Indications for Couple Therapy in BPD
In general, couple therapy is appropriate for individuals presenting with relationship difficulties. These individuals are involved in an intimate relationship and the relationship is perceived as continuing into the future. In addition, the partner expresses a willingness to participate in therapy.
For BPD patients, couple therapy may offer unique advantages over individual psychotherapy. Most of the therapeutic efforts have been focused on individual psychotherapy, and their response to therapy has been complicated by a number of factors. First, patients with these disorders tend to not engage in therapy. Patients with BPD frequently drop out of therapy within the early months of treatment ( 13, 14). A prospective study of sixty young-adult borderline inpatients referred for psychotherapy and pharmacotherapy indicated that 43% of patients failed to complete six months of treatment ( 13) and similar high dropout rates occurred in pharmacological studies ( 15). In a study of successful individual psychotherapy, Waldinger and Gunderson ( 16) found that only 10% or fewer patients with severe personality disturbance were considered to have successfully completed therapy. Second, psychotherapy research suggests that individuals with personality disorders require increased length of treatment in comparison to other disorders to demonstrate change. The relationship between length of psychotherapy treatment and symptom-pattern improvement has been most effectively shown by Kopta and colleagues ( 17). Their work indicated that individuals with personality disorders required the greatest number of sessions versus other disorders in order for 50% of patients to show recovery. This 50% recovery rate for personality disorders occurred at an average of fifty-two sessions.
Our experience suggests that not enough attention has been given to marital-therapy interventions with patients with BPD. Couple therapy, similar to group therapy, can dilute the intensity of the transference relationship that is rapidly formed in therapy with BPD patients ( 18). The negative transferential aspects are typically projected onto the spouse while the therapist receives the positive projected aspects of the transferential relationship. As long as the therapist can avoid reacting based on these projections, the engagement in therapy can be enhanced.
Interventions may stabilize a crisis that has been activated for the individual with BPD involved in a martial relationship. Couples with a partner suffering from BPD often demonstrate a repetitive cycle of going from crisis to a sense of security and comfort, to a new crisis. Attachment mechanisms best explain how the couple fluctuates between crises, even leading to suicidality for some, to feeling secure and comfortable in the relationship. According to attachment theory ( 19), the accessibility and responsiveness of our primary attachment figure, such as a marital partner, provides us with a sense of personal security. A stable intimate relationship satisfies our primary need for trust, safety, and dependency on another person. Distress in a couple occurs when the basic attachment needs for security, protection, and closeness are not met. A real or perceived threat of attachment disruption can lead to anxiety and distress and even suicidal behavior ( 20).
However, the crisis will quickly dissolve when the attachment relationship is reestablished and there will be a return to previous levels of stability. Even in disturbed couples, therapy can stabilize an attachment crisis and lead to dramatic improvement over short periods of time. Longer-term therapy, however, can lead to a working through of the attachment difficulties and some modification of the interactional styles. The longer contract can be useful to create more long-lasting changes. To summarize, using couple therapy may potentiate therapeutic engagement and response in individuals with BPD.
The selection of patients for couple therapy requires a careful individual assessment of both spouses and a characterization of their psychological health and personality pathology. The selection of candidates for any psychotherapy requires the presence of certain talents, honesty, perseverance, and a desire to change ( 21). Paris ( 8) suggested that the patient's work history is the best predictor of treatability with psychotherapy for personality-disordered patients.
When completing the individual assessment of the patient with borderline psychopathology, it is important to take a careful treatment history. The nature of previous treatments should be reviewed as well as patients' response to these treatments. If patients have a history of repeated negative experiences to therapy and they report having felt victimized by the experience, this would be an important feature to document. Patients who act out against the therapy boundaries may be at risk of having a very negative reaction to therapy. Frances and colleagues ( 22) used these two historical features as indications for deciding that the patient should be offered no therapy as the best option regarding care.
