Clinical Social Work

PRACTICAL APPLICATION OF SELF- PSYCHOLOGY AND GLASSERS’ REALITY THEORY TO THE BORDERLINE PERSONALITY DISORDER POPULATION

Borderline personality disorder is a personality disorder that lies on the border between neurosis and psychosis. The essential features of this disorder is a pattern of marked impulsivity and instability of affects, interpersonal relationships and self-image which alternates between the two extremes of devaluation and idealization. These persons experience swift mod changes that can vary from anger to depression in a short time. Self- injurious tendencies are also part of this disorder.

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They experience a feeling of emptiness and are always bored. One of the core features of this disorder is emotional dysfunctionality which might cause suicidal and self mutilative behaviors. The disorder has the tendency of causing turmoil in relationships. A person suffering from it experiences a love-hate relationship with others. They tend to change their feelings towards people abruptly especially in case of minor misunderstandings. This is due to the inability of persons with borderline disorder to accept grey areas and their belief in extremes. These patients have distorted sense of the social norms that are generally accepted or may not sense these norms at all. This results in their distrust and lack of cooperation with others.

Stern (1938), was the first to use the term borderline in reference to a group of patients who could not be handled with the classical psychoanalytic methods. Other theorists tried to describe this ill-defined group of patients using other terms. The word borderline first appeared in the DSM 111 in 1980 after which it was highly researched on. To date the name of this disorder is still considered problematic though it has not been changed to anything else yet.

Originally people suffering from this disorder were thought as and actually diagnosed with other mental disorders that portray the same traits as borderline personality disorder. The original diagnostic and statistical manual of mental disorders would have diagnosed people with this disorder as suffering from emotionally unstable personality. The second edition of this manual still contained nothing that described this disorder. It is the third edition that made it a diagnosable disorder from a systematic description of observable clinical character traits. This description was maintained in the fourth edition of the manual in 1990.

BPD is a serious mental disorder that affects the proper functioning of the brain. It affects brain activity. People suffering from BPD are unable to activate neurological networks that control feelings. For people with this disorder, the frontal cortex of their brain is less active and their limbic regions are easily stimulated. The limbic region is the part of the brain that regulates our emotions while the frontal cortex modulates the limbic region. The failure to function properly of these two critical regions of the brain result in emotional instability and impulsiveness common in people with the disorder. BPD patients also have reduced serotonin activity in their brains. Serotonin is the brain chemical that controls moods and suppresses aggressive behavior which are evident in BPD patients (Siever 2007).

The subgenual anterior and cingulate cortex are also affected in people with this disorder (well Cornell medical Centre 2007). Activity in this section of the brain is reduced which leads to the disinhibiton evident in BPD patients. These parts of the brain facilitate behavioral inhibitions. The presence of this disorder increases activity in the amygdala which controls anger and fear and other limbic regions of the brain. The anterior insula is the part of the brain which responds when social norms are violated. For people with BPD, this part of the brain does not respond but only responds when there is money received (Baylor college of medicine 2008).

It is important to look into the causes of BPD. Most experts agree that there is no single cause for the disorder but rather it is caused by a combination of factors. Genetics do play a role in the occurrence of BPD. One may inherit some tendencies like aggression and emotional instability from their parents which are part of BPD. It is not clear whether there is a borderline personality disorder gene. Study that studied twins showed that in identical twins, if one twin had BPD, there is a two in three chances that the other twin will get the disorder too. Studies show that there is a 60% chance of conveying borderline personality disorder by genetic abnormalities (Friedel 2012).it seems like the genes which increase the chances of this disorder occurring can be passed from persons who have the disorder themselves or other related disorders like bipolar disorder, depression and ADHD.

There are a number of environmental factors that seem to prevail for people with this disorder. Unresolved fear and anger from childhood may result in distorted thinking patterns in adults. Being a victim of emotional, physical and sexual abuse, neglect by both or one parent and the presence of a family member with serious mental health are some of the factors that contribute to the occurrence of BPD. Poor parenting can cause the occurrence of this disorder. This includes the failure of one parent to protect the child from abuse by the other parent, a family member or an outsider. People exposed to these traumas can develop BPD.

Social and cultural factors may increase the risk of prevalence of BPD. For instance being part of a community with a culture that encourages unstable family relations may increase the chances of one suffering from the disorder. This disorder starts during the adolescent years of an individual or early adulthood. However early signs of the disorder may present themselves during childhood. A person suffering from the disorder is at risk and highly probable to be s victim of violence like rape or bodily harm.

