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In an exclusive interview, psychiatrist Erwin van Meekeren emphasizes the significance of acknowledging the unique circumstances and personal characteristics of clients or patients when working with individuals diagnosed with Borderline Personality Disorder (BPD).
While evidence-based treatment methods serve as the starting point for many interventions, they need to be applied with variability and consideration for the context. This requires additional sources of knowledge, such as the experiential knowledge of patients and professionals, as well as insights from social sciences, ethics, and qualitative research. Erwin shares his perspective on how this should impact clinical practice: "This means, among other things, considering the challenges within the context of daily life, including work conditions, hobbies, and interests. The impact of limitations differs greatly from person to person."
Diagnosing borderline personality disorder can be complicated in practice. "An individual may exhibit various characteristics, such as emotion regulation problems, without meeting the criteria for a borderline diagnosis. Additionally, there is significant overlap between borderline and other classifications such as PTSD and ADHD. Moreover, there is also considerable overlap among different personality disorders, as individuals are rarely assigned just one classification."
ErwinVan Meekeren approaches borderline personality disorder as a unified concept with typical characteristics. The fundamental features of a personality disorder involve disturbances in identity, self-esteem, and effective interpersonal functioning. "Interpersonal vulnerability is often considered a core concept," Erwin explains. "This highlights the necessity of contextual thinking and acting, which involves taking into account the societal context but also the relational context, as well as professional and therapeutic aspects."
In addition to individual factors such as genetic predisposition, personality traits, coping styles, and general health conditions, environmental factors play an evident role in the development, perpetuation, or exacerbation of borderline personality disorder. "These factors include childhood experiences like neglect, physical violence and sexual abuse. Societal experiences also play a role, such as stigmatization. This is prevalent among many individuals with mental disorders. Moreover, experiences within the healthcare system contribute to the persistence of borderline personality disorder charactristics. While this may be surprising and maybe even a painful thing to hear for mental health professionals, it is a crucial factor to acknowledge. Why? Because it presents the easiest opportunity for improvement! The reality is that many individuals with borderline personality disorder have subjectively negative experiences within the healthcare system. They are often misdiagnosed and consequently receive incorrect treatment. They are referred from one therapist or social worker to the other. They do not receive appropriate guideline-based treatment and are often prescribed excessive medication."
Individuals with borderline personality disorder are generally at risk of losing social connections. This can result from stigmatization, trauma or attachment issues, and their behaviors, which can be perceived as awkward or inappropriate in social interactions. "Due to their life experiences, they often have a poor self-image and low self-confidence," Erwin continues. "They struggle with intimacy and have difficulty collaborating effectively with others. Consequently, they encounter challenges in friendships, romantic relationships, as well as in academic and work settings. Loneliness subsequently leads to further physical and mental disorders. Societal phenomena such as pandemics, polarization, and political ideologies that emphasize self-reliance exacerbate these challenges."
Let's delve into the challenges within working relationships. How should we understand them? Erwin explains: "Attachment is one of the factors influencing these relationships. Collaboration is, after all, dependent on the attachment styles of individuals. Secure attachment contributes to successful collaboration, while disruptions in attachment have the opposite effect. We are equipped with an innate attachment system. Secure attachment between a child and their caregiver is crucial for the child's ability to function adequately as an adult. Individuals who have not experienced secure attachment carry the marks of this in their adult lives. They struggle to trust others or themselves. When attachment goes awry, it can have dramatic consequences, such as chronic activation of the attachment system, where reassurance and emotional regulation are no longer possible. In practice, we encounter individuals who, due to their negative experiences, no longer want or dare to engage with mental health professionals. I also see patients who are afraid of losing contact and constantly cling to others. They have difficulty regulating their emotions and maintaining appropriate proximity and distance in relationships. This applies equally to their relationships with healthcare providers."
Stress is a part of everyday life. As stress increases, so does arousal. When we identify the source of stress or gain control over it, the arousal curve decreases, returning to its natural fluctuating state within the optimal zone, or what is known among therapists and social workers as the window of tolerance. Each person has their own individual lower and upper limits. These limits can become chronically restricted, for example, due to traumatic experiences, leading to a faster entry into either hyperarousal or hypoarousal. In hyperarousal, individuals are constantly alert and easily startled. They may react with anger or fear to certain triggers. Hypoarousal, on the other hand, manifests as freezing, staring into space, and being less responsive. In hyperarousal, individuals enter a fight-or-flight mode, while hypoarousal poses the risk of passive surrender. These states also play a role in the working relationship between individuals with borderline personality disorder and their healthcare providers.
