Underneath your blackest emotions, far above your brightest wishes, stands a world for you to hold.


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When Hope is Not Enough
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Motive-oriented therapeutic relationship (MOTR) – A new treatment for borderline personality disorder

Motive-oriented therapeutic relationship (MOTR) was postulated to be a particularly helpful therapeutic ingredient in the early treatment phase of patients with personality disorders, in particular with borderline personality disorder (BPD).

A new treatment for borderline personality disorder

A group of Swiss investigators reports on a new type of psychotherapy for borderline personality disorder in the current issue of Psychotherapy and Psychosomatics.

Motive-oriented therapeutic relationship (MOTR) was postulated to be a particularly helpful therapeutic ingredient in the early treatment phase of patients with personality disorders, in particular with borderline personality disorder (BPD).
This randomized controlled study using an add-on design is the first study to test this assumption in a 10-session general psychiatric treatment with patients presenting with BPD on symptom reduction and therapeutic alliance. A total of 85 patients were randomized. They were either allocated to a manual-based short variant of the general psychiatric management (GPM) treatment (in 10 sessions) or to the same treatment where MOTR was deliberately added to the treatment. Treatment attrition and integrity analyses yielded satisfactory results.

After performing the inter-to-treat analysis, results suggested a global efficacy of MOTR, in the sense of an additional reduction of general problems, i.e. symptoms, interpersonal and social problems. However, they also showed that MOTR did not yield an additional reduction of specific borderline symptoms. It was also shown that a stronger therapeutic alliance, as assessed by the therapist, developed in MOTR treatments compared to GPM.

These findings suggest that adding MOTR to psychiatric and psychotherapeutic treatments of BPD is promising. Moreover, the findings shed additional light on the perspective of shortening treatments for patients presenting with BPD.



Brandon Marshall’s Comeback

Marshall believes his borderline personality disorder was triggered by the stresses of his NFL career.

Brandon Marshall’s Comeback

Chicago Bears wide receiver Brandon Marshall shares the story of his battle with borderline personality disorder.

BRANDON MARSHALL places a foot on the broken concrete ledge of the old schoolyard and hoists himself up. Two drained Miller Lite cans crunch underfoot. He tucks his thumbs under the straps of his orange backpack and peers up at the Larimer School, a once-grand Italian Renaissance building named after this neighborhood in the east end of Pittsburgh. All of the elders in his neighborhood matriculated here, but it’s been closed for 34 years, its terrazzo floors now littered with asbestos. Over the door, letters are blocked in yellow paint: know thyself.

Marshall’s videographer focuses his lens, framing him in front of the school. Three years ago, when Marshall got out of treatment for borderline personality disorder, he began taping a documentary. The videographer has been with him ever since. In this scene — meeting the property owner to discuss redeveloping the school — Marshall explains why he hasn’t been in touch sooner. “I’m just now getting right” is how he puts it.

This neighborhood was once home to myriad shops and bakeries and Italian immigrants, but gradually it lost almost 90 percent of its population, leaving behind empty lots and one of the poorest census tracts in Pittsburgh. Marshall moved to Florida in fourth grade, but most of his extended family is still here. He loves coming home and wants to help transform Larimer into a livable area. But it’s not a good place for him to stay for too long. It’s not just the risk of getting caught in someone else’s trouble. “When we look at how the disorder presented itself in me,” he says, “a lot of it comes from here.”

Following his diagnosis three years ago, Marshall, now 30 and a Pro Bowl wide receiver for the Chicago Bears, set an ambitious goal: become for mental health what Magic Johnson is for HIV. He wants to make an off-limits subject commonplace. He’s reaching out to players who might need help, teaming with mental health organizations through his charity and raising awareness and cash for early-detection programs. “Where we are now is where the HIV community was 25 years ago,” he says. “We can raise all the money in the world, but people might not go get help. They’re still going to see it as a taboo topic. So it’s important for us to get the conversation started.”

In July 2011, Marshall called a news conference to announce the diagnosis of BPD. Three months earlier, his wife, Michi, had been arrested and Marshall had been hospitalized after an argument. Police said Michi had stabbed him with a kitchen knife in self-defense; the two later said he was cut by broken glass. Out of respect for his marriage, he wouldn’t share details, he told reporters, but he wanted them to know that his wife was no villain. He remembered her looking up at him from the back of a police car, pain in her eyes, and saying, “Someone will learn from this story.”


Clarifying Interpersonal Heterogeneity in Borderline Personality Disorder

 A latent class analysis clarified this finding by revealing six homogeneous interpersonal classes with prototypical profiles associated with Intrusive, Vindictive, Avoidant, Nonassertive, and moderate and severe Exploitable interpersonal problems. 

