Working With Families & Young Adults With Borderline Personality Disorder (BPD) – Part I

Compromise, The Middle Path And Psychotherapy

How the MIDDLE PATH approach can assist with the treatment of those young adults with emotional dysregulation and their families.

In a recent article in the American Journal of Psychiatry, Dr. Anthony Bateman found that well-structured general psychiatric management was as effective as Dialectical Behavior Therapy (DBT) on all outcomes in the treatment of Borderline Personality Disorder at the end of 2 years. When multiple treatments were compared, outcomes were generally equivalent. Dr. Bateman suggested that “part of the benefit of treatment for people with BPD comes from the experience of being involved in a carefully considered, well-structured and coherent interpersonal endeavor.” (Anthony W. Bateman FRC. Psych., American Journal of Psychiatry. 2012; 169:560-563.)

At the OPI Intensive we believe that our unique approach to family treatment is carefully considered and structured and utilizes a coherent interpersonal approach. Our therapists skillfully combine DBT and concepts from psychoanalytic/dynamic family therapy approaches that we have found result in more favorable treatment outcomes for families we work with. The skillful and focused integration of these approaches is what we mean by the Middle Path approach.

We have found it more efficacious to employ elements from multiple approaches yet remain focused and coherent while addressing the core issues within the family dynamics. It seems illogical and extremely limiting to doggedly adhere to limited evidence based models that are predicated on a fundamentally flawed and fragmented diagnostic system. This system correlates very poorly with the complex young adults and their families sitting before us in the office. Adherent reliance on a singular brand of therapy denies these young adults and their families many beneficial therapies and also negates the role of a skilled and well-trained therapist whose responsibility is to create an integrated and individualized treatment approach.

At OPI Intensive and with all OPI Living Programs, we continue to learn and are enriched by addressing the uniqueness of our participants and their family presentations. We do not find it valuable to stick to a formulaic approach designed to fit all people; instead, we craft an approach which is informed by listening to the particular presentations of our clients and families. The ultimate evidence for us is to look at how well these specific participants and their families are really doing as opposed to how well they fit within an empirically verified model of human behavior and treatment.

Which is more real, the person sitting directly in front of us, or the diagnosis? The information from texts, articles, statistically validated composites of people and treatment methodologies or the complex, unique people seeking help in our offices?

I am not saying by any means that one should disregard the knowledge from text books, articles, the Diagnostic and Statistical Manual of Mental Disorders (DSM) or evidence based models, but not to be so naïve as to place more value and credibility on these measures than on the reality of the human being and family in the room. It is simply not in the best interests of the individual or family for the therapist to be so narrowly engaged. Skilled and well-trained therapists must explore all the available options and treatments and use their CLINICAL JUDGMENT to formulate a customized, comprehensive, integrated and structured treatment approach on behalf of clients. This is the middle path of a skilled clinician – to look at all that’s available and to pick the approaches most appropriate for that particular individual.

In my own training, beginning in medicine, then surgery, we were taught to think. Even in a medical subspecialty such as surgery, which is far more procedure orientated with more defined diagnoses and outcomes, we were expected to use clinical judgment, and not treat the labs but the complex living human being for whom we were responsible. You do not just treat a diagnosis, you treat a person.

Perhaps William Osler, a 19th CENTURY physician said it most clearly:

“The practice of medicine is an art, not a trade — A calling, not a business; a calling in which your heart will be exercised equally with your head.” (Quote from an article by Ronald Pies, MD Psychiatric Times, December 2001, “Can Psychiatry be both a Medical Science and a healing Art?”).

Osler described this middle path for those who wish to relieve suffering and help those in need. I believe human beings are far more complex than any singular belief that I or others may have, and there is no single theoretical position or treatment approach that works for all patients all of the time. The middle path is not to disregard the DSM or evidence based treatment approaches. Rather, you should use them as guidelines to inform your clinical decisions. Judgment, training and experience should work together to insure that you help and not harm clients and their families.

For additional information about families and BPD, read the other articles in my series on Working With Families & Young Adults With Borderline Personality Disorder (BPD).