Links and Stockwell (2001) propose a hierarchical model to determine the appropriateness of couple therapy when there is a partner with borderline personality disorder. They feel that "Patients with a history of impulsive, self-destructive, and treatment-threatening behaviors are not candidates for couple therapy until individual therapy reduces their impulsivity. For highly impulsive patients, the prognosis is guarded. Their relationship might well continue but their lives continue to be crisis-ridden for years" (page 505). This recommendation be logical, but may come from the therapist who has begun or is contemplating initiating individual therapy with an identified highly impulsive individual. However, the couple therapist beginning or deeply immersed in couple therapy may not realize the relevance of borderline personality issues in an individual until there is some triggering and a resultant impulsive response. Terminating couple therapy because of the therapist sudden realization of impulsive borderline behaviors would be clinically and ethically questionable. Without a doubt, couple therapy with such a couple would be highly challenging and perhaps, with poor anticipated therapeutic outcomes, but the couples therapist should persist and possibly, still be clinically effective.
Chessick (1976, page 542) characterizes rage as the greatest impediment to change for an individual. "…the intensity of the raging, fear, mistrust, and the annihilation fantasies is much greater… it is primarily the rage that threatens to fragment the patient's whole psychic structure, and most workers with borderline patients have agreed that dealing with rage in such patients is the main problem of the treatment. It probably also represents the limiting factor on the therapist both as to whether the patient is treatable at all and how far the patient can come in the improvement of interpersonal relationships. Patients who have been so profoundly disappointed in their childhood often retain a crippling residue of rage and mistrust that cannot be overcome by intensive psychotherapy or anything else, and this a fact that the patient himself at one point or another may have to face as the treatment draws to a close". In the couple, rage is often also the major destructive element that makes improvement difficult. Ancient accrued rage causes the individual to say and do things eventually beyond what the partner can understand or will tolerate or accept. When it is finally too much, the partner terminates the relationship… or proposes couple therapy. Although, still raging, fearful, and mistrusting, the threat of rejection- the end of the relationship can motivate the individual to accept trying couple therapy. This may be a couple with poor prospects for success in couple therapy as well as poor prospects for remaining together.
On the other hand, Links and Stockwell believe that "Couples characterized by identity disturbance benefit from couple therapy and may demonstrate meaningful change; however, therapy can extend over one to two years. Individuals with borderline personality disorder in the affective cluster with a healthy spouse benefit from psychoeducational interventions and may progress after only several months of therapy" (page 505). They feel that two partners with similar identity-cluster characteristics may result in mutually enmeshed attachment to each other. While having difficulties, the two would retain "a strong commitment and attachment to the relationship. The development of mutually gratifying projective identifications between the partners leads to a 'closed system'. Akhtar characterizes the relationship as having 'pathological homeostasis.'" Such couples may be the best candidates for therapy. "The acute attachment crises can be stabilized in therapy and once a therapeutic alliance is established, sustainable change can be achieved by modifying the internal working models and reworking the projective identifications" (Links and Stockwell, 2001, page 500).
All individuals with borderline personalities disorder do not present identically, and thus individual and couple therapy with them would not only be recommended differently, but also proceed differently. When assessing the individual, the therapist may find someone who fits all if not most criteria from the Diagnostic and Statistical Manual- Fourth Edition or Fifth Edition (DSM-IV or DSM-V) for the borderline personality disorder diagnosis. Or, may find the individual fitting several criteria without qualifying for the diagnosis. Or, the individual may exhibit some criteria but to a lesser degree than considered clinically significant. In this book, reference to the individual with borderline personality disorder is used to include the individual who qualifies for a formal DSM diagnosis and one who has several criteria without qualifying- that is, the individual who may be described as having borderline tendencies. Borderline tendencies and the borderline personality diagnosis should be considered well within the range of human emotional and psychological reaction and behavior. Such individuals have been identified and written about throughout history and in every society. Arguably, all criteria in more measured form can be and has been largely productive personally and for relationships when they activate interpersonally and socially appropriate behavior. The distinction from common reaction and behavior has to do with the disorder's intensity and negative effects on self and others. Links and Stockwell compared individuals who were married throughout the follow-up period of their study to those who stayed single the entire time. "Initial differences between the individuals who were single throughout and those who were married throughout were related to the severity of impulsivity. Those who were single throughout were younger by about seven years, more impulsive, and had more dissociative features than their married counterparts. The married subjects did not differ from the single subjects with regards to overall levels of borderline psychopathology at their initial assessment. At follow-up, those who were single throughout had significantly higher levels of impulsivity and more borderline psychopathology than those who were married throughout" (page 493). Their findings can be interpreted as consequential of the healing effect of marriage.
At the same time, could the married individuals be considered to be "less borderline" or less reactive behaviorally despite emotional triggering? Or, is it the fact of marriage versus being single or some other causal factor that made marriage more viable that also subsequently reduced borderline pathology? Certainly getting married and being able to sustain a marriage may indicate functionality, while being unable to find a marital partner or sustain a marriage may be indicative of other differences. In Bernstein et al. (2002) examination of late onset of borderline personality disorder, Dr. Reich's assessment of the client found that the client had "intolerance of aloneness, fears of abandonment, affective instability, vulnerability to dissociation, self-mutilation, and chronic suicidal ideation" (page 295). She had "a premorbid tendency toward interpersonal hypersensitivity and emotional dysregulation." She seemed over-reactive to criticism and emotionally vulnerable as demonstrated by increasing use of alcohol to self-medicate growing depression. "A more detailed childhood and early adult history would probably have shown further evidence of borderline traits: high levels of emotional reactivity, identity disturbance, and difficulty tolerating aloneness. But Ms. R. appears to have compensated for these vulnerabilities and would not have met criteria for BPD until the onset of symptoms of affective illness in her late 30s…" It would seem that at an earlier time, a therapist finding her not fulfilling the criteria for a borderline personality diagnosis may have diagnosed dysthymic disorder or major depression, while noting and working on borderline tendencies. The therapist can interpret that borderline symptoms were and are the result of depression or conversely, decide depression to be the result of borderline issues.
Commenting on the same client as Dr. Reich, Dr. Zanarini noted that borderline personality disorder is first noted in the late teens and early twenties. This does not mean the disorder develops suddenly in adolescence or early adulthood. Zanarini noted that the client reported four borderline symptoms of BPD in childhood: "self harm in the form of beating herself with her shoes; stress related or defensively related dissociative symptoms; an identity disturbance centering around a view of herself as inadequate, incompetent, and defective; and strong abandonment concerns that led to her becoming so dysfunctional after her father's death that she was unable to attend school for a time." In addition, she reported binge drinking in her 30s, distant and conflictual relationships with her husband and her teenage daughter. By 40 years old at her first hospitalization, "she had exhibited six of the nine DSM-IV criteria for BPD over the course of her life. A more careful questioning concerning the affective symptoms of BPD—intense and inappropriate anger, chronic feelings of emptiness, and mood reactivity or lability—would probably reveal that these were ongoing problems for Ms. R. as well" (Bernstein et al., 2002, page 297). Exploration for and examination of potential differences or issues does not require a diagnostic label. Each of the client's issues may and should have instigated some attention whether or not a formal diagnosis was warranted. In addition, the therapist may prefer to avoid diagnostic labels or work with an individual alone or in a couple. The individual may not qualify for the diagnosis such as Ms. R. at a given time. However, the therapist may nevertheless find that recognizing borderline tendencies, borderline instincts, and/or borderline modeling can enhance therapeutic assessment and thus, clinical strategies and treatment especially in couple therapy.