How does it live with BPD

"Psychotherapy in the day center for borderline disorders" Institute for psychotherapy with day center for borderline disorders, psychosocial services in Vienna

Summary

This article deals with the treatment of patients diagnosed with “borderline personality disorder” in an outpatient, therapeutic setting. Since September 2009 we have been offering an intensive, disorder-specific, behavior-based therapy program over 12 weeks for affected patients in the day center of the Institute for Psychotherapy of PSD Vienna (Psychosocial Services Vienna). Day clinic offers have many advantages, e.g. B. the more direct transfer of what has been learned into everyday life, but also require a lot of flexibility and immediacy in the treatment.

Patients suffering from a borderline disorder often require, depending on the severity of the disease, a very complex range of treatments that can be offered more easily in a specialized institution than in individual practices. As a psychotherapeutic institution of the PSD Vienna, we are well networked and can act quickly and efficiently even in the event of a crisis. The care situation of affected patients in Austria is precarious, the outpatient offers for this patient group are not available in sufficient quantities.

In general, the psychiatric-psychotherapeutic care situation of patients with borderline personality disorder (BPD) represents a major therapeutic but also financial challenge for all treatment facilities -80% in the forensic area is the BPS the Personality disorder with the highest clinical relevance (Bolm 2009).

After a brief description of the underlying technical concepts, the therapy program of the Day Center for Borderline Disorders (TAZ-B) is presented.

Therapeutic processes and problems relating to this clinical picture are illustrated using two case studies. The article closes with an outlook into the future of treating patients with borderline personality disorder.

Summary

This article is about the treatment of patients suffering from borderline personality disorder (BPD) in a psychotherapeutic day care center, which was founded in 2009. The concept of our treatment is based on DBT (dialectical behavioral therapy) and lasts 12 weeks. The patients benefit from a complex well structured weekly schedule, which includes DBT skill training, psychoeducation, training of social competence, occupational therapy, sports, nutritional advice, art therapy and individual therapy. Our team consists of psychotherapists, occupational therapists and a psychiatric nurse.

The Psychosocial Services Vienna (Psychosoziale Dienst Wien) include medical help, crisis intervention and psychotherapeutic treatment.

Two case studies show how patients can develop their competences, mindfullness and wellbeing.

introduction

For over 15 years we have been working at the Institute for Psychotherapy with the day center for borderline disorders of the PSD Vienna (Psychosocial Services), among others. particularly intensive with the treatment of patients diagnosed with “borderline personality disorder (BPD)”.

We started in 2002 with a regular DBT skill training group, which quickly became very popular. The increasing need for disorder-specific therapy options for BPD patients has led to a steady expansion and further development of our treatment offers over the years. Skill training groups and schema therapy groups for patients with borderline disorders are therefore fixed components of our specific psychotherapeutic offer.

In autumn 2009 the day center for borderline disorders (TAZ-B) was founded as an important addition to our offers. Long-term sensible daily structure and intensive, disorder-specific therapeutic offers are essential, especially for patients with BPD, in order to break the cycle of frequent short-term inpatient crisis interventions and to establish steps towards more stability.

In the outpatient psychiatric care sector, the TAZ-B has become an important point of contact for affected patients. a. from Vienna. Our experience shows, however, that patients from the federal states also repeatedly have a great interest in treatment in the TAZ-B. Occasionally, patients from almost all federal states have now taken part in a treatment cycle. Some patients took a lot of organizational effort into this.

Treatment offer and background

The Institute for Psychotherapy with a Day Center for Borderline Disorders, as a psychotherapy facility of the Psychosocial Services Vienna, is embedded in an outpatient social psychiatric total treatment offer for mentally ill patients. We are responsible for patients with different psychiatric diagnoses such as affective illnesses, anxiety disorders, compulsions, schizophrenic illnesses or personality disorders. Exclusion criteria are addictions and forensic issues.

After a detailed initial consultation at the institute, the patient is reserved and assigned to a specific therapy offer. After clinical-psychological clarification, we can offer individual therapy, disorder-specific group offers or admission to the day center.

We also see social problems as an important criterion for treatment at the Institute for Psychotherapy. Due to the early onset of the disease, many affected BPD patients do not have a completed education. This makes starting a career even more difficult, and problems with the housing situation or debts are often the result. Family support is seldom given, and positive social contacts are often lacking in general. In addition to psychotherapy, social work is therefore an important pillar of treatment.

As part of the psychosocial services in Vienna, patients in the social psychiatric outpatient clinics also find competent specialist care. If necessary, social work support can also be used there to clarify the social problem. In crisis situations outside of our opening hours, patients can contact the PSD's social psychiatric crisis service and find professional help. The good cooperation and networking with the other institutions of the PSD Vienna is extremely important and helpful for us as a psychotherapeutic institution.

Because of these good framework conditions, a comprehensive range of care services based on the treatment guidelines of the DBT concept (Dialectical Behavioral Therapy) could be implemented for the TAZ-B.

Fault model

The borderline personality disorder is to be understood as a disorder of affect regulation as well as a disorder of social interactions. The causes of the disease are very complex and so far not fully understood (see Fig. 1). In any case, the following empirically proven risk factors can contribute to the development of a borderline personality disorder:

  • early (sexual) experience of violence (especially from close caregivers)

  • female socialization

  • physical violence

  • neglect

  • lack of security

  • invalidating attachment experiences

Also of importance are genetics and comprehension difficulties, neurophysiological and neurobiological dysfunctions in the regulation of emotions. However, 65% of those affected were victims of sexual violence, 60% experienced physical violence and neglect (Bohus and Schmahl 2006).

Since the introduction of DSM-III, BPS has been assigned to cluster B of personality disorders (antisocial, borderline, histrionic and narcissistic personality disorder). The diagnosis is made according to clear diagnostic criteria (DSM IV or ICD 10).

Many affected BPD patients suffer from additional mental disorders. Common comorbid disorders are depression, anxiety disorders, PTSD, sleep disorders, but also alcohol and drug abuse. The disease shows different courses in men and women. Reasons for this may be differences in socialization, or the gender-specific tendency to certain comorbidities. Men seek professional help less often and are more likely to abandon ongoing treatments. Men are more likely to have addiction problems, external aggressions or antisocial behavior, women more often suffer from often severe eating disorders and self-harming behavior.

The prevalence of borderline disorder in the general population is given as 1.5 to 3%, depending on the study. This can be referred to as a very common disorder. We find more affected women in clinical samples. However, it is now assumed that men and women are equally often affected by the disorder (cf. Dulz et al. 2011).

Psychotherapy and borderline disorder

In many cases, borderline personality disorder can now be treated with psychotherapy. For this purpose, both psychoanalytically oriented and behavioral therapy-oriented disorder-specific methods have been developed. The prognosis for people diagnosed with “borderline personality disorder” with disorder-specific psychotherapeutic treatment is therefore relatively good.

Psychotherapeutic methods for the treatment of borderline personality disorder, the effectiveness of which has been empirically proven:

  • Scheme Focussed Therapy - ST (J. Young)

  • Mentalization Based Treatment - MBT (Bateman & Fonagy)

  • Transference Focussed Psychotherapy - TFP (O. Kernberg)

  • Dialectical Behavioral Therapy - DBT (M. Linehan)

Disorder-specific psychotherapeutic interventions are the treatment of choice in BPD, pharmacological interventions are to be classified as rather secondary (SGPP 2018).

According to current studies, DBT and ST are currently considered to be the most effective psychotherapy methods in the treatment of borderline disorder.

Schema Therapy (ST) is considered a further development of cognitive-behavioral therapy procedures. Successful behavior therapy techniques are combined with elements from Gestalt therapy and depth psychological perspectives. According to this understanding, the borderline disorder arises from the interaction of various dysfunctional functionalities of the patient. The activated mode is discussed in the therapy. The causes of schemata often lie in previous traumatic experiences. The aim of schema therapy is to give patients insight into which needs were not adequately met in childhood and how current needs can be better satisfied (cf. Roediger 2011).

The Mentalization Approach (MBT) represents a synthesis of developmental psychology, attachment theory, psychodynamic, cognitive-behavioral, trauma-related and neurobiological findings and the “theory of mind”. This approach can therefore be seen as a common feature between all psychotherapy schools. Mentalizing means experiencing and understanding behavior in connection with internal states and processes. The goal of MBT is to promote this understanding. A clear concept and stable representations of internal states (thoughts, feelings, wishes, needs) should be developed (cf. Bolm 2009).

The Transference-Focused Psychotherapy (TFP) is a specific psychodynamic psychotherapy developed for patients with cluster B personality disorders. This method is based on object relationship theory and differs significantly from other psychodynamic therapy approaches. Compared to classic psychoanalytic settings, a clear structure and direct, supportive relationship design are of greater importance in the TFP (Clarkin et al. 2001).

In the Dialectical Behavioral Therapy (DBT) the therapist also sees himself as a "coach". The DBT is mainly based on behavioral skills. The therapy is complemented by Far Eastern elements. The basic therapeutic attitude of DBT is characterized by acceptance, stability, patience and compassion. A validating atmosphere and support in solving problems are important. In DBT, disturbed emotion regulation is seen as a core problem of the disease. Dysfunctional behavior is closely related to the respective internal tension. These states of tension lead to self-harm or other impulsive behaviors. Interpersonal problems also occur more frequently, as tension can also lead to aggression. At the beginning of the treatment, a written treatment contract is concluded in order to create a good working basis.

DBT methodology (cf. Bohus 2019)

  • Dialectic between acceptance and change

  • Problem solving techniques

  • Stabilization techniques

  • Cognitive restructuring

  • Exposure method

  • Validation strategies

  • Conveying skills (teaching - training - feedback)

  • Processing of dysfunctional schemes

The complex BPS problem is dealt with in the DBT according to hierarchical therapy goals. The therapy goals are structured according to the degree of self-endangerment. The therapy should always work towards the most important goal:

  1. 1.

    Suicidality / self-harming behavior

  2. 2.

    Behavioral alternatives

  3. 3.

    Dealing with emotions

  4. 4.

    Lifestyle

The treatment requires time and personal commitment from therapists and patients, but also a lot of patience and perseverance.

Therapy in the day center for borderline disorders of the PSD Vienna

Since 2009 we have been able to offer a 12-week intensive therapy program for patients with a borderline personality disorder in the Institute for Psychotherapy with a day center for borderline disorders at PSD Vienna. We have increasingly adapted and further developed the program. Our therapy program is based on a basic behavior therapy concept and well-founded empirical studies by DBT.

Primary goals of participation in the day center (TAZ-B)

  • Activation of resources

  • Sensible daily structure

  • Increased self-control

  • Increase in quality of life

  • Increase in resilience

  • Development of new perspectives

  • Finding access to your own feelings

  • Improve self-esteem

Disorder-specific treatment elements in BPS according to the DBT concept (cf. Bohus 2019)

  • Individual therapy

  • Telephone contacts / crisis intervention

  • Skill training (16 weeks)

  • Day center (12 weeks)

if necessary:

  • Specialist treatment in the social psychiatric outpatient clinics

  • Immediate psychiatric help

  • Inpatient admission or crisis intervention at the regionalized psychiatric departments

The complexity of the symptoms of this clinical picture requires a high degree of flexibility on the part of the treatment team and the willingness to constantly accept new requirements in order to be able to offer the comprehensive and intensive range of therapies that these patients need.

Most of our patients are female (85%), many of the male borderline patients tend to be cared for in other facilities due to their comorbidities, such as addiction problems or outwardly directed aggressions.

Participation in the therapy program takes place after a detailed initial discussion and a well-founded clinical psychological diagnostic evaluation. A certain level of motivation and resilience are prerequisites for successful participation. Five therapeutic units take place daily (see Tab. 1).

Clinical psychologists, psychotherapists (VT) and occupational therapists work closely together in the therapeutic team.

Effective therapeutic elements are skill training, social competence training, Euthyme procedures, occupational therapy, art therapy, mindfulness and relaxation, activation and sport, nutrition and psychoeducation, but also (professional) orientation. By working together in the entire team, the individual units become a positive “whole”. As part of art therapy, for example, topics from the skill training group are integrated and deepened using various materials and media.

Occupational therapy offers assistance in regaining the ability to act in everyday life. Deficits and resources of the patient can be determined more precisely, goals can be defined and striven for, and support can be offered in the execution of tasks. Making new experiences, being accepted, but also exchanging ideas with other affected persons are also important elements of the treatment.

Psychotherapy takes place in the TAZ-B predominantly in a group setting. In addition, regular one-on-one interviews are offered as part of the care provider.

If we ask patients what the disease means for them, it becomes clear how much the impairment is felt in all areas of life. Those affected are often confronted with many prejudices and devaluations from their environment. "Borderline" means permanent stress for the affected patients.This illness is enormously exhausting, apparently out of nowhere the mood can tip into the abyss.

For me, borderline means ...

  • Severe tiredness

  • Despair

  • is energy consuming

  • frequent loss of reality and dissociation

  • Having to swallow medication

  • many tears

  • a part of me that I integrate into my life

  • Have to learn strategies or skills

  • to make life more difficult emotionally

  • effort

  • Think black and white

  • To be understanding, compassionate, but also very vulnerable

  • All or nothing - there is no in-between

  • become explosively aggressive

What others think about borderline ...

  • hopelessness

  • BPS patients do not find friends and are unspeakably exhausting

  • the borderline illness is a reason for termination

  • be different

  • is diagnosed more often in women

  • is mostly acquired

  • "Prolonged puberty"

  • BPS means additional emotional work

  • there is no cure

  • Combination of symptoms of different clinical pictures

  • often occurs in combination with other mental illnesses

  • means learning to live with it

Finally, I would like to give an impression of our work in the TAZ-B using two case studies. The selected examples are intended to illustrate the diversity of our participants.

We walk a bit of life together with our participants and offer them the opportunity to have new experiences, to process things better and to develop healthier strategies for the current challenges of life.

Case studies

Case study 1 - Ms. S.

After an outpatient rehabilitation, the 25-year-old patient is referred to us for further treatment in the TAZ-B. Due to the various limitations of everyday functions, their resilience is estimated to be very reduced. Ms. S. is already receiving psychiatric treatment and is receiving TRITTICO 150 mg, SEROQUEL XR 50 mg and ESCITALOPRAM 10 mg.

Diagnoses

  • Emotionally unstable personality disorder, borderline type (F 60.31)

  • Recurrent depression, moderate episode (F 33.10)

  • Chronic pain symptoms (F 45.4)

In the detailed first interview, the patient describes her childhood in Slovakia, which was characterized by massive violence by her parents and chronically invalidating conditions. From the 15th year Ms. S. was on her own. The stress she experienced and the severe neglect led to self-harming behavior even in her early youth and ultimately to a serious suicide attempt through tablet intoxication with a subsequent long inpatient stay.

Due to her psychological problems, the patient was unable to successfully complete school. In order to survive, she had to earn her living in the red light district and in the drug scene. During this time, too, there were many traumatizing experiences. Ms. S. lives in Vienna from the 20th year of life. Here, too, she has already had many negative relationship experiences and was badly disappointed and betrayed by her partners.

Ms. S. reacted again and again with increased physical symptoms such as attacks of fever, paralysis of the legs and pain all over the body. She was quick to react impulsively and aggressively.

Therapy goals

  • Improve social skills

  • Work on self worth

  • Become “braver”

  • Improve emotion control

  • (Re) discover interests

At first it was very difficult for the patient at the TAZ-B to develop a little trust in therapists and the range of therapies. Due to language problems, too, she was reluctant to get involved in the group. We only managed to come into better contact with the patient step by step and also get to know her humorous side.

Ms. S. developed over the 12 weeks into a reliable, lovable and hard-working participant. Having a place where she was welcome and safe was important. She was a fighter who, despite her often severe pain symptoms, was very interested and committed. Ms. S. was able to achieve most of her therapy goals or take steps in a constructive direction. Social competence training and the skills training group were particularly helpful and enabled her to acquire new skills, apply them and thereby gain new experiences. She experienced her rediscovered access to her creativity as a great resource. Through occupational therapy she was able to acquire various new techniques that gave her great pleasure and increased her self-esteem.

Unfortunately, her financial and social situation was still very tense at the end of her participation. Contact with the debt counseling service was established with our support. Ms. S. applied for rehabilitation allowance in order to achieve a certain level of financial security. Unfortunately, there were few supportive, constructive contacts in their environment. However, she was able to better distance herself from some destructive people and focus more on her own goals.

Ms. S. stayed in contact with us even after completing her therapy in the TAZ-B and regularly came to the sports group, which is also an offer for former participants.

Case study 2 - Ms. T.

Ms. T., 47 years old, contacts us on the recommendation of the ÖGK (Austrian Health Insurance Fund) and asks for psychotherapeutic support. After the initial consultation, the patient is primarily reserved for individual therapy, which she can begin after a short waiting period. Due to her currently very difficult life situation and an emerging more massive psychological crisis, Ms. T. is also reserved for participation in the TAZ-B. Since her youth, the patient has been receiving psychiatric treatment from a resident specialist and is currently receiving CIPRALEX 10 mg and ATARAX 25 mg.

Diagnoses

  • Emotionally unstable personality disorder, borderline type (F 60.31)

  • Recurrent depression, moderate episode (F 33.10)

  • Binge eating disorder (F 50.9)

Ms. T. grew up with her younger brother in her family in a small village in Burgenland. The parents had a difficult marriage, Ms. T. became the mother's confidante and accomplice at a young age. She didn't really feel loved, but she tried very hard to get attention and care from her parents. The father fled into other relationships, Ms. T. often kept secrets. Appearance played an important role in the family, v. a. to be slim too. She was often devalued and ridiculed, although she was never actually "too fat". The mother often suffered from depression and migraines. As a result, she could not take care of the needs of the children. The patient took on responsibility for the younger brother at an early age, who as the son of the family had a different, better status.

The patient found the choice of training difficult. Knowing what she wanted and believing in herself was made difficult by the severely reduced self-esteem. Ms. T. began various professional training courses, but did not complete an apprenticeship.

She escaped early on into marriage to an Italian and subsequently lived abroad for almost 20 years. In the relationship with her husband, Ms. T.'s path of suffering continues. He was dominant, not appreciative, or supportive. The patient tried to be a good mother for her three children, but repeatedly suffered from depressive phases and often sought therapeutic help over many years. For the sake of the children, she did not want to get a divorce for a long time. She took refuge in destructive behaviors such as overeating, self-punishment through self-imposed prohibitions, or dissociative daydreams. So far, the patient has only been treated for her depression.

After the divorce, Ms. T. returned to Austria at the age of 40. She hoped for better career opportunities here. Her almost adult children stayed in Italy, Ms. T. suffers greatly from the physical distance. The patient found it difficult to get used to again in Austria. She struggled to find a job and felt lonely alone in her apartment. Since then, there have been repeated massive psychological crises, some of which have also required inpatient stays for crisis intervention. She was unemployed and felt overwhelmed by the pressure of the AMS. However, Ms. T. could not imagine going back to work either.

At the beginning of psychotherapy at the institute, the patient was psychologically very unstable. She could not concentrate well, suffered from reduced self-esteem and pronounced fear of failure. She felt hopeless, resigned, and unproductive. She also slept a lot and ate very irregularly.

The clinical psychological tests carried out confirmed the diagnoses of emotionally unstable personality disorder of the borderline type (F 60.31) and recurrent depression, which was present at the current point in time in moderate severity (F 33.10). A bing eating disorder (F 50.9) was also found.

In the TAZ-B, the patient was one of the older participants. The average age of the participants is around 27 years. Ms. T. was nevertheless able to fit into the existing group and benefited from the exchange and cooperation with the other group members.

In the beginning, the patient repeatedly got into depressive crises, but was able to accept the offers of conversation from her caregiver and take up assistance. For her, v. a. a reality check of their current emotions and perceptions, strengthening their self-compassion, dealing with self-criticism and feelings of shame, improving tension regulation and focusing their strengths and qualities (cf. Diedrich 2016).

Ms. T. had great resistance to the handicrafts offered in the TAZ-B program. She managed to overcome this and to participate constructively in all group offers. Today, in retrospect, she is very proud of the workpieces that were created in these units.

The individual therapy was continued after the completion of the TAZ-B cycle. Even now in the time of the Corona crisis, the patient tries to continue working on her issues and difficulties. She manages to deal with herself in a mostly constructive way and to cope with bad days without falling back into her "old pattern". The therapeutic relationship with her is stable and sustainable. Ms. T. has good goals which she will strive for after the current general situation has normalized.

outlook

Since September 2009, around 500 patients have taken part in a therapeutic stay at the TAZ-B. For many participants it was an important step on the way towards more perspective, health, quality of life and stability.

Borderline patients need a lot of support, reliability, relationships and stability. Very often these patients lack stable, authentic, interpersonal relationships in their private context. Many of our patients find it very difficult to build trust in other people due to the disabling conditions they experienced in childhood. To experience some appreciation and acceptance in the context of the treatment offer in the TAZ-B, I see a great opportunity and an important therapeutic task.

literature

Used literature

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Author information

Affiliations

  1. Institute for Psychotherapy with Day Center for Borderline Disorders, Franzensbrückenstraße 5/4, 1020, Vienna, Austria

    Susanne Margreiter

Corresponding author

Correspondence to Susanne Margreiter.

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S. Margreiter states that there is no conflict of interest.

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Margreiter, S. "Psychotherapy in the day center for borderline disorders" Institute for psychotherapy with day center for borderline disorders, psychosocial services in Vienna. Psychotherapy Forum24, 115-122 (2020). https://doi.org/10.1007/s00729-020-00155-0

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keywords

  • Outpatient psychotherapeutic care
  • Borderline disorder
  • PSD Vienna
  • Case studies

Keywords

  • Psychotherapeutic day care center
  • Borderline personality disorder
  • Psychosocial services in Vienna (PSD Vienna)
  • Case studies