To decide whether couple therapy is appropriate for a borderline patient, we developed a hierarchy based on the individual's "core problems" ( 23). Hurt et al. ( 23) recommended that effective treatment planning begin with a characterization of the patient's core areas of difficulty. Based on cluster analyses of BPD criteria, Hurt et al. ( 23) described three clusters of criteria that could be used to define different groups of patients who would need different treatment strategies and would form different therapeutic or healing relationships. The three clusters proposed by Hurt et al. ( 23) provided our framework for deciding on the appropriateness of couple therapy and the approach to utilize. The rest of the paper will be devoted to describing the three-level hierarchy and to using a case to illustrate the type of patient that falls within each level.
Hurt et al. ( 23) characterized an impulsive cluster of patients who evidenced a history of impulsive, self-destructive, and treatment-threatening behaviors. The borderline patient with high levels of impulsivity is not a good candidate for couple therapy. Highly impulsive individuals tend not to be able to sustain marital relationships. However, at moderate levels of impulsivity, the marital relationship can help temper the impulsivity. Our research data indicated that the level of impulsivity is a strong predictor of the course of BPD personality disorder ( 12). Not only does past impulsivity predict future impulsivity; it also predicts the levels of affective and psychotic symptoms over time. Therefore, high levels of impulsivity that lead to serious consequences or a wide array of impulsive behaviors are indications for individual rather than couple therapy. Suicide threats and attempts can be problematic if they are frequent or of high lethality. In our experience, the borderline patient in a relationship tends to demonstrate less suicidality. As these behaviors or threats are often a form of communication, they can be appropriately dealt with in couple therapy and alternative forms of communication can be learned. Substance abuse can be a significant problem; however, if the therapist is. able to integrate substance-abuse therapy with couple therapy, significant progress may result.
Impulsive borderline patients will give a history of numerous therapy contacts that were terminated before completion, and therefore, they present a challenge to any therapist. These patients may be difficult to engage, and engaging them will be a central part of therapy. However, if they do not characterize the previous therapy experiences as very negative, these patients may be accessible for further work. Often the borderline patient goes through a series of brief therapies; however, the cumulative impact of the therapies may lead to important changes. Gunderson ( 2) observed this phenomenon and likened it to a "bucket brigade" in that each bucket of water in succession, that is each brief therapy, was a factor in decreasing the raging or impulsive fires within the borderline individual.
Individual or group therapy, utilizing cognitive behavioral approaches, should be the first line of treatment to decrease the impulsivity and develop alternate coping strategies. In the case example, we illustrate that such a couple should be referred for individual help. However, part of the intervention can be directed at developing a safety plan for each of the spouses while individual therapy works on dampening the level of impulsivity.
These borderline individuals demonstrate chronic feelings of emptiness, identity disturbance and intolerance of being alone. Hurt et al.( 23) describe how these individuals need someone as they rely on external input for self-definition. The borderline individual with identity-cluster characteristics joins with a spouse with similar identity features of the borderline disorder. They enter relationships that allow them to develop some stability of identity as a result of their enmeshed attachment to their partner. Paradoxically, although this couple may experience crises, they will have a strong commitment and attachment to the relationship. The development of mutually gratifying projective identifications between the partners leads to a "closed system" ( 24). Akhtar ( 21) characterizes the relationship as having "pathological homeostasis." However, couples with these features are the best candidates for couple therapy. The acute attachment crises can be stabilized in therapy and once a therapeutic alliance is established, sustainable change can be achieved by modifying the internal working models and reworking the projective identifications.
Borderline individuals in the affective cluster demonstrate intense, inappropriate anger, instability of affect, and dramatic and stormy relationships. Although, relationships will be intense, often a healthy spouse can serve as a receptacle for the emotional outpouring. The healthy spouse will tolerate the confusion and anger, however, only if the borderline partner meets some of his/her needs. Couples in which one spouse has BPD and the other demonstrates relative psychological health require another specific couple intervention. In our experience, a psychoeducational model for the healthier spouse can stabilize and maintain the relationship. Gunderson et al. ( 3) have recently described a psychoeducational approach for family members of borderline patients that would be applicable for the well-functioning spouse.
Case 3: Borderline Couple with a Healthy Caretaker Spouse
John was borderline and symptomatic; Patty was healthy and a caregiver in this relationship. They had been married for five years when Patty contacted us for couple help. John, now in his early forties, had been diagnosed with BPD ten years earlier while he was in treatment for acting-out, aggressive behavior, which had ended a previous brief marriage. He had been depressed and suicidal and had entered long-term therapy and been placed on an antidepressant. He was currently off this antidepressant and attending therapy with his individual therapist only on a sporadic basis.