Erwin explains, "To function properly, absorb information, regulate emotions effectively, and understand interactions, one must remain within the optimal zone. While every person may temporarily step outside the safe and optimal zone when suddenly overwhelmed, individuals with borderline personality disorder are more vulnerable to leaving their comfort zone. Therefore, professionals have the crucial task of helping individuals reestablish and maintain their Window of Tolerance. This can be achieved by punctuality, devoting ample time and attention to individuals, being well-informed about available information, and applying various stress-reducing interventions."
"Adequate collaboration often falters due to power struggles between individuals with borderline personality disorder and their healthcare providers," Erwin continues. "In such cases, the question arises: 'Who is in charge here, who makes the decisions?' Individuals may have become hypersensitive to the display of power by professionals, whether intentional or not. Many patients feel obligated to adapt unilaterally to the healthcare system and professionals, particularly concerning the allocation of time and adherence to protocols. Professionals may become irritated by patients' assertions, such as 'I read on the internet...' or 'I absolutely (don't) want antidepressants,' leading to a defensive or even upset reaction on the professional's side."
Feeling seen and heard is crucial for individuals during their formative years. Safety, reliability, and predictability are essential. Erwin: "During this period, individuals develop their own identity, become aware of the impact of their behavior on others, learn to navigate between freedom and limitations, and strike a balance between the two. When this development is disrupted due to violations of autonomy and abuse resulting from personal losses, emotional neglect, or physical and sexual violence, individuals become easily triggered by displays of power, real or perceived. This may lead to excessive dependence or an excessive need for autonomy, often expressed in statements like 'I decide for myself' or 'Who are you to decide for me?', even when they feel a need for help. Sometimes, strong passivity and dependence develop, where the patient or client fails to take sufficient personal responsibility, particularly in making choices. Alternatively, unproductive power struggles arise with others, including professionals, who may exhibit real or perceived displays of power. This can lead to symmetric escalation: both parties intensify their behaviors. Obviously, that is no something you should want."
"People may also ascribe power to 'the white coat', or to psychiatrists who decide on admission or not. This can be due to individuals associating these figures with a dominant father or past experiences of abuse of power, as well as negative experiences, including within the healthcare system. Often, these people get to hear perceived displays of power in statements like 'We have exhausted all treatment options,' 'You don't fit into our program,' 'I won't prescribe medication or refer you,' or 'We won't admit you'. Power dynamics play a crucial role in collaboration problems. On the one hand, some individuals are hypersensitive to displays of power, while on the other hand, healthcare systems and individual professionals can inadvertently fuel this hypersensitivity."
According to Erwin van Meekeren, professionals also carry their own baggage. They, too, are shaped by their upbringing, past experiences, and educators. "They have their own sensitivities and allergies and hold political, moral, and ethical views. This is often seen in statements like 'You shouldn't take sick leave so quickly,' 'Stop exaggerating,' 'Take care of yourself,' 'Take responsibility,' 'Adapt,' or 'Maintain your identity.' They may also have developed a dislike of individuals who are overly dominant or excessively submissive. These factors can impede adequate collaboration. Psychotherapists know this phenomenon as 'countertransference'."
How can we effectively manage all these factors? "The key message is to give contextual factors a significant place in our thinking and actions", says Erwin. Those who feel called to do so can work towards combating stigmatization and exclusion, and improving mental healthcare. Every professional can make an important contribution within their own context, in their work relationships and within their team. Ask patients about their desires for social participation and relationships, whether they are satisfied with their social networks, and whether they would like to change anything. Inquire about their education, work, or dreams. Take small steps towards those goals. This goes beyond 'curing' symptoms or managing cognitions, emotions, and behaviors."
He also urges professionals to approach parents and other loved ones as people who mean well, may be overwhelmed, and may not know how to best support their loved ones' problems: "Assist them by adopting a curious, open, and benevolent attitude and try to see the perspectives of all involved parties. Avoid using simplistic phrases like 'You need to learn to let go.'"
Erwin concludes with a call to give a more prominent place to a systems approach in the treatment and support of individuals with borderline personality disorder. "Replace the traditional focus on the individual with an emphasis on the relationship between family members more frequently. Instead of explaining individual behavior as purely intrapsychic, view it as an element within the circular interaction and pattern formation between individuals. Put on a systemic theoretical lens and focus not only on patterns occurring within individuals but also on patterns that emerge between individuals. Consider individual behaviors, beliefs, and narratives more frequently as 'reactions to the other' without denying individual pathology."
Erwin van Meekeren, MD is a Dutch psychiatrist. Throughout his career, he has focused on the field of personality disorders with attention for context. He also conducts psychiatric assessments for work-related issues. He has published numerous articles and books. Additionally, with organizations such as the Dutch Borderline Foundation, Triade Borderline, and the National Family Council for Mental Healthcare.