The Borderline Couple
George Stoupas
For some clinicians, the term “borderline” can evoke feelings of fear or hopelessness. This word can conjure images of dramatic suicide attempts, out of control aggression, or walking on eggshells. Clinicians without experience with this population may believe the widespread clinical folklore that people with Borderline Personality Disorder (BPD) cannot be treated or are limited to short-term crisis stabilization. Thankfully, this is not the case. Since the original publication of The Disordered Couple 20 years ago, there has been substantial research on Borderline Personality Disorder—perhaps more than for any other personality disorder. This research suggests that Borderline Personality Disorder is treatable and that people with this disorder can achieve lasting remission with the proper care. The same is true of couples. Dialectical Behavior Therapy (DBT)— now seen as the gold standard in BPD treatment—has been modified for the treatment of couples.
This chapter addresses couple therapy for cases in which one or both members have Borderline Personality Disorder. Working with these couples can be challenging for even the most seasoned clinicians. The chapter provides a basic overview of Borderline Personality Disorder, diagnostic criteria, and prevalence. It includes a brief discussion of etiology and reviews current research regarding couples with this disorder, including assessment recommendations and treatment inventions. Systemic case conceptualizations and cultural considerations are also addressed. Finally, the chapter ends with an in-depth case study demonstrating successful couple therapy for BPD.
Overview: Theory and Research on the Borderline Couple
Borderline Personality Disorder affects between 1.6 and 5.9% of the general population (American Psychiatric Association, 2013). In clinical settings, this estimate increases to nearly 20%. Fruzzetti and Fruzzetti (2003) note that individuals with less severe problems and/or those for whom problems arise only in romantic relationships are not included in DSM estimates; they estimate that approximately 50% of the couples in their clinic exhibit significant borderline features. Despite the interpersonal instability associated with this disorder, a large number of people with BPD—up to 30%—report being involved with a romantic partner through dating, cohabitation, or marriage (Bouchard, Sabourin, Lussier, & Villeneuve, 2009). Because of this, clinicians who work with couples should have an understanding of this disorder as well as how it impacts assessment, case conceptualization, and treatment.
Etiology of Borderline Personality Disorder
Borderline Personality Disorder can be seen as the product of a number of factors with many possible diagnostic pathways. These include genetic and biological factors, childhood trauma, and dysfunctional patterns of communication in early caregiving relationships (Fruzzetti, Shenk, & Hoffman, 2005). The family environment can either protect against or exacerbate the effects of biological vulnerabilities. Zanarini et al. (1997) found that 92% of people with BPD surveyed report having experienced emotional neglect or denial as children. Battle et al. (2004) report that a BPD diagnosis statistically predicts the experience of parental neglect. These early caregiving relationships create the foundations for later intimate relationships. The Biosocial Transactional Model (Fruzzetti & Fruzzetti, 2003; Fruzzetti et al., 2005) provides a conceptualization of BPD that highlights the role of interpersonal relationships, and is therefore useful for clinicians working with BPD couples.
Linehan (1993) characterizes BPD as chronic emotional dysrégulation that disrupts ones ability to think clearly and manage behavior. This dysrégulation is based on vulnerability to negative emotion, emotional regulation skills deficits, and problems in how other people respond to ones emotional expressions. In this characterization, emotional vulnerability means being particularly sensitive to emotions, as well as reacting to them quickly and intensely across situations. People with emotional vulnerability also have difficulty returning to baseline following arousal; they feel upset longer, and their emotional arousal may grow exponentially as new situations arise. These deficits are thought to be related to invalidation and overprotection by caregivers during childhood. Emotional invalidation occurs when a persons legitimate emotional experiences are rejected as invalid or illegitimate by others. This can be done harshly, such as a parent saying “you always cry for nothing, you little baby.” It can also occur as the result of the other persons misunderstanding or preoccupation, as in the case of a parent saying “oh, c’mon, you’re not really upset” or ignoring the child’s tears. Fruzzetti and colleagues (2005) outline other types of invalidation, including invalidation of thoughts, wants, and internal experiences, as well as invalidation of public behavior. Caregivers may minimize the child’s difficulties, such as in the case of expecting emotional and behavioral maturity beyond the child’s developmental level. Caregivers may also invalidate the child’s sense of self by questioning his or her perceptions of events, causing confusion between what the child feels and what others feel, as in the case of parental over involvement.
According to Sperry (2016b), BPD subtypes are related to different parenting styles: parental overprotectiveness leads to dependence, demandingness leads to histrionic behavior, and inconsistency leads to passiveaggressiveness. In general, these experiences result in adults with self-views that state “I don’t know where I am or where I’m going” (p. 105). For people with BPD, self-esteem, interests, values, and loyalties fluctuate depending on their mood. Dysfunctional family environments teach children self-destructive and self-defeating coping strategies like aggression, impulsive emotional outbursts, and threats of self-harm. The experience of abuse and/or abandonment leads to fluctuating idealization and devaluation of significant others, as well as seeing oneself as defective and unworthy.
