What can borderline patients and their families expect from specialized treatment?
The treatment of borderline patients can generate many anxieties and expectations for them and their families. When seeking specialized care, they are often already tired and disheartened, as several professionals may have been consulted, some of whom may have made mistakes in diagnosis and treatment. Additionally, there are professionals who, responsibly, refer them elsewhere due to a lack of specialized care. Both scenarios reinforce the belief that there is no solution for these cases, thus prolonging the patient's suffering.
Promoting the evolution of these patients is not an easy task; it is essential to work on both their dynamics and the family environment, as one influences the other.
The family, at times, is either very distant or excessively interfering in each other's lives, resorting to criticism and accusations. In these moments, they may use an aggressive tone of voice and words, what we call expressed emotion, a communication that comes "unfiltered"; if they could wait for the anger to pass, the words would be different and so would the tone. They believe that all family problems are linked to the disorder and provoke feelings of guilt that the individual does not know how to handle.
The patient presents emotional and financial dependence on the family. They suffer intense psychological distress, unlike most people. There is also the behavior of sabotaging all areas of their life, causing them to become stagnant.
Chronologically, they are adults, often quite intelligent, but they feel and suffer in a way very similar to that of a child or a baby. Emotionally, the resources they use are from a very primitive phase, functioning on a basis of "all or nothing", love or hate, entirely good or entirely bad (Sassi; Kernberg; Gabbard). It is an absolute way of experiencing the world, very different from what is expected of someone their age, who relativizes some truths and understands that a person is not entirely bad or entirely good, for example.
Their network of relationships is usually restricted to family. They have a recurring behavior of isolating themselves, pushing people away, and even causing others to distance themselves, which means they end up losing the best nourishment for their mental and emotional world, which favors the refinement of emotions and personality. Those who remain alone too much end up emotionally impoverished and may become ill. As Sassi says: "Food for the body is food, and for the mental world is people".
The first year of treatment is the period when the most resistance occurs, and depending on the patient, this time may be extended. They have many absences, may not use medications correctly (not taking them or taking too much), buy medications on the "black market", etc.
Throughout the process, there may be relapses in alcohol and drug use, abusive credit card purchases, unprotected sex with strangers, self-harm, suicide attempts, among other impulsive behaviors.
It is not an easy task for this profile to share their thoughts and feelings with the therapist because they are difficult to access patients. This occurs due to the fantasies they have about themselves and others. They fear that the professional and the team may judge them or even abandon them, as most of their relationships have done. If these fantasies are not addressed, therapy and treatment may not happen.
Improvement begins when they find a place where they feel heard and understood. Then, self-harm and suicide attempts decrease. Small changes happen gradually, alternating with relapses into the "two steps forward, one step back" mode.
The development of emotional and financial autonomy, gaining the trust of family members, and maintaining emotional ties occur gradually over the years as a result of reflections made in individual and family therapies, as well as guidance and prescriptions from the psychiatrist.
Some patients achieve a general improvement in their quality of life after about six years of treatment. Recently, for these patients, we have dared to talk about a cure because they have undergone a significant change in the way they think about life and conduct it, and they no longer meet the criteria for the disorder.
Some patients may take longer to achieve this, and others may become chronic, remaining dependent on treatment to survive. Death by suicide is around five percent.
The factors that contribute to the significant improvement of the patient are: a specialized team that works in harmony with each other and with a specific method; family members who encourage and participate in the process, either through family therapy or by being present when requested; and finally, the patient who from the beginning shows a greater capacity to speak and attend therapy and treatment in general.
BIBLIOGRAPHICAL REFERENCES
1. Gabbard, Glen O. Transtorno de Personalidade Borderline do Grupo B: Borderline, in: Psiquiatria psicodinâmica na prática clínica. 5. Ed. – Porto Alegre: Artmed, 2016.
2. Gomes, Heloisa Szymanski Ribeiro. Terapia de família. In: Psicol. cienc. prof. vol.6 no.2 Brasília, 1986.
3. Joseph, Betty. O paciente de difícil acesso (1975), in: Melanie Klein Hoje. Desenvolvimento da teoria e da técnica. v.2. Artigos predominantemente técnicos. Rio de Janeiro: Imago Ed., 1990.
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5. Zito, Daniely Marin; Sassi Junior, Erlei. Psicoterapia Psicodinâmica Modificada Para Transtorno de Personalidade Borderline: O Método.
6. https://personalidadeborderline.com.br/