Featured Team Members: Mariah Loftin, MA, LPC
The American Psychiatric Association defines Borderline Personality Disorder (BPD) as a mental health condition that results in a pervasive pattern of instability in relationships, a negative self-image, as well as impulsive and self-damaging behaviors. What is evident from this definition and my work with individuals with BPD is how they can struggle in many aspects of their lives. Overcoming those challenges can, oftentimes, be impossible on their own. Appropriate therapeutic treatment is essential so individuals can find relief from their symptoms and have successful lives. At Open Sky, our goals for students and families with BPD are to experience the supportive environment within which we are able to accurately assess what is happening, provide education and understanding of BPD, and support individuals learning skills to manage their symptoms after Open Sky.
What causes BPD?
Psychoeducation can help individuals and families understand what they have been going through, on a clinical level. Frequently questions like, “What did I do?”, “Why am I struggling?”, and “Is this my fault?” can emerge. What we know is there are many factors that contribute to BPD. It is the product of a complex interaction of the ways in which a person is genetically influenced, neurobiologically mediated, psychologically experienced, socially shaped, and environmentally impacted (Clarkin, Meehan, and Lensenweger, 2015). Essentially, how we behave in the world is much more complex than we initially thought.
Research by Goodman, Mascitelli, and Triebwasser (2013) through functional magnetic resonance imaging (fMRI) and anatomical MRIs done on people with BPD has supported an increase in our understanding of what is happening on a physiological level. Their findings show that individuals with BPD have
- Increased brain activity in the amygdala, which can result in increased emotional reactions
- A smaller or underdeveloped prefrontal cortex, which is the part of our brain that supports decision-making, impulse control, and emotion regulation
- Lower levels of neurotransmitters, key components of the emotion-regulation circuit that impact mood, sleep, and learning
An increase in emotional reactions, impulsivity, and decreased mood regulation can be explained at a physiological level. However, it is essential to understand that many factors combine together to impact our delicate human development. Genetics, social and cultural surroundings all impact individual personalities, as do childhood events, such as medical or sexual trauma, childhood abuse, unstable family relationships, and chronic stress. This foundation of understanding can support individuals and families having compassion for each other and themselves. As we begin to grasp an understanding of what BPD is we have to move into what we do about it.
Individuals with BPD typically struggle with relationships in many contexts—family, work, academics, and therapeutic. Research done by Sadie Dingfelder shows us that people with BPD leave treatment programs early about 70% of the time, often because of their struggle to regulate their emotions and a small therapeutic push can trigger a strong reaction. At Open Sky, students with BPD do not typically leave, as the container of the wilderness environment paired with familial support and boundaries encourage students to continue to engage in treatment.
A key component of treatment for individuals with BPD is in the foundation of wilderness: experiential therapy. While highly effective for treating many diagnostic profiles, it is uniquely equipped for treating BPD. Experiential therapy moves treatment away from concepts discussed in an office environment to actively using skills while one is having an emotional experience.
BPD has historically been seen as difficult to treat; a chronic condition with a poor prognosis. However, when we look at current research it tells us that, with appropriate treatment, individuals with BPD have so much potential for change and experience notable decreases in their symptoms over time. Dialectical behavior therapy (DBT) and cognitive therapy (CT) are the two most researched treatment modalities for BPD. DBT and CT skills support individuals using strategies and building skills to regulate their emotions, which results in a decrease in emotional variability. We also see a decrease in their self-damaging and impulsive behaviors. The goal of these treatment modalities is to support individuals in developing alternative ways to work with their overwhelming and confusing emotions.
Our core curriculum at Open Sky emphasizes:
- Identifying core beliefs
- Confronting habits that contribute to negative behaviors
- Identifying and reinforcing positive core beliefs with habits that support them.
CT identifies core beliefs as “schemas” individuals have about themselves, others, and the world that help explain affect, behavior, and motivations. Schemas seem to play a central role in the maintenance of chronic problems, often evident in people with BPD. Students and families are encouraged to examine how some of their behaviors and motivations are driven by negative schemas as opposed to positive ones.
In my work with young adults, we explore past behaviors that align with Maslow’s hierarchy of needs and identify the individual’s values, furthering the development of positive schemas. Treatment of chronic issues, such as BPD, involves testing maladaptive beliefs and identifying and strengthening alternative, more adaptive schemas (Padesky, 1994). At Open Sky there are daily opportunities to identify and experience positive schemas to reinforce behavioral change, whether through individual and group therapy, yoga and meditation, interaction with guides and peers, or by overcoming daily challenges in the wilderness.
Individuals at Open Sky are also taught DBT skills and provided with daily opportunities to use them. These skills include:
- Opposite action (if an emotion does not fit the facts of a situation and urges an unhelpful or harmful action, perform an opposite action instead.)
- Labeling emotions as a warning for potential negative behavior
- Increasing positive experiences to boost confidence
- Mindfulness practices
- Increasing distress tolerance
We know that repetition is the key to developing new habits and the wilderness setting is uniquely capable of developing lasting healthy habits due to the many opportunities to form and practice these habits individually and within the group.
Psychiatric support
Those who struggle with BPD are frequently diagnosed with other mental health disorders. Medication can be a useful tool for stabilizing one’s mood; treating depression and anxiety; decreasing suicidal ideation, impulsivity, and anxiety; and managing other symptoms of BPD. Frequently, a combination of medication and treatment results in the best outcomes for people with BPD. At Open Sky, students and families have the option to work with our psychiatrist to further overall stabilization.
Building Skills for the Future
The wilderness is a unique setting in which to treat BPD. At Open Sky we offer individual and group therapy with DBT and CT skill building. Daily activities allow students to practice these skills on an experiential level, which is the most effective way to form new habits. Our family systems work also enables the development and use of positive communication skills. Most often, this holistic approach leads to a decrease in overall symptoms and provides individuals the opportunity to meet their goals and take control of their lives during and after Open Sky.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
Clarkin, J., Meehan, K., Lenzenweger, M. (2015). Emerging approaches to the conceptualization and treatment of personality disorder. Canadian Psychological Association, Vol. 56 (2), 155-167.
Dingfelder, Sadie. (2004). Treatment for the ‘untreatable’: Despite the difficult-to-treat reputation of personality disorders, clinical trials of treatments show promise. Monitor on Psychology, Vol. 35 (3), 46.
Goodman M, Carpenter D, Tang CY, et al. Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder. J Psychiatr Res. 2014;57:108-116.
Goodman, M., Mascitello, K., Triebwasser, J. (2013). The neurobiological basis of adolescent-onset borderline personality disorder. Journal of the Canadian Academy of Child and Adolescent Psychology. Vol. 23 (3): 212-219.
Padesky, C. (1994). Schema change processes in cognitive therapy. Clinical Psychology and Psychotherapy, Vol. 1 (5), 267-278.
Verheul, R., et. al. (2003). Dialectical behaviour therapy for women with borderline personality disorder. The British Journal of Psychiatry. Vol. 182 (2) 135-140
April 3rd, 2018