Over this ten-year period, his emotional state and behavior had been stabilized and he had become the owner and director of an art gallery. He had hired Patty as his executive assistant and they had married eighteen months later. Patty and John were referred to us for couple therapy by John's individual therapist. Patty felt that she was burning out as the caregiver in the relationship. She was exhausted from absorbing John's constant anguish and expression of suicidal wishes. They needed our help in creating some changes or the marriage would be in jeopardy. John felt that he had had enough therapy, but was eager for some peace in the relationship as well and was willing to participate to save the marriage.
Assessment and Therapy
This was a couple with one spouse suffering with BPD and a healthy spouse as a caregiver. They were appropriate candidates for couple therapy. We felt they could use some psychoeducation and direction in terms of fine-tuning and balancing their relationship and creating some increased security and change. We contracted with them for two individual sessions and four couple sessions.
Our focus was to talk frankly with them about the borderline diagnosis and the importance of the changes needed in the relationship to stabilize the crises. Patty needed John to back off when he was dysphoric and find more methods for self-soothing. He needed to respect her limits on how long they discussed a topic that was contentious. We taught them the time-out strategy. John also agreed to sit down rather than pace the room during discussions. They both learned to identify and distinguish their own emotions more clearly. John showed his dysphoric moods when he was anxious or distressed or feeling insecure. Individual cognitive-behavioral strategies to challenge his inner dialogue or voice with a more soothing and appropriate script seemed to help him. Party's reaffirmation that she was committed to the marriage also reassured John and helped him be more responsible for his own behavior. Patty in turn realized that her leaving the room or the house to end the discussions relieved her distress but frightened and disturbed John about the security of the marriage. She would learn to stay and ask for a reasonable time-out to collect her thoughts and cool down the discussion.
Patty learned how to recognize when John was in high gear and to develop strategies to diffuse or to help him gain control of his emotions. Her stability and commitment meant that the therapy sessions became working sessions for the couple. Patty developed better coping strategies and felt more comfortable setting limits on John's angry behavior. She felt that she should come every so often after the contract for our support, either by herself or with John. She also set the limits and expectations that John must continue on his antidepressant medication and see his individual therapist regularly. She created more safety and balance for herself by taking some of the art history courses that they had discussed, seeing friends, and spending some relaxed holiday time with John. The couple did well in terms of developing new coping strategies, and increasing the safety, security, and commitment in the marriage. They felt much more stable and able to work out emotional issues than they had before counseling. We saw them once at six-month follow-up and periodically for the next two years. They continued to do well.
The importance and influence of a healing relationship on the course of BPD have not been recognized. Couple therapy may offer distinct advantages for those patients with BPD in relationships. This paper outlines a hierarchical model based on the authors' clinical experience with BPD patients. The proposed hierarchical model defines the appropriateness of couple therapy, the recommended approach, and also characterizes the course and outcome of therapy. Patients with a history of impulsive, self-destructive, and treatment-threatening behaviors are not candidates for couple therapy until individual therapy reduces their impulsivity. For highly impulsive patients, the prognosis is guarded. Their relationship might well continue but their lives continue to be crisis-ridden for years. Couples characterized by identity disturbance benefit from couple therapy and may demonstrate meaningful change; however, therapy can extend over one to two years. Borderline individuals in the affective cluster with a healthy spouse benefit from psychoeducational interventions and may progress after only several months of therapy. We hope this model, based on clinical observations, will stimulate more theoretical and empirical investigations of the role of couple therapy in the management of BPD.
- Links, Paul, & Michelle Stockwell; Is Couple Therapy Indicated for Borderline Personality Disorder?; American Journal of Psychotherapy; Fall 2001, Vol. 55, Issue 4.
Reflection Exercise #7
The preceding section contained information
about indications for couple therapy in BPD. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are the three clusters that provide a framework for deciding on the appropriateness of couple therapy and the approach to utilize? Record the letter of the correct answer