BPD in Romantic Relationships
In adults with Borderline Personality Disorder, these types of developmental experiences set the stage for intimate relationships in terms of how these they interpret their partners’ behavior and respond. In general, people with BPD have a lower probability of being married, more breakups, and significant dysfunction in romantic relationships compared to other personality disorders (Bouchard & Sabourin, 2009). Montigny-Malenfant et al. (2013) examined the interactions of couples in which the female partner had BPD. They found that these couples exhibited significantly more negative behaviors than community control couples. These included controlling the discussion, criticism, blaming, and threats. Miano, Grosselli, Roepke, and Dziobek (2017) found that women with BPD exhibited more stress compared to their partners, felt more relationship insecurity, and were more hostile than healthy controls. These researchers attributed the differences to a heightened stress response, which predicted more negative communication patterns and more perceived distance from partners. Bouchard et al. (2009) also found significantly higher rates of rejection anxiety as well as physical and psychological violence—both as perpetrator and victim.
Bouchard and Sabourin (2009) provide a summary analysis of research regarding couple dysfunctions in Borderline Personality Disorder. Overall, these couples report less relationship satisfaction and more distress. In terms of sexual functioning, there are often problems such as heightened sexual impulsivity, reduced satisfaction, boredom, greater preoccupation with sex, and, conversely, sexual avoidance. Sexual problems were more likely to be reported by women with Borderline Personality Disorder compared to men. Women with BPD report earlier age of first intercourse and more lifetime sexual partners, and were more likely to have been the victims of date rape. People with this disorder may view sex as a means to secure relationship commitment and avoid rejection.
Partner choice has a significant impact on overall well-being and functioning, as partners who are psychologically healthy can stabilize the relationship. Unfortunately, those with this disorder typically have poor judgment when it comes to choosing mates. Behaviors associated with BPD, like aggression, drug and alcohol abuse, and self-harm, discourage healthy individuals from entering into intimate relationships with those who have this disorder. Bouchard et al. (2009) found a high rate (55.9%) of personality disorders in the partners of borderline women, compared to DSM-5 s estimated rate of 15% in the general population. Lavner, Lamkin, and Miller (2015) examined 172 community newlywed couples and conducted followup analyses over a period of ten years. They found that people with BPD symptoms tended to have partners with similar symptoms, lending support to the idea that people with this disorder practice some degree of assortative mating. They also found that difficulties present at the beginning of the marriage tended to persist over time; however, these difficulties did not predict divorce. The authors speculate that couples may simply adapt to the dysfunction, or that those with BPD symptoms may be reluctant to leave troubled relationships for fear of being alone.
DSM-5 and the Borderline Couple
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes Borderline Personality Disorder as “a pattern of pervasive instability in interpersonal relationships, self-image, and affects, and marked impulsivity” (American Psychiatric Association, 2013, p. 663). Symptoms of this disorder include frantic efforts to avoid abandonment, a pattern of intense relationships in which other people are idealized or devalued, unstable self-image, recurrent suicidal gestures, impulsivity, intense anger, paranoia, emotional reactivity, and feelings of emptiness. People with BPD frequently engage in risky, impulsive behavior—such as spending money, abusing drugs and alcohol, or sex with strangers. Additionally, stress-related paranoia (e.g., about a partners infidelity—real or imagined) may give way to dissociation. This diagnosis frequently co-occurs with other disorders, including Major Depression, Substance Use Disorders, and Post-Traumatic Stress Disorder.
DSM-5 and Assessment Considerations
Given the potential for emotional volatility, some clinicians may wonder whether couple therapy is appropriate for those with Borderline Personality Disorder. Links and Stockwell (2001) suggest that couple therapy actually has unique advantages over individual interventions for these clients.
They recommend that clinicians conduct an extensive clinical history to determine which of the three following clusters best describes the borderline member of the couple: impulsive, identity, or affective (described below).
The “impulsive” cluster is characterized by chronic self-destructive and otherwise harmful behaviors. This includes suicide threats and/or attempts, aggression, and substance abuse. Those who fall into this category often have difficulty maintaining relationships over a significant period of time because of these destructive behaviors, and typically report instability in their previous treatment relationships and multiple premature terminations. Because of this, Links and Stockwell (2001) suggest that individual therapy is more appropriate for these clients. It can work to decrease impulsive behaviors and develop improved coping skills. Partners can be involved to establish a safety plan and address their own needs. Once the partner with BPD makes sufficient progress and can cope with couple therapy without acting out, then it can be initiated.
Clients with Borderline Personality Disorder who fall into the “identity” cluster have chronic feelings of emptiness, significant difficulty being alone, and disturbance of identity. Lacking a stable sense of self, these people depend on others to define themselves. Though crises and conflicts frequently occur, the borderline partner remains deeply committed to the relationship. According to Links and Stockwell (2001), this kind of relationship is the best candidate for couple therapy. Through a safe and supportive therapeutic environment, the goal is to achieve a more stable sense of self independent of the other person, thereby changing the dynamics of the relationship.
Finally, the “affective” cluster consists of individuals who experience intense and unstable emotions, particularly anger. These emotions are usually inappropriate to the situation and excessively intense. This affective intensity triggers out of control behaviors, which lead to chaotic relationships. Coupled with a psychologically healthy person, people in this cluster have a safe receptacle for their emotions. The healthy partner will tolerate these intense emotions if the borderline partner meets some of his or her emotional and/or physical needs. Links and Stockwell (2001) suggest that couple therapy can be effective with these couples when the healthy partner receives education about how to diffuse high intensity situations, establish boundaries, and practice self-care. The case example at the end of this chapter describes a couple representing this cluster.
