Individuals with an impaired and unstable sense of self can present some really interesting challenges in their relationships. And the kinds of difficulties folks are likely experience with any borderline personality is largely dependent upon what traits tend to be the most dominant in their weakly organized character. Last week’s post addressed some of the problems likely to be experienced with borderline individuals who have prominent dependent, histrionic, or other more “neurotic” features in their makeup (See: Borderline Personalities in Relationships). This week’s post discusses the kinds of problems one can expect to encounter in dealings with borderline personalities whose dominant traits (e.g., antisocial, narcissistic) place them at the more character disturbed end of the neurotic-character disordered spectrum.
Individuals with a unstable sense of self but who also tend to be inordinately self-centered and disregarding of the rights and needs of others (i.e. have narcissistic and antisocial personality traits) are among the most difficult to work with or live with (for more information about narcissistic and antisocial personality traits see Character Disturbance pp. 78-134, In Sheep’s Clothing pp. 37-56 as well as the article: Personality & Character Disorders Pt. 6: Narcissists and Aggressives). They’re prone to significant violations of reasonable social limits and personal boundaries. And they’re also prone to various kinds of manipulative behavior. But unlike their more “neurotic” counterparts, these mostly character-impaired borderlines don’t just inadvertently manipulate others out of their neediness and inadequacies. Rather, they more deliberately engage in dramatic, often hostile gestures to keep others both entangled and exploited.
A young man with a very checkered history and a self-described “pathological liar” (Note: as always, details in this vignette have been altered to ensure anonymity) was required by his company’s Employee Assistance Program (EAP) to get an outside psychological assessment. He had many problems both at home and at work and was on the verge of being fired from his job. His main issues were his erratic and episodically explosive behavior with his supervisors, fellow employees, and customers. He had a history of making grandiose claims about his abilities but when tested on the job and then failing to perform would alternately blame others (often verbally unloading on them in language that simply couldn’t be tolerated) or make up excuses and stories. And on more than a few occasions he had verbally berated not only co-workers but also his immediate superiors, lashing out in gross disproportion to the matter at hand, only to express great contrition afterword and give assurances he would never do anything like that again (For more on what genuine contrition looks like see the article: What Real Contrition Looks Like). His company’s EAP had earlier referred him to a physician who diagnosed him with Bipolar Disorder and placed him on mood stabilizing medication (Interestingly, but not atypically, no personality disorder diagnosis was conferred at the time nor was it cited as the “primary” diagnosis). This seemed to help some but his behavior was still erratic and unpredictable. And when anyone brought things to his attention he would readily deny doing them or lie about the circumstances leading up to his behavior. When “cornered” with abundant evidence of his culpability, he was prone to either explode or to brood, call in “sick” for several days, or drop hints to acquaintances that he was seriously thinking of “leaving this sorry $$#ss world for good,” which would simultaneously frighten, enrage, and evoke guilt in those who still had anything to do with him. He’d long been suspected of stealing others’ lunches out of the break room refrigerator, and telling falsehoods about others to get them into trouble. And he had a habit of pitting one employee against another by spreading untrue rumors and falsely claiming victimization at someone’s hands. One day, he was placed on administrative leave. The next day, he stormed into work and threatened a person he thought “responsible” for his dismissal. Two days later, his wife checked him into a hospital after he “threatened” to harm himself. For the several days he was gone from home and work, folks felt like they could finally breathe. One co-worker said it was like “being on vacation” to be at work without him there, and everyone dreaded his possible return.
Now, certainly there are similarities in this vignette to the ones in last week’s article (see again: Borderline Personalities in Relationships). But there are also some very clear differences which make the point that borderline personalities can differ quite a bit based on the dominant traits in their personality. The man in the above vignette would frequently show the grandiosity, self-centeredness, and readiness to blame others for known personal failures common to narcissistic characters. And his penchant for lying, stealing, manipulating, etc. all bespoke his antisocial attributes. Moreover, while some of his behaviors were impulsive and later regretted to some degree, they were always deliberate and ill-motivated. And there was no self-initiated attempt on the part of this man to seek help. Such things are the very definition of character disturbance.
Borderline personalities like the one above are extremely difficult to work with in therapy, even when the most state-of-the-art techniques are employed. That’s because the features associated with character disturbance are so much more difficult to ameliorate than those associated with neurosis, especially in folks with weakly organized personalities.
Two general types of therapy have been shown to have the greatest potential with borderline personalities: Classic psychoanalysis and specialized forms of Behavioral (especially Applied Behavioral Analysis or ABA) and Cognitive-Behavioral Therapy (CBT), most notably, Dialetical Behavior Therapy (DBT). Psychoanalysis is a lengthy and costly mode of therapy, often involving sessions 5 days a week for 50 minutes a day (It’s basic objective with borderline personalities is to re-shape personality from the ground up), and its efficacy is highly dependent upon the intellectual and verbal level of the patient as well as their insight capacity. Behavioral and cognitive-behavioral approaches are therefore generally preferred, and most of the time sound medical management is also required to help stabilize mood (at least until internal controls can be developed and solidified) and either prevent or reverse psychotic breaks.
Great strides have been made within DBT and ABA, especially with a particular form of ABA that focuses on “microbehaviors” and which has demonstrated remarkable results with individuals who have autistic spectrum disorders. In ABA, the patient becomes extremely mindful of all sorts of seemingly insignificant behavioral predispositions, and with the assistance of shaping contingencies gradually acquires the adaptive habits (e.g., how to self-regulate emotion, how to delay the immediate expression of an impulse, how to conduct interpersonal exchanges in a mutually respectful manner, etc.) most folks acquire as a matter of course during their growth and development but which are inherently more difficult for borderline personalities to learn. When seeking help for someone with BPD or even borderline tendencies, it’s important to consider the benefits of securing a professional well-versed in specialized CBT, DBT or ABA.
This Sunday’s Character Matters will be a live program, so I invite everyone to join the discussion.