Diagnosis of the disorder is problematic with it being underdiagnosed or misdiagnosed. A psychiatrist, psychologist, clinical social worker, or a psychiatric nurse can successfully detect BPD through the interview and a discussion of the symptoms. A critical medical examination can eliminate the possibility of other disorders with the same symptoms. This is conducted through the inquiry from the patient of the symptoms, personal and family mental health history.

It is difficult to distinguish BPD with mental illnesses with overlapping symptoms. For instance a simple description of depression may not point out the existence of borderline personality disorder. It is possible for the disorder to co-occur alongside other personality and mental illnesses. For women the disorder is likely to co-occur alongside depression, anxiety disorder and eating disorders. The disorder majorly co-occurs with other disorders like substance abuse or antisocial personality disorder.

Even with all these information available, there is no single test that diagnose BPD. For now all medical practitioners do is look at the clinical manifestation of the symptoms in order to diagnose the disorder. The disorder is considered difficult to treat but recent research point towards effective treatment of the disorder. It can be treated through psychotherapy or talk therapy. Medication may also be recommended to treat specific symptoms. Psychotherapy is one of the options for treatment available. It can relieve some symptoms. People in therapy should try to get along with and trust their therapist for the process to work. Types of psychotherapy used include cognitive behavioral therapy which helps them identify and change their core beliefs and behavior correcting the wrong perceptions.

No medication has been approved for the treatment of the borderline personality disorder. However medication in most cases accompany the psychotherapy. The medication manages certain symptoms. For example medication is given to reduce anxiety, aggression and depression. Several medications are normally given at the same time. This study seeks to explore how the two theories mentioned in the title can help in the management of the borderline personality disorder.

SELF-PSYCHOLOGY

The theory of self-psychology was developed by Heinz Kohut (1913-1981). Its clinical application was conceived in the 1960s, 70s, and 80s and is still developing to date as a contemporary psychoanalytic treatment. In this theory, effort is made to understand individuals from their subjective experiences through vicarious introspection and interpreting the understanding of the self as the central agency. The theory has become one of the four psychologies with the other three being drive theory, ego psychology and object relations theory. Self-psychology theory accepts and in cooperates some aspects of the other three theories but at the same time critiques and modifies them. The theory embodies the concepts of empathy, self-object, mirroring, idealizing alter ego and tripolar self.

The theory was developed at a time when there was focus on individual self-definition and fulfilment. It was an era obsessed with the self with the ultimate goal of perfecting the self. To develop this theory kahut set aside his belief in the classical theory and took the lead from his patients in discovering this theory. One of his patients, who was key to the development of this theory insisted that he be perfectly attuned to her every word. It is from this that he learnt of empathy as experience near observation and from this the rest of his study sprouted.

The patient would get annoyed and accuse him of ruining what she had accomplished every time he intervened and made a reflection that went against what she had arrived at on her own. He relinquished his clinical assumption that her anger was an expression of her resistance to his analysis, which he recognized was affecting his ability to grasp his patient’s experiences. He learnt to see and understand things from her perspective.

The theory of self-psychology calls for the understanding of patients from their subjective experiences. The therapist should empathize rather than analyze the patient and help the patient deepen the understanding of their own emotions and interpersonal situations. The theory maintains that human beings do not live in a vacuum and that their welfare is embedded in their social interactions. The therapist is expected to refrain from making judgmental statements and rather to constantly inquire how the patient sees their interpersonal surrounding.

The theory encompasses some concepts that are important to look into in order to understand how it works. There is the concept of self which kohut did not define explaining that the self is a reality and not knowable in its essence. He further asserted that it is possible to describe the various forms in which the self exists, explain their genesis and origin and demonstrate several components that make up the self but we will still not know its essence. Baumeister (1999) defines the concept of self as an individual’s belief about their self, including their attributes. It is a supraordinate configuration that exists from birth (berrzoff).

The self is a system of organizing personal experiences.it is the essence of ones well-being that is comprised of feelings, sensations, thoughts and attitudes towards oneself and the world. Kohut sees it as the centre of the personality ( Eagle 1984). It explains the development of mature individual and also the presence of personality disorders.

