The borderline paradox: Looking beyond trauma

To the Editor

Lee and Kulkarni (2017) are right to highlight the paradoxes and interpersonal challenges in managing persons with borderline personality disorder (BPD), and we echo their call for a sensitive approach to this patient group. We wonder, however, if their assumptions about the aetiological role of trauma obscure the complex interplay of other psychological and sociocultural determinants, and risk confusing compassion with collusion.

The role of childhood trauma in BPD is important but should not be overstated. Exposure to trauma is not a sufficient condition for the development of BPD, and childhood trauma does not consistently lead to BPD (Paris, 2014). Genetic predisposition, temperament, chaotic families and the iatrogenic harms of unnecessary psychiatric hospitalisation can all contribute to the manifestation of the disorder in a given individual.

The increasing prevalence of BPD in the developed world (and the recent appearance of the disorder elsewhere) might reflect subtle environmental influences at a population level. For example, deliberate self harm (DSH) could be conceptualised as a cultural meme susceptible to the contagion effects of social media. The simultaneous dissolution of what Millon (1987) termed ‘reparative and cohering social customs’ can intensify the existing identity confusion of adolescence.

Both DSH and suicide attempts may serve psychodynamic goals beyond either maladaptive help seeking or the inward direction of emotional pain. Ostensibly internalising acts can provide the patient a clinical context for adopting the role of aggressor, resulting in the projection of anger into caregivers. It is for this reason that negative countertransference reactions may be both an entirely normal response to the borderline patient in crisis and a helpful diagnostic ‘canary in the coalmine’. It is the clinician response to the countertransference and not the experience itself which is modifiable.

Unfortunately, patients with BPD are prone to perceiving therapeutic limit-setting and reasonable behavioural consequences as being invalidating or punitive. Decision-making capacity and hence moral responsibility are generally preserved in BPD. Effective treatments, such as dialectical behaviour therapy (DBT), are those that promote accountability and steer the person away from the siren song of victimhood. As the individual develops greater control of their emotions and behaviours, they are less likely to generate stigmatising attitudes from others and are more disposed to creating virtuous cycles of interpersonal effectiveness. These principles sit comfortably within the goals of the recovery model and should inform our practice.