The Role of UPR in the Treatment of BPD

Psychotherapy is the first line of treatment for people with borderline personality disorder (BPD). People with BPD find it hard to keep relationships with others and have a hard time controlling impulses and emotions. In addition to that, there is a general feeling of emptiness, sudden changes in moods, and a constant probability of harming themselves. These difficulties, which are sometimes catalyzed by past cases of abandonment or a change in the view of others, make it hard for these individuals to engage with treatment for the condition (Zanarini & Frankenburg, 2007). Increased research in the past decade has produced cumulative evidence that demonstrates the effectiveness of various treatment approaches for borderline personality disorder. Currently, the high prevalence, comorbidity, and mortality rates make BPD one of the most stigmatized conditions. The ability of BPD to mimic other psychiatric illnesses such as anxiety and mood disorders as well as psychosis complicates the diagnosis process of this condition. Most of the psychological interventional for BPD such as dialectal behavior therapy, transference-focused therapy, and schema-focused therapy are administered as outpatient therapies that last between six and twelve months with a week or two of individual sessions. All these approaches view BPD from the point of developmental trauma where a patient’s ability to observe and describe on experience is affected ( Kulkarni, 2017) . 

The treatment here is focused on approach-specific strategies where a therapeutic relationship is built using trust and rapport. The person-centered therapy (PCT) has not received similar consideration to those mainstream treatment approaches because of the overall decline in its application through the years. However, this approach has demonstrated effectiveness in treatment despite its common use as a supportive therapy. Past studies done in the psychology of well-being hypothesize unconditional positive regard as an inherent determination for survival developed during infancy.Unconditional positive regard is considered a proxy of well-being and healthy development because of the lack of distress associated with it ( Lux, 2010). 

The purpose of this paper is to study the role of UPR on the treatment of BPD based on the conceptualization of existential analysis. The existential analysis is a person-oriented psychotherapy method that works through verbal induced processes, and whose aim is to enable an individual to make emotional and mental experiences that are free ( Frankel, Rachlin & Yip-Bannicq, 2012). This method also seeks to enable authentic decision making that would help an individual deal with the world and life in a responsible way. Existence, which is at the center of existential analysis, encompasses a life that is full, meaningful, shaped with freedom and responsibility (Zanarini & Frankenburg, 2007). A full life means a life that is lived in wholeness. According to existential analysis, man cannot be whole by himself but only through relationships with others ( Frankel, Rachlin & Yip-Bannicq, 2012). 

Existential psychotherapy aims to free the individual from distortions and traumatizations that influence the individual’s behavior and experiences ( Frankel, Rachlin & Yip-Bannicq, 2012). The process here takes place through the phenomenological analysis of emotions that define experiences. This form of analysis is applied to individual sessions where the therapist and the patient sit on chairs on a regular frequency ( Farber, Suzuki & Lynch, 2018). The therapist offers personal interventions and opinions only when it suits the situation and bound to be helpful. Therefore, the empathy of the therapist contributes to improvements in the client’s accessibility and emotional understanding. 

Unconditional Positive Regard 

Currently, the prevalence of exposure to traumatic events in the general population stands at high estimates of 80% ( Flanagan, Patterson, Hume & Joseph, 2015). The experience of trauma mostly leads to the development of posttraumatic stress that, in turn, leads to problems in occupational as well as social functioning. In some instances, this stress can lead to posttraumatic growth where the affected individuals develop a new perspective on the world and self. This new perspective is usually beyond the previous functioning level that an individual had before posttraumatic growth. More than fifty years ago, Carl Rogers developed the view that positive regard, empathy, and congruence are the necessary conditions for therapeutic change (Zanarini & Frankenburg, 2007). 

Unconditional positive regard is a treatment for BPD that emphasizes on increasing awareness of an individual’s thoughts and feelings and focusing on mindfulness ( Murphy, Joseph, Demetriou & Karimi-Mofrad, 2017). Over the years, Carl Rogers’ approach has been given various names including client-centered therapy, nondirective therapy, and person-centered therapy. Here, Rogers discovered that there is a need for a therapist to possess certain attitudes towards a client for there to be a positive change in the condition of the client. Therefore, the condition of the therapist facilitates the process of the client by increasing the awareness of experience and self-acceptance. The unconditionality of an individual’s positive regard depends on the extent that the individual discriminates the worthiness of self-experiences ( Frankel, Rachlin, & Yip-Bannicq, 2012). 

Rogers believed in the inherent good and creativity of people and held the view that thedestructive state only occurs as a consequence of external constraints or an override by a poor self-concept ( Murphy, Joseph, Demetriou, & Karimi-Mofrad, 2017). The benefit of unconditional positive regard is felt to the individual who experiences it. The development of self-worth and positive regard for others also play crucial roles in the well-being of the individual. A stronger sense of self-worth brought about by unconditional positive regard makes the individual more confident to work towards life goals and achieve self-actualization ( Geller, & Greenberg, 2002). This can be demonstrated in a child’s life where unconditional love and acceptance by parents and family members contribute to the development of confidence in the child. In adulthood, an individual’s self-image is shaped by the regard held by others. 

Unconditional positive regard is different from other unconditional qualities such as parental love because it requires one’s acceptance and warmth even when the other person has done questionable things ( Murphy, Joseph, Demetriou & Karimi-Mofrad, 2017). Since positive regard is not withdrawn if the individual makes a mistake, then this approach encourages such individuals to explore new things and make mistakes. The consequence here is the possibility of the individual to achieve self-actualization. Conditional positive regard, on the other hand, is where the positive regard is dependent on the recipient. For example, a child may be loved for behaving in a way that has been approved by parents and not for the person that the child is ( Lynch & Sheldon, 2017). 

The common consequence of conditional positive regard is that it leads to the constant seeking of approval from others. Rogers viewed that a child has two basic needs of self-worth and positive regard from other people such as caregivers ( Lynch & Sheldon, 2017). The feeling of self-worth is important in psychological health because it promotes the likelihood that an individual can achieve ambitions, goals, and self-actualization. People have the need to be regarded positively by others because it makes them feel loved, respected and valued. 

The ability of a psychotherapist to provide positive regard is critical in the success of the therapeutic process. The therapist can provide the client with appropriate conditions for growth by showing unconditional positive regard. Here, the positive regard leads to self-acceptance and helps the client take responsibility for themselves and their actions ( Murphy, Joseph, Demetriou & Karimi-Mofrad, 2017) . In showing unconditional positive regard, the therapist must accept the client’s feelings, thoughts, and behaviors without criticizing or evaluating them . 

Unconditional positive regard provides a path through which the therapist engaging with individuals struggling with BPDcan connect with them in a healthy and interactive way. Therapists interact with different types of people who often make choices that are dangerous to self or others around them. In most cases, it can be difficult for a therapist not to engage those dangerous patterns and try to correct them ( Murphy, Joseph, Demetriou & Karimi-Mofrad, 2017). However, doing so would be counterproductive since the clients would end up feeling that they cannot express themselves with honesty, and hence distract the treatment process. This scenario demonstrates the importance of applying unconditional positive regard. 

Turning Towards 

The theme of turning towards emerges within the second of four foundational questions to a full life of “Do I like to be?” Within Existential Analysis this question is phenomenological most associated with the experiences of depression, grief, chronic fatigue, and burnout ( Frankel, Rachlin & Yip-Bannicq, 2012). Alternatively, this is the realm of existential psychology that we bring a sense of quality to our existence. We can be here, but how do we choose to be here? How do I structure, color, dress my life, by what do I stand by to give it meaning and structure? This theme of TT is, like UPR, paramount to life. The degree to which we were turned towards by others in life, will mirror the amount we’re able to turn towards ourselves, and in turn mirror the amount we’re able to turn towards others ( Dodson, 2019). In the absence of unconditional positive regard, it would be easy for a therapist to dismiss an individual struggling with BPD as a lost cause. In such a situation, it is important to turn the attention inwards and view oneself as a person worthy and capable of self-determination. In most occasions, the expression of destructive behavior from a patient originates from a feeling of lack of self-worth and inadequacy. 

The development of depression and other mental health problems is associated with turning against the self. This is the process by which an individual develops solid negative mentalities and attitudes that bring about internal criticism. Humans form attitudes and judgment according to the feelings and beliefs that they have. However, people struggling with negative emotions express negative evaluations of their feelings. This means that they not only have the bad feeling but also feel bad about those bad feelings. There are several reasons that can make an individual turn against self and the negative feelings ( Dodson, 2019). First, turning against the self can be caused by misdirected anger. For example, an individual that is angry with others but cannot express that anger towards them is most likely to redirect it inwards. In addition to that, people do not like feeling negative emotions. 

The common belief that negative feelings are horrible adds to the determination of individuals experiencing such feelings to avoid them. The arising need to rid the consciousness of negative feelings contributes to the bad feelings about those emotions. Furthermore, negative feelings have the tendency of influencing problematic decisions and actions. For example, an individual that is irritated by another may be oriented towards being hostile to the other, hence threatening the relationship. Sharing the feeling of sadness with another can turn out to be a burden in many ways such as emotional and financial. The feeling of shame towards self can make an individual act vulnerable and inferior ( Westen, Jay, Silk, Lohr, Cohen & Segal, 1992). Therefore, individuals with negative feelings try to suppress them because they perceive the feelings as problematic based on the actions that they influence. 

Another reason that leads to turning against the self is a sensitive or reactive emotional system that is negatively oriented. Individuals with neurotic temperaments without the knowledge on how to cope with them perceive others who appear to be calm and in control of their emotions as better off (Zanarini & Frankenburg, 2007). The resultant feeling from such perceptions causes hyper-sensitive individuals to criticize themselves. Turning against the self makes the emotional system of an individual to be conflicted leading to more negative affect, frustrations, and inner criticism. 

Turning towards the self and reversing the cycle of turning against the self involves various steps. Here, the therapist recognizes the negative feelings that the client has and how those feelings affect the consciousness making the body to send signals of sadness or suffering. Turning towards the self also involves the self-conscious part that gives the idea of how one should feel and how they should think about how they feel. That part is crucial in turning towards the self because it is critical of the negative feelings and keeps them off the stage of consciousness (Dodson, 2019). This judging part, annoyed with the negative feelings, tries to get them to go away making the client to express feelings of frustration towards self for having those feelings. Identifying the destructive effects of turning against the self can help a client develop a different attitude that will lead to motivation and acceptance, hence making the client to be more mindful and have the ability to adapt. 

Overlap of Unconditional Positive Regardand Turning Towards 

Buber philosophy of truly seeing another, a Thou. This is, of course, the foundational philosophy for much of the existential-humanistic tradition. Central to this point of view is our experience of these individuals. Do I love and integrate into myself that which the patient brings up in me that is also so troubling. I’m working with my own experience just as much as I’m working with my own. Phenomenology starts with understanding the inner felt experiences of the patient. This is characterized by the inability of the ego to grasp oneself or the inner felt experience ( Westen, Jay, Silk, Lohr, Cohen & Segal, 1992) . Since the ego cannot function, then the patients cannot create themselves, hence leading to the feeling of being torn apart for the loss of access to oneself. 

The response to disturbed access to oneself is the expression of sharp intensive stimuli. The effect on BPD patients is the lack of self-image, not having a stable intention with their goals. These patients cannot empathize, have relationships defined by conflicts, and have continuous anxiety to be left alone and abandoned. The TSM-5 describes borderline symptomatology along the basic schema of the ego (Zanarini, 2000). These symptoms include the lack of impulse, control, and violence among others. These can be summarized as an intensive way of feeling, full of power and violence that the patients have experienced before and of which they make use of now. 

Affectivity in borderline patients is differentiated from emotionality by the feelings that are associated with it. Therefore, the borderline disorder can be said to be a disorder of relationships that comes ashore in the form of terrible anxiety of being abandoned. The patients here cannot relate to either oneself or to others. The relationships that these patients manage to form are characterized by clinginess, meaning that the anxiety that they experience is real and not imagined. Although the anxiety is pathologically exaggerated, it has a psychological basis depending on the experience of the individual ( Wilkins, 2000). The main incapacity of this anxiety is the inability to relate. 

Conceptualization of BPD from the View of Längle 

Relationships are defined by feelings for self and others, and hence to be in a relationship would require the individual to be able to feel oneself in the presence of another ( Längle, 2018). Without a relationship with oneself, then such patients are numb inside and cannot express empathy for feelings from others outside their own self. Since the void created by the absence of the ego can only be filled by relating to another, people with the BPD condition make use of the relationship to compensate for the void of the ego ( Längle, 2018). When they experience somebody, who does not get too close to them, then life for them is flowing and has meaning. These relationships are not defined by personal connections but by functional closeness where the patient and the other individual can connect through an activity.The effect of life created by these relationships then gives them an idea of “who is me?” ( Längle, 2018). Therefore, the ego in the borderline patient is fundamentally dependent on the relationship because of the capacity to feel oneself from the inside. 

The patient here is, of course, aware that he is himself or herself, hence creating a major distinction from other conditions such as schizophrenia and psychosis. To extend to which BPD patients are dependent on relationships is intense to the point that a loss of the relationship is felt mortally like death. The borderline ego can be demonstrated as a laser light hologram whose presence can be felt even though it is not really there. When the light of this hologram is switched off by taking away the relationship with the other, then it is dark ( Längle, 2018). 

The darkness that is representative of the switched off light makes the individual feel like there is no existence, hence creating a vital intensity for the need of survival. The greed for light created by the presence of darkness when the light is switched off can make the individual transgress boundaries and potentially hurt oneself because of the feeling of not having enough. This feeling of falling short in life creates greed for life ( Längle, 2018). Here the individual looks for anything that would stimulate the feeling of life and may go to extremes such as pain, drugs, cutting oneself, and body sensations that create a little bit of ego. Patients who get to this point cling to it as a grasp onto the light and life. 

The feelings that such patients have is different from those expressed by people suffering from depression. Whereas in depression patients have the consciousness of the darkness and heaviness of life and that life is not good, the borderline person feels that life is good and does not wish for that feeling to end. In both cases, however, a similarity can be observed on the fact that the relationship to life is disturbed ( Längle, 2018) . The characteristic greed to stimuli in BPD patients can be described as some kind of psychic stimulus bulimia, which is, in fact, a common symptom in borderline patients . 

Since these disorders lie in the structures of the ego, the borderline patients are not able to distance themselves from the disorder. Therefore, the knowledge of the disorder in one-self or the self-mentalization of it is not possible. This explains why small things can lead to the breakdown of the ego function leading to intense coping reactions that build up around the experience of intensive pain. The loss of the relationship is painful because it means that the relationship to one self is also lost. The phenomenal content of the felt experience is the “I am not liked as I am” feeling which leads to “I cannot like myself.” ( Längle, 2018). 

The realization of one’s self can have a crucial impact on a patient. This realization is a turning point because it separates the individual from victimization by others or by circumstances. Here, the individual realizes that “I can choose my own being.” Collectivist trends and conformist tendencies have influenced the loss of the sense of being and its confusion with the sense of the self. Most often, the sense of being is subordinated to the economic status of an individual. However, the realization of “I Am” is not a solution by itself but a pre-condition to solving an individual’s problems. The experience of being also mirrors the experience of nothingness that is illustrated in hostility, severe anxiety, or threats of death ( Längle, 2018). This state of nonbeing is always present at varying intensities at all times. 

Early Life Experiences of BPD 

Early life experiences are central to the formation and structuring of BPD. It is important to point out here that from an existential-humanistic point of view the being or person that shows the symptomatology of BPD are human dynamics and things of life. Genetic disposition plays a role in the development of BPD. Cases of conspicuous children who grew up in families and environments show that the genetic element is present in this condition. Although the temperament of babies is mostly assumed to be determined by genetics, the biological influence cannot be ignored. The dependence of infants on their caregivers for survival influences the development of personalities, temperaments, and perceptions (Zanarini, 2000). 

The significance of the interaction between infants and caregivers demonstrates how the forces of nature and nurture interact with each other to influence the development of personality in infants. Babies demonstrate different temperaments with varying sensitivity and reactions to environmental stimuli such as noise and light. These differences show that babies have genetically-determined temperaments (Zanarini, 2000). However, it is common for the temperament of the baby to influence the response of the caregiver with placid babies more likely to receive physical affection than reactant babies. The responses, in turn, affect the way that the child develops emotionally. 

The anxiety that is present in most relationships is usually triggered by old fear associated with childhood experiences. Anxiety in relationships is expressed by the fear of abandonment or engulfment. The fear of abandonment is mostly expressed by emptiness, insecurity, neediness, and intrusive thoughts. The childhood origin of this type of anxiety comes from the response of parents to the child’s attachment seeking behavior at the infancy stage of life (Zanarini, 2000). 

A healthy attachment between an infant and a nurturing caregiver leads to the development of trust and safety. The response of the parent to the child’s call for comfort, feeding or any other type of attention affects the view of the child about the nature of the world. When the parent is available, then the child internalizes the message that someone will always help when there is a problem. However, if the message communicated to the infant shows that the world is not a friendly place, or people cannot be relied on, then the ability of the child to withstand uncertainties or maintain relationships in adulthood is negatively affected (Zanarini, 2000). 

Adverse childhood experiences have a complex relationship with BPD. Although the exposure to these adverse events increases the likelihood for the development of BPD, not all cases of stressed or abused children develop the condition. This observation means that there are multiple risk factors involved in overwhelming a child’s system to cause the development of BPD. The observation also suggests that there may exist a function that limits the effects of adverse childhood experiences (Zanarini, 2000). Exposing children to harmony or pain through the display of such behavior in the relationship of parents can also trigger the borderline condition. When parents cannot contain the feelings of the child and detoxify them by accepting them calmly but instead react with feelings contrary to own affects leads to a buildup of the aspects to a point where the child goes through forced adjustments. 

Conclusion 

The realm of borderline personality disorder is rapidly changing in terms of treatment. Unconditional positive regard, as developed by Carl Rogers, is a person-centered therapeutic method that is based on the belief that people have an ingrained ability and desire to work towards self-actualization. Through unconditional positive regard, one is able to view another person as a human being with distinct experiences and be able to isolate the behaviors of that person from them without judgment of those behaviors or flaws. When this is combined with empathic understanding from a therapist, then individual can move from the state of turning against the self into interpretations based on reality, hence lessening the borderline effect. Borderline patients are not able to distance themselves from the disorder because it lies in the structures of the ego. Early life experience for infants, especially those aged two years or younger, can contribute to the development of borderline personality disorder in adulthood. Although genetics has a contribution towards this condition, nurturing experiences that reflect on relationships and responses intrinsic needs affects an individual’s perception of the world and, consequently, the ability to form and maintain relationships in the future. 

References  

Dodson, C. (2019). Living With Depression - Pt. 2 - Turning towards Life . Retrieved on 2 May 2019, from https://www.calebadodson.com/writing/depression-turning-towards-life 

Farber, B., &Doolin, E. (2011). Positive Regard. Psychotherapy (Chicago, Ill.). 48. 58-64. 10.1037/a0022141. 

Farber, B., Suzuki, J., & Lynch, D. (2018). Positive Regard and Psychotherapy Outcome: A Meta-Analytic Review. Psychotherapy . 55. 411-423. 10.1037/pst0000171. 

Flanagan, S., Patterson, T. G., Hume, I. R., & Joseph, S. (2015). A longitudinal investigation of the relationship between unconditional positive self-regard and posttraumatic growth.  Person-Centered & Experiential Psychotherapies,14 (3), 191-200. doi:10.1080/14779757.2015.1047960 

Frankel, M., Rachlin, H., & Yip-Bannicq, M. (2012). How nondirective therapy directs: The power of empathy in the context of unconditional positive regard.  Person-Centered & Experiential Psychotherapies, 11 (3), 205-214. doi:10.1080/14779757.2012.695292 

Geller, S. M., & Greenberg, L. S. (2002). Therapeutic Presence: Therapists experience of presence in the psychotherapy encounter.  Person-Centered & Experiential Psychotherapies, 1 (1-2), 71-86. doi:10.1080/14779757.2002.9688279 

Kulkarni, J. (2017). Complex PTSD – a better description for borderline personality disorder?  Australasian Psychiatry, 25 (4), 333-335. doi:10.1177/1039856217700284 

Längle, A. (2018, February 20). Borderline – existential understanding and treatment [Video file]. YouTube . Retrieved from https://www.youtube.com/watch?v=A6uFsNzXhJ8 

Lux, M. (2010). The Magic of Encounter: The Person-Centered Approach and the Neurosciences. Person-Centered & Experiential Psychotherapies, 9 (4), 274-289. doi:10.1080/14779757.2010.9689072 

Lynch, M. F., & Sheldon, K. M. (2017). Conditional Regard, Self-Concept, and Relational Authenticity.  Journal of Humanistic Psychology, 1-19. doi:10.1177/0022167817696842 

Murphy, D., Joseph, S., Demetriou, E., &Karimi-Mofrad, P. (2017). Unconditional Positive Self-Regard, Intrinsic Aspirations, and Authenticity.  Journal of Humanistic Psychology, 002216781668831. doi:10.1177/0022167816688314 

Westen, D., Jay, M., Silk, K., Lohr, N., Cohen, R., & Segal, H. (1992). Quality of Depressive Experience in Borderline Personality Disorder and Major Depression: When Depression is Not Just Depression. Journal of Personality Disorders, 6. 382-393. 10.1521/pedi.1992.6.4.382. 

Wilkins, P. (2000). Unconditional positive regard reconsidered.  British Journal of Guidance & Counselling, 28 (1), 23-36. doi:10.1080/030698800109592 

Zanarini, M. (2000). Childhood experiences associated with the development of borderline personality disorder. The Psychiatric clinics of North America, 23. 89-101. doi: 10.1016/S0193-953X(05)70145-3. 

Zanarini, M., & Frankenburg, F. (2007). The Essential Nature of Borderline Psychopathology. Journal of personality disorders, 21. 518-35. 10.1521/pedi.2007.21.5.518. 

Zhang, H., Watson-Singleton, N. N., Pollard, S. E., Pittman, D. M., Lamis, D. A., Fischer, N. L., Kaslow, N. J. (2017). Self-Criticism and Depressive Symptoms.  OMEGA - Journal of Death and Dying, 1-22. doi:10.1177/0030222817729609