Empathy is often includes a notion of warmth, sympathy or approval. This was not the meaning kohut gave to the word. For him it meant the person’s projection of their personality into the personality of another in order to understand them better. It is the intellectual identification with the person of another. For him it meant to possess the ability to understand from within the experience of another, a way of knowing.

He was of the opinion that mental health could only be acquired in an empathic environment which provides the necessary sustenance for this mental health. For the self to develop a balance must exist between the presence of empathy from one surrounding and the failure to have empathy in the same environment. This can be used in therapy if the disappointment caused by lack of empathy can be expressed and understood. The theory of self-psychology provides that empathic attunnement is crucial to development and that continued failure to feel empathy can affect growth (benzoff).

Empathy is used in therapy to create a relationship between the patient and the therapist that is critical to the application of self-psychology. Kohut referred to empathy as vicarious introspection. It allows the therapist to reach conclusions with less dialogue, creates a bond with the patient and thereby making them feel more understood. According to kohut this bond itself has a curative effect. Kohut did not introduce the concept of empathy but only acknowledged its powerful therapeutic effect.

There are external objects talked about in the theory of self-psychology that are part of the self. This are referred to as self-objects in the theory. These objects are not experienced separately and independently from the self. They are persons, activities or objects that make the self complete.

Kohut gives an example of an infant’s caretakers as part of their self-objects and interactions between the caretaker and the infant as forming part of the infant’s self. Self-psychology involves he observation of the patients’ connection with these objects. In kohut’s explanation, they include everything from transference phenomenon, relatives and items. Kohut states that if psychology is explained as an incomplete self, self-objects are the perfect cure.

Kohut states that the function played by the self-object is taken for granted and this function does not become visible until the relationship with the object is broken. The creation of a relationship with a new self-object affects both self and the self-object. This objects are stated as having a critical effect on the health, cohesion and formation of the self. The self-psychology theory postulates that these self-objects are vital to every individual for they help in mirroring, and serve as similar selves for one to be one with. They function to give the self all it needs to be cohesive and energetic. Even though most self-objects are persons, the functions can be performed by pieces of art, literature, music and other symbols. A cohesive self is well consolidated and possesses inner self-regulation.

Frustration occurs when the self cannot access the self-objects when in need. Kohut talks of optimal frustration which he says characterizes the early relationship between a child and their mother. Self-soothing arises as an internal structure of dealing with this frustration. Dependence on these objects are important during traumatizing times and during transitions that disrupt a person’s life.

Kohut explains that a person should become less dependent on self-objects to acquire total inner-regulation but emphasizes that limited dependence should be maintained throughout one’s life. He explains that for one to be a properly function adult, it is important to orient to ones self- object needs. Individuals with weak and mature relations with the self-objects and openly admit their need for the self-objects, have relatively stable levels of self-esteem and a sense of wellbeing. On the other hand people who deny these needs or are strongly attached to self-objects have personality disorders and are unable of maintaining healthy feelings towards themselves and the world.

Another concept critical to the theory of self-psychology is that of idealized parent imago which simply refers to ideals. Imago refers to a representation of an idealized person. The idealization aspect refers to the need to have a strong, calm person to idealize and identify with in order to feel safe and complete.

According to kohut, three axes are important for the development of a healthy self. These are; the grandiosity axis, the idealization axis and the alter-ego connectedness axis. The idealization axis refers to the ability of an individual to maintain a stable system of setting goals and ideals.

This is made possible by the identification of a person, a self-object with whom the individual can merge with. According to Kohut a child should ideally be admired by both or one of the parents and enjoy a relationship with them that makes them feel that through their special relationship, they are associated to the admirable qualities. An individual with a parent imago to idealize, they develop the mature qualities of the idealized. The individual is able to grow from the qualities of others and eventually proudly develop their own qualities. The merger experience transfers the qualities of the idealized to the self.

The concept of idealization has some inherent problems. Too much idealization can devalue the self and cause feelings of worthlessness, being little and ashamed. The issue of sharing qualities through a merger is also problematic. The proponents of the self-psychology admit all the shortcoming of this concept but chose to focus on the clinical applicability of the concept.

Kohut identifies another concept of twinship also referred to as the alter ego. This refers to the need by an individual to feel that there are other people in the world who are like them. This mutual recognition serves as a sustenance from self-objects. This need is crucial to the development of a cohesive and vigorous self.

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