particular, can make successful therapy almost impossible.
Therapists Rarely See Patients Outside of the Office
Perhaps the biggest obstacle to treatment is that therapists don't see the BPD patients as they actually are. Therapists see them in a controlled environment for a short period of time, a setting where all the attention is focused on the patient. Since borderline patients have the most difficulty when they feel abandoned or rejected, a therapy session where the patient has 100% of the attention is not an environment in which they will be triggered.
Therapists do not see the patient act out, so the former will often inadvertently reinforce the patient's belief that there is nothing wrong, that the accusations against the patient are exaggerated, or that it is everybody else who has the problem. Validating these beliefs is counter-productive because one of the most challenging hurdles to treating BPD is getting the patient to understand that their perception is distorted. If this distorted perception is validated, it becomes even harder to address.
Find the Right Therapist
Therapy for BPD patients can be positive if approached correctly and if the patient truly wants to get help. Choosing the right therapist is crucial to success, perhaps more so with BPD than with other illnesses. There are many excellent therapists out there, but there are also many therapists who do not understand BPD or personality disorders very well. These therapists can inadvertently make the disorder harder to treat, especially if they are unaware of the manipulative aspects of BPD and the other cluster B personality disorders that often exist with it.
If the therapist your family is working with does not listen to you, does not take your concerns seriously, does not believe what is being said about the borderline patient, takes sides, or in any way seems to make things worse, find a new one. There are great therapists out there, and with a little patience, you can find one who can help you and your loved ones.
Do you think borderline personality disorder is misunderstood by most people?
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