Borderline Personality Disorder: An Evidence-based Guide for Generalist Mental Health Professionals

Clinton: Hello! This is Clinton Power, founder of AustraliaCounselling.com.au and it’s my great pleasure today to be speaking with Dr. Roy Krawitz who is a New Zealand psychiatrist with the Waikato District Health Board and an honorary clinical senior lecturer at Auckland University. He’s been specialising for the last 25 years in working with people with borderline personality disorder and in dialectical behaviour therapy as a trainer and therapist for the last 10 years. Roy has authored five books on borderline personality disorder, and he’s published research of the effectiveness of his therapy, his generalist borderline personality disorder training, and of the DBT service he works in. I very much appreciate your giving of your time to speak with the Australian therapist today, Roy, and welcome to the call.

Roy: Thank you very much and nice to make contact with you.

Clinton: I’d like to begin by asking you, what is considered some of the characteristics that would tend to define someone with borderline personality disorder?

Roy: In the DSM-IV and now DSM-V, there are nine diagnostic criteria, for what it’s worth, and technically you’ve got to meet five out of the nine to pass the threshold for the diagnosis, and when I try to, I usually get about seven or eight, but they’re divided into three broad clusters of identity, affect, and impulsivity.

I don’t know if you want me to run through the nine, but what I’m looking for when I’m seeing somebody that would be a lead to the possibility of the diagnosis is a pervasive, enduring instability in a whole range of areas across the person’s life like relationships, accommodation, money, study, work, et cetera.

Of course, the sort of prototypic action that is often associated with BPD or borderline personality disorder is self-harm behaviours and suicidality.

Clinton: Are there any statistics on how many people are thought to be affected by this condition in Australia and New Zealand?

Roy: I’m not aware of any prevalent studies in Australia or New Zealand, but studies done in the United States, initially early studies were suggesting 1 to 2% community prevalence. The most recent and very large study of about 35,000 people community studies had a prevalence of about 5.8%. That last figure I’m not quite sure what to make of it because it’s obviously quite different from the previous figures, but it was a big, large robust study.

Clinton: What is thought to cause BPD? Do we know anything about that?

Roy: The causal understandings are in the theory level, and I think most or probably the mere consensus view that is a combination of biological and environmental factors and different clinicians and theoreticians would place different weightings on each of these so the idea is that a person is born with a certain kind of temperament.

For example, a high intensity of emotional experiencing, which is neither good nor bad, and then depending on the environmental circumstances that temperament is satisfactorily worked with and developed or becomes problematical, with the person feeling misunderstood or obviously in a much more severe situation with sexual and physical abuse. The theory is that there’s a transactional interaction essentially between nature and nurture in a deteriorating fashion. I think that would be the general consensus and different theoreticians would be weighted more towards the biology and the psychological factors.

Clinton: I’m wondering if someone doesn’t necessarily have to have experienced severe sexual or physical trauma to develop this condition.

Roy: The incidence of sexual abuse in the literature varies somewhere between 40% to 70%. In my experience in the work that I do in the public system it’s 90%, so it’s more unusual if the person doesn’t have that history, and just as what you say on the other hand, there are a significant number of people who do not report a sexual or physical abuse history.

I think this is particularly important in terms of working with families if we’re looking at causality as well as the obvious major traumas of sexual and physical abuse for example it might be that we have parents who are doing the best of their capacity and are generally doing pretty good job or will be doing pretty good job for the other children, but with this particular temperament, it might be that there is a prevalence afoot. When we’re working with families with an obvious trauma history, we’re very keen to try to embrace a non-blaming approach, which is not blaming neither the client nor the parents.

Clinton: Yes, I’m curious about how did you come to be so interested in this area because you’ve also written a number of books specifically on this character style, haven’t you?

Roy: Did I come about interested in borderline personality disorder?

Clinton: Yes.

Roy: I kind of fell into psychiatry by the chance when I was told in a residency that I’d spend three months in psychiatry and I reluctantly went along and fortunately really loved it. That was my past of about 35 years ago, and I decided I essentially wanted to practice psychological therapies. I got some experience and training in some psychological therapies at that time and then borderline personality disorder felt like the next challenge and the challenges remain after 25 years.

Clinton: That’s quite a passion.

Roy: Yeah, definitely a passion. Generally, as long as the things are going well enough I really, really enjoy my work.

Roy: No bigger studies that I’m aware of to that effect, but certainly my colleagues working with adult mental health, some of my colleagues working with adolescents and children, they generally believe that being alert to the possibility of the diagnosis or the traits or the problem behaviours is really important for obvious reasons that you can address it.