Clarifying Interpersonal Heterogeneity in Borderline Personality Disorder Using Latent Mixture Modeling
Aidan G.C. Wright, Michael N. Hallquist, Jennifer Q. Morse, Lori N. Scott, Stephanie D. Stepp, Kimberly A. Nolf, and Paul A. Pilkonis

The publisher’s final edited version of this article is available at J Pers Disord

Significant interpersonal impairment is a cardinal feature of borderline personality disorder (BPD). However, past research has demonstrated that the interpersonal profile associated with BPD varies across samples, evidence for considerable interpersonal heterogeneity. The current study used Inventory of Interpersonal Problems – Circumplex (IIP-C; Alden, Wiggins, & Pincus, 1990) scale scores to investigate interpersonal inhibitions and excesses in a large sample (N = 255) selected for significant borderline pathology. Results indicated that BPD symptom counts were unrelated to the primary dimensions of the IIP-C, but were related to generalized interpersonal distress. A latent class analysis clarified this finding by revealing six homogeneous interpersonal classes with prototypical profiles associated with Intrusive, Vindictive, Avoidant, Nonassertive, and moderate and severe Exploitable interpersonal problems. These classes differed in clinically relevant features (e.g., antisocial behaviors, self-injury, past suicide attempts). Findings are discussed in terms of the incremental clinical utility of the interpersonal circumplex model and the implications for developmental and nosological models of BPD.

Keywords: Borderline Personality Disorder, Interpersonal Circumplex, Mixture Modeling, Latent Class Analysis, Interpersonal Problems


Today’s Take: Unique therapy gives hope to ‘hopeless’

There was a time not too long ago when clients with chronic suicidal, self-harming or other self-destructive impulses were considered impossible cases to treat.

Many of them were survivors of severe childhood trauma — trauma that left them feeling worthless, unable to trust other people and having difficulty responding to treatment.

For such clients, traditional therapy proved ineffective.

The dangerous pattern of self-harming/suicidal behavior makes it difficult for clients to accept help. It is both frightening and frustrating. Often, friends and family feel helpless and are not sure who to turn to for support.

In the past, these clients were often termed “impossible” or “hopeless.”

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With Borderline Personality Disorder always look for the trigger

Look for the Trigger

Look for the Trigger

In When Hope is Not EnoughI suggest that when asking a validating question, the question that is most effective is: “What happened?” I recommend this because it is open ended and, more importantly, with BPD something usually DID happen to trigger emotional dysregulation. There is almost always a local trigger. This is why I don’t recommend attributing emotional dysregulation to childhood trauma or abuse. With emotional dysregulation, something typically just happened to trigger it.

While the conditioned responses – rage or running away – can sometimes be attributed to childhood and the interpretation of the precipitating event can be conditioned from childhood, the actual event is a trigger that sets off emotional dysregulation. If your loved one with BPD is raging at you or running for the hills, the emotions that fuel these actions were triggered by something.

Sometimes it is difficult to see the trigger. Sometimes the trigger will seem trivial to a non-BPD.

A quick example from my life. My wife is big about feeling safe and secure. She has a trigger around money. She’s afraid that we will not have enough money and will grow old on the streets. A few months ago we got a bill from the high school for exams for our kids. This bill was rather high and the feeling of insecurity around money triggered fear in my wife. That fear quickly morphed to anger at me (because I make the money in our household). She raged at me for not being successful enough, not making enough money.

The trigger here was the bill. Ordinary enough thing to come in the mail, but that triggered the emotional dysregulation.

My suggestion to non-BPDs is to look for that trigger. Understand what triggers the emotional dysregulation. If a trigger is coming down the line, be prepared for it. It’s impossible to avoid all triggers – and you might not want to in the long run. It’s no wonder though that forums for BPD and the related behavior (like self-injury) have MIGHT BE TRIGGERING warnings.

Why Borderlines are NOT Psychopaths

I have often heard Non-BPDs (or family and friends of those with borderline personality disorder – BPD) refer to their borderlines as “psychopaths”. There was the semi-famous story of the divorced husband who was running a blog called “the psycho ex-wife” (read more about that saga here) which had an “arm chair” diagnosis of this man’s ex-wife as having BPD. While she may or may not have BPD, the reference to the word “psycho” is a misnomer.

There are several BIG differences between borderline personality disorder and psychopathy. One of the most important is the function of the amygdala – an almond shaped structure in the mid-brain that activates when emotions are felt. Borderlines have an over-active amygdala while psychopaths have an under-active amygdala in certain circumstances.

Additionally, the aggression profile is completely different. Borderlines (and essentially all other mental disorders, including Antisocial Personality Disorder – ASPD) exhibit reactive aggression, while psychopaths exhibit instrumental aggression (more here).

Although my blog is mostly about BPD, in the past week months, I have become more interested in psychopathy. The reasons are two-fold: 1) the tragedies of mass killings, about which I am perversely interested – particularly the video posted by Elliot Rodger which to me reeks psychopath (although I’m no doctor) and 2) I have a close friend whose son behaves much like a budding psychopath. While I can go into why this boy seems psychopathic (and, believe me, I have never thought this about any other child I’ve ever met), I’ll reserve that for another time.

What I did want to post here is links to some information about psychopathy. If you spend a little time with the subject, you’ll find that psychopathy is NOT related to BPD (or is it the same as sociopathy or ASPD). Psychopaths are distinct from sociopaths as well as from borderlines. To refer to people with BPD as psychopaths is just plain inaccurate and incorrect.

Here are videos that can help in an understanding of psychopathy: