In psychology, Equifinality refers to how different early experiences in life (e.g., parental divorce, physical abuse, parental substance abuse) can lead to similar outcomes (e.g., childhood depression). In other words, there are many different early experiences that can lead to the same psychological disorder.
The Equifinality model relating to BPD postulates that both the ‘nature’ and ‘nurture’ paradigms are equally valid. In brief, it suggests that a biological vulnerability, perhaps inherited in BPs with a family history of neurological disorder or created as a result of neurological changes secondary to PTSD in childhood is a necessary element of Borderline Personality disorder. The biological sequelae of childhood trauma is an area which we are only just beginning to understand. New studies suggest a wide range of neurobiological changes as a result of childhood sexual abuse (Seiver L. J. 1997).
In addition to the biological factor, however it may arise, trauma of one kind or another does appear to be vital. This may be sporadic as is often the case in physical or sexual abuse or more chronic as already noted via the mechanism of Linehan’s ‘invalidating environment’.
It is no secret that this particular client group can be something of a nightmare when it comes to finding effective therapeutic interventions. The treatment of BPD is fraught with difficulty, particularly in an inpatient setting where many borderline behaviours result in discord among the staff or where the demands made upon an individual nurse can become extremely unrealistic.
Treatment of BP falls into two main categories – pharmacology, incorporating a range of medication options and psychotherapeutic techniques ranging from supportive counselling to psychoanalysis. Although many of the treatments available fall firmly outside the remit of the RMN it does no harm for nurses to understand the options available.
Pharmacological treatments include:
- SSRIs to combat the deficiencies in serotonin absorption.
- Neuroleptics to treat psychotic symptoms as well as dysphoria.
- Carbamazepine has been used in the treatment of behavioural and affective problems (Cowdry R.; Gardner D. 1988).
- Thyroxin as many BPs have symptoms of hypothyroidism. It has been reported that alprazolam can decrease behavioral control and that amitriptyline increases paranoia, assault and suicide threats (Cowdry R.; Gardner D. 1988).
Psychotherapeutic approaches to Borderline Personality Disorder are dogged with the same problems of compliance as pharmacological approaches are. This is in no small measure due to the difficulty Borderline patients have in forming the stable relationships generally seen as a prerequisite for therapy.
Nevertheless ‘talking cures’ are effective in conjunction with medication and it seems that both types of intervention are necessary. If counselling is designed to help people think through their difficulties and learn to take control of and responsibility for their emotions it makes sense to give the brain a fighting chance to work properly at the same time.
The most effective form of therapy for BPs seems to be ‘Dialectic Behavior Therapy’ (Linehan M. 1993 2). This is at first glance a very strange juxtaposition of traditions drawing as it does from ‘cognitive behaviour therapy, ‘supportive counselling’ and ‘Zen Buddhism’. The term Dialectic refers to the inherent dichotomy of BPs experience in which everything is polarized into extremes such as rejection/acceptance; good/bad; active; passive and crisis/calm. The term Dialectic refers to the scenario of opposing viewpoints characterized by thesis and antithesis in classical philosophy.
In essence, the technique is designed to promote insight and change via skills training, introspection and validation. This in itself is seen as dichotomous as validation and acceptance in the mind of the BP (black and white thinkers)is not conducive to encouragement to change.
The downfall for acute psychiatric wards is that the procedure typically takes 1 – 3 years and requires a consistent approach from two separate therapists who will (in certain circumstances) make themselves available to the BP around the clock. Needless to say, this is not a realistic option for ward-based mental health systems.
However many of the techniques of DBT are extremely valid and can be used in acute. In particular, the principles of validation and skills training are very appropriate.
But herein lies the rub. If such an approach is to work it requires firm boundaries and a consistency of approach which is historically very difficult to maintain on acute. This is particularly true in the treatment of BPs who can be adept at eliciting a range of responses from staff via the mechanisms of transference and counter-transference.
What we do have is the opportunity to promote self-acceptance and, in conjunction with medication prescribed by our medical colleagues, the chance to promote a range of skills from problem-solving to anger management. It seems that BP is less of a lifestyle choice than many of us, myself included, previously thought. There are very real psychological and biological/organic deficits which can be addressed and treated effectively.
“The Hippocampus”… is essential for the laying down of long-term memory. The amygdala, in front of the Hippocampus, is the place where fear is registered and generated.”(Carter R. 1998 p.42)
Given the essential functions of these two areas of the brain, we can begin to understand the possible neuro-biological origins of certain Borderline traits such as emotional lability, splitting (the tendency to characterize things as ‘all good’ or ‘all bad’), and the condition’s dissociative traits.
It is interesting to note that many researchers have identified serotonergic dysfunction in the brains of BPs. This may have marked implications for the maintenance of mood and also go some way towards explaining the frustration and rage routinely exhibited by sufferers (Seiver L.J. 1997).
Article written by Stuart Sorensen – RMN (Thank you Stuart)