I Hate You--Don't Leave Me - Jerold J. Kreisman [91]
Split Treatment
Many patients receive care from more than one provider. Often, therapy may be administered by a nonmedical professional (psychologist, social worker, or counselor), while medications are administered by a physician (psychiatrist or primary care doctor). Advantages of this protocol include less expense (thus accounting for its encouragement by managed care companies), involvement of more professionals, and separation of therapy and medication issues. But this separation can also be a disadvantage, since it allows the potential for patients to split providers into “good doctors” and “bad doctors” and to become confused about the treatment. Close communication among professionals treating the same patient is essential for the process to be successful. In most cases, a psychiatrist skilled in both medical management and psychotherapy techniques may be the preferred approach.
Can Borderlines Be Cured?
Much like the disorder itself, professionals’ opinion about the prognosis for those afflicted with BPD has whipsawed from one extreme to the other. In the 1980s Axis II personality disorders were generally thought to be enduring and stable over time. DSM-III asserted that personality disorders “begin in childhood or adolescence and persist in stable form (without periods of remission or exacerbation) into adult life.”12 This perception was in contrast to most Axis I disorders (such as major depression, alcoholism, bipolar disorder, schizophrenia, etc.), which were thought to be more episodic and responsive to pharmacological treatment. Suicide rates in BPD approached 10 percent.13 All of these considerations suggested that prognosis for BPD was likely to be poor.
However, longer-term studies published over the last several years demonstrated significant improvement over time.14,15 In these studies, tracking borderlines over a ten-year period, up to two-thirds of the patients no longer exhibited five of the nine defining criteria for BPD, and therefore could be considered “cured,” since they no longer fulfilled the formal DSM definition. Improvement occurred with or without treatment, although treated patients achieved remission sooner. Most patients remained in treatment, and relapses diminished over time. Despite these optimistic findings, it was also discovered that although these patients no longer could be formally designated as “borderline,” some continued to have difficulty with interpersonal functioning that impaired their social and vocational relationships. This suggests that the more acute and prominent symptoms of BPD (which primarily define the disorder), such as suicidal or self-mutilating behaviors, destructive impulsivity, and quasi-psychotic thinking, are more quickly responsive to treatment or time than the more enduring temperamental symptoms (fears of abandonment, feelings of emptiness, dependency, etc.). In short, although the prognosis is clearly much better than originally thought, some borderlines continue to struggle with ongoing issues.
Those who conquer the illness display a greater capacity to trust and establish satisfactory (even if sometimes not very close) relationships. They have a clearer sense of purpose and a more stable understanding of themselves. In a sense, then, even if borderline issues remain, they become better borderlines.
Chapter Ten
Understanding and Healing
Now here, you see,