I know in some quarters there’re some misgivings about making a diagnosis early on and in adolescence, but this is what my adolescent colleagues are telling me. I guess at the end of the day, to me, it’s not the diagnosis per se is not what’s so relevant but identifying problems and looking for solutions to those problems.

Clinton: Many of the therapists I speak to are almost wary of working with people that display some of these traits, and I wonder if you could speak to them. Is it warranted that we need to be wary or wanting to refer on clients that may present in this way?

Clinton: What would you consider some of the characteristics that therapists need to develop if they want to work with this population because I think,  being honest, it can be a very challenging population to work with.

Roy: At the top of the list I would think about a desire or willingness to work with this client group so to see the work despite or possibly because of its challenge is something that the person wants to do, and I think that would go, I don’t know what percentage, a huge way towards developing decent outcomes because if the clinician is energized, then it’s likely that they’re going to tend to improve in competency levels to tend to the wariness that you are talking about before.

I would put that right at the top. After that, I think research would say whether it’s in BPD or any other area that developing competencies involves going out, enduring the work and getting as soon as possible feedback about how you’re going inside this context.

I think getting together with a supervisor or group of people who have BPD expertise, preferably in an evidence-based treatment that’s to your liking is going to be the best possible pathway.  Then the other pathways of specific trainings and reading, but I’d put a supervision or a peer team right at the top of that list.

Clinton: Of course, great advice. Are there psychotherapy treatment models that are considered more effective for this population than others?

Roy: Everybody’s got their particular bias. Just in terms of randomized controlled trials, DBT I think to the best of my knowledge, stating randomized-controlled trials. Then there are bunch of other treatments with two randomized-controlled trials of mentalization-based therapy, transference-focused psychotherapy, schema-focused therapy, STEPPS ,which is a standalone and add-on 20-week DBT skills group to treatments, and I hope I haven’t left out anything else and then a number of studies which just one randomized controlled challenge and some of those done in Australia.

Clinton: Right, okay. Your particular passion is DBT. What have you seen that that helps with good outcomes?

Roy: In summary, and I don’t know if this is kind of the answer that you’ve been seeking towards. I think DBT in many ways brings together many aspects, which have an evidence base to them into a cohesive package.

I’m guessing here because we don’t know precisely what the mechanisms of change are, although there’s some research on it. I’d go for that cohesive package, really. In other treatment models there are different theory basis and they also got a cohesive package of treatment, which allows a clinician to fall back on at times of difficulty. That’s a broad umbrella view and then I could name a whole bunch of things about DBT, which aren’t particularly alike but with the other models that you’ve got …

Clinton: I’d like to hear that because there’re probably many therapists that may not actually be familiar with DBT and what it offers.

Roy: DBT obviously draws on evidence-based behavioral practice of which there is a whole a lot of research on it, particularly the people from the acceptance and commitment therapy of a couple decades ago pulled down a whole lot of stuff from Eastern psychological practices, which is really what we’re citing, particularly mindfulness and acceptance-based traditions from Eastern psychological practices, but I’m aware that it also comes from Western psychological practices such as traditional psychodynamic therapies.

Then of course synthesizing that together with dialectics, which is about synthesizing change-focused therapies and behavioural therapy with acceptance-based interventions and doing what in DBT we refer to as the dance or jazz of DBT, dancing from one moment to the next in terms of how to respond to a client in the most effective way.

DBT, some people say ‘see DBT is not rocket science and it’s a very structured treatment to do this and this and this and this,’ and there’s some truth to that but within that structure, a huge amount of dancing around and creativity.

Clinton: Of course, I’m imagining was it mindful aspects of DBT that would be very helpful for this population, particularly with that inclination to respond very deeply and intensely.

Yes, for sure and I would believe that mindfulness or maybe one could argue it’s equivalent in psychodynamic theory of mentalization is relevant for all human beings to live an effective life. I think certainly Bateman and Fonagy I think quite persuasively argued that mentalization is part and parcel the lone effect of therapies. Adding to that is to note, in my personal opinion, part of DBT practice, we language it a bit different in terms of mindfulness.

Clinton: I believe you have in mindfulness practice yourself, do you find that helps in your clinical work?

Roy: I hope so. I’ve been studying all this and as people will know it is definitely considered a mechanism change for the therapist to be able to mindfully watch their own internal experience or to mentalize on their own internal experience and you will be familiar with all the reasons why we went through that.

Clinton: Absolutely, yes. I guess I’m just struck by your prolific writings in this area. Have you now written four or five books on borderline personality disorder? I know just last month, you’ve released Borderline Personality Disorder: An Evidence-based Guide for Generalist Mental Health Professionals available on Amazon.

Where does that come from because that’s an incredible amount of passion and research and information. I’m just guessing. This area completely fascinates you.

Roy: It does. The work somehow it encapsulates all of me. In order to do the work effectively, I have to bring out my very best emotionally and intellectually and functioning as a team member, and I find it that very energizing. I suppose the energy, not entirely, but most of my energy from my writings and particularly the books have come from a sense of there’s a gap in the market. There’s something that needs to be written, so I’ve written stuff based on my perception of that gap and hopefully it’s been helpful to a few people.

Clinton: Wonderful and I’m curious in working at the Waikato District Health Board, tell us a little bit about what it’s like working and do you work in teams in terms of a treatment model or how do you treat patients there?

Roy: New Zealand public mental health service and all credits in Waikato District Health Board I think since the year 2000, the District Health Board has been in a sense I think championing for the treatment of people with borderline personality disorder and that’s manifested with the DBT program since the year 2000. We’ve got two separate programs into two geographical areas and that includes three DBT skills groups and with a team attached to each of those and …

Clinton: It’s a combination of individual work and group work for your patients?

Roy: Yeah. What we provide is a standard full comprehensive DBT as it’s been done in the majority of the research trials and that’s got full components, the individual therapy, so an hour a week with a client roughly, group skills training which is two to two and a half hours per week for group of six to eight clients, telephone call availability to an individual therapist, and then lastly, we talked about what passion what I think is effective in DBT.

The other element is the DBT team meeting, which is absolutely critical. That team meeting is certainly different from traditional multidisciplinary team meetings where the emphasis is on helping the therapist be a better therapist. The therapist comes and says, “I have a problem with … can you please help me?” We apply DBT interventions to our colleague to assist them in whatever direction they want to go.

Clinton: Wonderful it sounds like a very comprehensive program you’re offering there.

Roy: It’s a full standard comprehensive DBT program, which in the public service is pretty awesome really.

Clinton: It is and I may be wrong here but I’m not sure if Australia offers something kind of similar. Are you aware if they do?

Roy: When I was living in Melbourne I made some inquiries, and I was aware that there were a number of DBT programs running in the public system. I’m not sure how many of those were full, standard comprehensive DBT programs. I know some of them were only partial.

There’s certainly been some research coming out of various areas of Australia where they have been doing some full standard and comprehensive DBT. I don’t know what percentage of area mental health supports have that. I think it’s probably like in New Zealand public mental health systems would have a high percentage of DBT programs than Australia would.

In Australia in my experience when I lived there, it was more strongly influenced than New Zealand public’s systems by psychodynamic and psychoanalytic traditions.

Clinton: For the therapist, perhaps, who wants to really immerse themselves more in learning more about borderline, what would you suggest? What would you recommend for someone to get started to really up skill in this area?

Roy: Get a supervisor who knows something about the way, preferably from an evidence-based treatment and then some training in the model of your choice, and if you want some readings, try some readings that may interest you.

For generalists, there was a book out of Melbourne from Spectrum, the state-wide personality disorder service for Victoria, about three years ago, which is excellent, and then there’s the book that I’ve just written with Anthony Bateman, which has just come out last month.

Clinton: Wonderful and also what we’ll do is we’ll put the links to your books on this page so therapists can easily access those, but obviously, that’s a great place for people to start as well.

I very much appreciate your giving of your time today to speak to the Australian Counselling community. I think it’s a very challenging area and really appreciate your expertise and sharing your knowledge with us on this.

Roy: It’s been a pleasure and thank you very much.

Clinton: Thank you. I hope we can speak again some time. Bye for now.

About Dr. Roy Krawitz:

Dr Roy Krawitz is a New Zealand psychiatrist (Waikato District Health Board) and Honorary Clinical Senior Lecturer (Auckland University) specializing for the last 25 years in working with people with borderline personality disorder (BPD) and in dialectical behaviour therapy (DBT) (therapist, trainer) over the last 10 years. Roy has authored 5 books on BPD and published research of the effectiveness of his therapy, his generalist BPD training and of the DBT service he works in. Waikato District Health Board is a New Zealand public health service that has supported BPD treatment with a full comprehensive DBT service since 2000.  

Books by Dr. Roy Krawitz: