Communication-Focused Therapy (CFT) for Borderline Personality DIsorder
Dr. Christian Jonathan Haverkampf, M.D.
Borderline Personality Disorder (BPD) is a condition that comes with emotional instability, particularly after interpersonal events. Communication-Focused Therapy (CFT) is a psychotherapy developed by the author, which can be applied to several mental health conditions, including borderline personality disorder. The focus is on a change in internal and external communication patterns through observing, awareness, experimentation and insight. Insight into the basic parameters, including needs, values and aspirations, can help the patient to make better decisions and feel more stable in the long-run.
Keywords: borderline personality disorder, BPD, communication-focused therapy, CFT, communication, psychotherapy, treatment
Table of Contents
For borderline personality disorder various therapeutic approaches have been used with varying success. Since the term is derived from psychoanalytic psychotherapy, a lot of treatment models have originated in that school of thought. CBT has been applied in the form of DBT, which is now widely used in hospitals and outpatient situations. There is significant support for the efficacy of standard dialectical behavior therapy (DBT) for the treatment of suicidal individuals with borderline personality disorder (BPD). However, most of these therapies do not directly address the communication processes which lead to the symptoms of the disorder.
The instability experienced in BPD is related to the maladaptive communication with oneself and others. This can lead to internal and external disconnects which then cause even more fear and anxiety. Even though patients with BPD experiences getting overwhelmed by too much emotional information, the actual problem is that messages are decoded and interpreted differently. Since this leads to a deficit in adaptive information, the next message which is interpreted against the background of this information will also be maladaptive. Ultimately, the system becomes unstable.
All present therapeutic approaches focus little on the processes that really lead to changes, the sending, receiving, and understanding of information. Understanding information requires seeing meaning and relevance in it. Patients with BPD often seem to have difficulties to get to the meaning of messages they receive, whether in the form of emotions or otherwise. Getting distracted easily and being overwhelmed by too many things going on simultaneously are a result of seeing not seeing enough meaning in things, which is a consequence of maladaptive communication patterns with oneself and others.
The fear of losing a relationship or bond with another is a consequence of perceiving too little rather than too much meaning in aspects of the relationship. The less relevant aspects of the relationship seem, the more fragile one will judge it, at least subconsciously. Projecting one’s doubts in the partner just increases the fear of losing the relationship. Since meaning is derived from the communication of information, the task is to develop better communication strategies, especially those for interpreting and analyzing messages contained in information received from others and oneself through various communication channels, the senses, the autonomous nervous system, thoughts or emotions and situations and events, and so forth.
Borderline personality disorder (BPD), also known as emotionally unstable personality disorder, is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of self, and unstable emotions. There is often frequent dangerous behavior, a feeling of emptiness, self-harm, and an extreme fear of abandonment. Symptoms may be brought on by seemingly normal events. The behavior typically begins by early adulthood, and occurs across a variety of situations. Substance abuse, depression, and eating disorders are commonly associated with BPD.
Interpersonal messages or thoughts about interpersonal relationships are the main events that lead to emotional instability and feelings of losing oneself and the world, often as described as experiencing or falling into a void. From this description, one can already see the enormous role played by communication in the pathogenesis of BPD. Communication-focused therapy (CFT) is targeted at working directly with the communication systems that give rise to the maladaptive communication patterns in BPD.
The emptiness in BPD is usually quite symptomatic, and self-harm is often a reaction to feel oneself again. Relationships often tend to be unstable, not because an individual with BPD is less able to have one, but because the interaction with another person, or the memory of it, give a feeling of connectedness, which prevents the sensation of an ensuing emptiness, and its loss feels like an existential loss to the person with BPD.
The emptiness and sense of void often seems to be lying over strong emotions. It is a defensive void at the surface, like a blanket that has been thrown over the unruly emotions underneath it. Since there is a disconnect from oneself, the emotions are ill-defined and scary in the sense that they may cause disturbance or damage to the individual. This fear of a core part of oneself keeps the vicious cycle turning, in which fears of fundamental aspects of oneself cause additional fear, distancing from the self, more disconnect, even more fears, more emptiness, more fears, and so on. Communication is the key to break through this pattern.
Individuals with BPD have patterns of communicating with others which often do not seem to work well for them. The patterns are frequently quite rigid in making an interaction about one or a few messages, such as confirmation of the stability of a relationship. This lack of openness probably contributes significantly to the symptoms and relationship difficulties an individual with BPD experiences.
Systems of communication are what gives rise to the individual communication patterns. (Haverkampf, 2010c, 2010b) Some of these may be biologically predetermined to a significant extent. An autistic person, for example, may never become a flamboyant extrovert. However, there is usually a significant freedom to change communication patterns within a communication system. Developing theses new communications happens through awareness for the existing ones and shaping and experimenting with new ones. The therapeutic setting offers the space to do that.
Before discussing communication-focused therapy further, it may be helpful to take a brief look at the preferred treatment model at the time of this writing.
There are several psychotherapeutic approaches for borderline personality disorder. Since the original concept came from the psychodynamic school, there is a very voluminous and detailed description of the etiology and treatment of BPD in psychoanalysis. There is both, an emphasis on content and interaction, as well as structured models to explain the dynamic of BPD. Unfortunately, treatment usually takes a long time, while the short-time focused approach of twenty to fifty sessions is seen as dealing with the underlying problems only partially.
On the cognitive-behavioral therapy (CBT) side, there is little focus on the underlying dynamics of BPD and a greater focus on specific tools and techniques to help in the moment. Through learning, it is assumed that they will have a more enduring effect. As a spin-off from CBT, dialectic behavioral therapy (DBT) DBT is the therapeutic approach most commonly used today.
Studies repeatedly find moderate before-and-after effect sizes for global outcomes as well as suicidal and self-injurious behaviors, while the dropout rates are said to be relatively low. Although DBT is clearly efficacious and increasingly available in practice settings, demand for DBT far exceeds existing resources. The multicomponent nature of DBT (individual therapy, group skills training, between-session telephone coaching, and a therapist consultation team) lends itself to dismantling in clinical settings. Group skills training in DBT is frequently offered alone or, in community mental health settings, with standard case management instead of DBT individual therapy. Other clinicians, often those in private practice, offer DBT individual therapy without any DBT group skills training.
The problem with DBT and most CBT models is that their approach to specific topics or content is highly manualized. This leaves little room for the communication process itself, which interestingly is not manualized, even though it is the component which brings about change. A manualized approach may specify that the patient should be asked about what thought causes sadness, but it is not the topic of the question which causes change. It is that the patient learns how to put together a meaningful message about the sadness she experiences when a certain thought comes up. Once she feels she can do it, the new strategy will be memorized and cause the change in the long-run. If it works for her, adopting the new strategy will be as close to permanent as possible.
The problem is that there is little investigation into what makes DBT or any other kind of psychotherapy work. It is unlikely that it is a particular topic the therapist raises, but what happens in the flow of information between therapist and patient. However, many psychotherapeutic models focus on the former to the exclusion of the latter. The success of psychotherapy is built on Sigmund Freud’s original concept of the ‘talking cure’, which seems to be all but forgotten in many modern approaches. Even interpersonal therapies, such as IPT, focus more on interaction schemata or models rather than the dynamic process of information exchange that underlies any meaningful work in psychotherapy.
The successes of many psychotherapeutic approaches, including DBT, are moderate at best. This should motivate us to find ways how to improve on existing models. This, however, would require to give up the belief in the exclusive benefit of a specific model, and look at what they have in common. The interaction between human beings, communication, is what they have in common.
Individuals suffering from BPD experience significant instability because of the importance they attach to connectedness with themselves and others. This overemphasis is actually a result of a perceived connectedness with oneself and others. The communication patterns used by patients with borderline personality disorder are not as effective in getting through the relevant and meaningful messages as in those who do not show the symptoms of BPD. This is probably due to a combination of variations in the systems of communication on a more general level and individual communication patterns on a more specific level.
While one sees the dynamic of the communication patterns, one can only infer the more general communication systems in place. Psychodynamic psychotherapy and its offshoot self-psychology are two approaches that attempt to develop and understanding for components of these larger communication systems, although this is done mostly through focusing on content. From a more communication-focused perspective, however, the flow of information, and the sense of the flow of information, are what makes meaningful messages, and change as a result of it, possible.
An approach to BPD is thus to bring in more meaningful content into the interaction and support the patient’s reflective and introspective processes with the aim of developing better internal and external communication patterns. Through questioning and reflecting on apparent conflicts or other points where communication does not seem to be working, the patient gets a better sense of him or herself and the interaction with another. This also helps build confidence in oneself and in the interaction processes with another.
The sense of an ‘existential crisis’ is quite common in BPD, when a person feels disconnected from oneself and others and feels as if falling into a deep, dark, empty place. The void is a feeling that communication links, and a sense of nurturing safety, have been severed. It is a loss of faith in communication with oneself and the environment as an instrument to satisfy one’s own needs, desires, values and aspirations. This loss of faith in the effectiveness and power of communication is what leads to the existential crisis. The individual feels muted and disconnected from the part of the self that holds everything together, namely communication, at the same time. It is also a crisis of meaning when the communication of meaningful messages is reduced or cut off, a crisis of meaning about oneself and the world.
This existential crisis which occurs at the lowest moments in the life of someone suffering from BPD can be prevented with modifications to an individual’s communication patterns. Therapeutic work on these communication patterns can also be done when a patient is in a crisis situation, but then the therapist should add enough support when working on awareness and experimentation with communication.
Individuals suffering from the type of anxiety ne often sees in BPD often see less meaning in the things they do. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.
Meaning helps to make the world more interesting and counter the sense of emptiness and void. It also what can motivate individuals to engage in intrapersonal and interpersonal communication. But seeing meaning in a message also requires that one is open to receiving a message and to interpreting it in a helpful way. This in turn depends on one’s ability to reflect on communication and to gain insight from engaging in it. Therapy can be helpful in promoting one’s metacognitive skills of developing insight into communication processes and to experiment with them in a safe and protected setting. By promoting the identification of meaning in everyday messages, anxiety is reduced and motivation to be in contact with others, and through it with oneself, is increased.
Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication patterns between patient and therapist through awareness, reflection, experimentation and insight. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT do not work directly with the communication process, which, however, is fundamental to any lasting change in the patient.
Communication consists of the sending and receiving of information and the encoding and decoding of meaning. All living organisms not only process information, but are continuously engaged in sending and receiving it, whether in an exchange with the external world or within themselves. The result of these communicated messages is some change on the inside or in the world around. Life requires communication. This does not mean total connectedness is always the desired state. Our partial disconnectedness actually makes us feel and live as distinct individuals. Our communication systems as a whole determine levels of connectedness, which are then implemented more or less successfully through the communication patterns we use in specific everyday situations. A significant amount of strategy is part of these interactions with other and with ourselves (in the form of self-talk, for example), yet the gradual development and emergence of communication patterns over time makes this task easier. Thus, these patterns have some resistance to change, which is also important to prevent too much variation and instability from day to day. In a therapeutic context, success usually does not happen from one day to the next but because these patterns are entrenched to some degree, any change in them will lead to enduring changes in everything that derives from changes in them, such as improved mood stability, more confidence, less ruminations, less anxiety, less compulsions and improvements in any symptoms that are somehow related to the internal and external communication patterns one uses.
Psychotherapy is working with and through communication. Change happens when information is understood and identified as relevant and meaningful. The information can come from within the patient, from the therapist or be generated in the interaction space between therapist and patient. However, to be meaningful the message has to have a novel element. Once a meaningful message is received, decoded and understood (it resonates), it brings about a change in the organism, even if only tiny, and leaves a trail, such as being memorized, which is then enduring. A change can then also influence how the person receives, processes and sends information in the future. This can then lead to a host of changes within and outside the individual, such as improvements in negative self-talk, at the work-place or in relationships. Just to see this happening can provide a patient suffering with BPD new found confidence and the motivation to continue the therapeutic process.
Change can cause anxiety because it seems to bring temporarily more uncertainty into a person’s life. However, working with communication processes more directly reduces fears because the increase in experienced connectedness reduces anxiety. One has to remember that it is after all the disconnectedness in BPD which causes anxiety, fear and the existential crisis. The connectedness here refers to the expectation of future communication. Patients with BPD are often unsure about their connectedness with others. Shifting the patient’s message flows into the center of attention creates expectations in the patient, while the therapeutic setting provides the promise for communication in the future. The particular relationship between two people, in this case patient and therapist, may facilitate a defined range of interactions, but it is communication which ultimately makes, maintains and can break the relationship. Thus, working constructively and in meaningful ways with communication patterns, the patient feels are relevant to him or her, can transform the therapeutic relationship into a great working relationship that brings greater insight on both sides, and helps the patient overcome the BPD symptoms.
When change is adaptive, it can help align an individual better with the environment. This brings greater stability in the long-run. Especially in BPD it is important that patients can experience the stabilizing effect of these changes. As the emotions are signals in which the nervous system integrates a large amount of information with the objective to bring about an adaptive change, hence being called an “e-motion”, working with the patient on the emotional communication is an important component of the change process. The objective is the free communication of emotional messages, at least within the patient, so that the patient can more accurately identify the own emotions and use this information for more relevant, better adapted and more meaningful change.
The basic change that needs to occur is greater awareness for the own internal and external communication patterns, which then provides some insight into the overall communication structures. One’s basic parameters, the individual needs, values and aspirations are reflected in the more global structures of the internal information flows. It is important to remember that a basic value is not directly stored information, but stored information about communication patterns and about the processing of information.
BPD often means that there is a greater fear or anxiety about extracting the meaning from a message. One reason for the fear might be that identifying and decoding a message could reflect more distance to another person or myself, in other words, that the content of it is less meaningful and relevant. The reason for this again lies in the maladaptive communication patterns which provide less information and make others and oneself appear less meaningful. As there is less or less accurate contextual information for new messages, they are less likely to be fully understood and meaning to be identified, and adaptive change is less likely. BPD is a vicious cycle of incomplete or distorted information from maladaptive communication patterns.
Any manualized psychotherapeutic approach which does not directly address a person’s communication patterns, will not be individualized enough. It is like giving an engineering student a manual on how to build a screwdriver, whether this is useful to her or not, rather than to really teach her engineering, which would allow her to build whatever she wants. The fit of the specific manual also depends on the accuracy of the diagnosis, which tends to be too unspecific, based on symptoms rather than the underlying problems, and notoriously unreliable, especially if the therapist is still inexperienced.
CFT focuses on the processes that lead to the symptoms, communication patterns which are maladaptive. Through helping a patient get a better sense and understanding for how communication works and what it does for the individual, he or she can begin to shape the communication pattern on the inside and on the outside more actively. Patterns and strategies can be seen, understood and reflected upon, which not only leads to greater insight, but to greater abilities in forming and implementing better communication patterns and strategies, which help the person to feel better and reduce the signals that something is ‘out of sync’, the symptoms of the mental health condition, such as in BPD.
The emotional signals are not what causes BPD symptoms, as we have seen above. The disconnection from or distortion of important information, which can be found in BPD as well as several other mental health conditions, is the cause of uncertainty, and thus feelings and fears that reflect that, which can then turn into a vicious cycle which can no longer regulate itself. Several symptoms in BPD, such as the classical sense of void, the fear of losing oneself or disintegrating, or not being strong enough to withstand emotional stresses, can be explained quite easy with this disconnection. Unfortunately, most schools of psychotherapy treat communication like a black box, which is assumed to do its thing and accepted as a given, thus neglecting that this is where answers can be found and with which lasting change can be brought about.
Learning to communicate requires becoming aware of it and reflecting on it, as well as using it in novel ways to make it work for oneself. This does not change the person or any of the basic parameters, values, needs and aspirations, but it makes living with and towards them more effective. In the case of BPD, the resultant greater sense of stability, emotionally, cognitively, in respect to the present or future, and otherwise, is instrumental and effective in reducing the symptoms.
Better communicating with oneself and others is an important technique towards reconnecting with oneself and the world, which also increases self-confidence, a strengthened sense of self, and increases the sense of effectiveness in getting one’s needs and wants met. In the process, many patients also rediscover basic interests, values and old aspirations. All this helps to rebuild a stronger sense of self, which helps to put the more intense emotional ups and downs BPD patients experience into perspective.
Reconnecting means becoming more aware of the information coming from within oneself, whether emotional or otherwise. It also means becoming better at identifying it and being able to put it into words or communicate it in another way. This can be worked on within a therapeutic setting. The therapist could, for example, discuss how the patient feels the own emotions and experiences talking about them with others. This can be combined with practicing to observe how the patient communicates about the own emotions in the therapy. Important is that the patient becomes more aware of how emotional signals are noticed and identified and what action then follows. Since an emotional signal is a call to new action or a change in action, it needs to be communicated somehow.
These basic parameters are, as already mentioned, variables determined by larger communication structures. In the brain, what one values and aspires to is not stored in a specific location, but a feature of and embedded in the neural network in many locations. Needs that go beyond such very basic biological needs as hunger or thirst are also a feature of the network. The more a patient has insight into these basic parameters, the easier it becomes to make decisions which adds to the sense of stability in patients with BPD. A greater emotional stability usually follows from this as well. Insight into these parameters also helps to make better decisions regarding interpersonal relationships, which also increases the sense of stability.
The most common way to identify these basic parameters in CFT is by looking at how a patient experienced different situations and how he or she interacted with others. This provides information on the internal and external communication patterns and the emotional and other information from inside. It also shows how an individual interacts with the environment, and where changes in communication patterns can make it easier for the patient to identify the own basic parameters, the needs, values and aspirations.
Good and meaningful communication requires the ability to send meaningful messages and to receive them. This means openness about oneself and the willingness to engage with the other are important. The fear of engaging with communication is usually a result of not understanding it, or understanding it only partially. Exploring communication patterns, reflecting on meaning and relevance, and helping the patient experience a safe communication environment in which he or she can be creative and innovate usually leads to a decrease in the fear and anxiety in the patient.
People with BPD often have difficulties with openness because they do not have a good image of themselves. The sense of self does not feel as complete or as whole and this leaves areas of uncertainty or outright bad memories. This is often another reason why the bond or connection with another feel important to the patient. However, this need can lead to restrictiveness and rigidity out of fear that something, including one’s own needs and wishes, can interfere with existing interpersonal connections. The connection with oneself is not experienced as strong enough to support one if an existing interpersonal bond brakes.
A greater ability to interpret messages from others, rather than making assumptions and then shying away from reading the message, helps to build a greater sense of stability, which makes openness easier. The simplistic assumptions about interpersonal relationships are probably strategies that worked partially at some point in the past to protect the individual and their sense of self. Over time, however, they can lead to superficial relationships and a fear of depth and meaning. In the therapeutic setting a patient can investigate and explore these strategies and experiment with new ones, both as a mental exercise and in the therapeutic relationship with the therapist. This makes openness easier, reduces anxiety, and allows the patient to experience the benefits of greater openness.
The next step form openness is engagement, which means encoding and sending meaningful messages out into the world. Patients suffering from BPD who manage their condition better all seem to have in common that they take an active interest in communicating with the world around them. One might say that the ability to communicate more freely means that the condition is less severe. However, it rather seems that they experience the same emotional instability, void and even an occasional existential crisis, but that they still keep engaged. On a closer look, it appears that they often are more motivated to engage, which means they see a greater benefit in engaging with others.
To see a greater benefit in engaging with other requires seeing a benefit in communicating. This can be furthered in therapy using the usual techniques to help the patient become more aware of the own communication patterns and the effect they can have on the environment. (Haverkampf, 2010b, 2010a, 2017a, 2017b, 2018) An approach to overcome the fear of communicating with oneself and others has been briefly discussed above. In any case, it is important to offer a safe and holding environment in which the patient can engage with the therapist in different ways and reflect on various situations in everyday life in which he or she engages with others. Experimentation with communication patterns is an important way to increase the interest in and reduce the fears of engaging with others.
One fear of engaging and sending out messages to others can be due to the fear of revealing something about oneself to others, which is particularly strong if one has already a negative view of oneself. As the work with internal communication helps to lower doubts and anxiety about oneself, work on the external communication helps to get more of a sense of control over one’s communication with the world.
Communication is the vehicle of change; the instruments are meaningful messages which are generated and received by the people who take part in these interactions. Patients with BPD are not only interested in interactions with others, but they often feel the need for interpersonal connections even more than their friends and colleagues. From the discussion above, the most plausible explanation is that they only partially understand messages from themselves and others, which makes them more dependent on interactions which they feel they can get the messages they so crave. This is not to say that there is a higher for certain messages, which, for example, also play a role in attachment, but that they are not understood and processed in someone with BPD as fully as in someone without.
Seeing meaning is the result of communication processes on the outside and on the inside. It requires understanding a message and perceiving something as relevant, though not necessarily in this order. Helping patents with BPD to see more relevance and meaning in interpersonal interactions, mainly by helping them to understand them better, reduces the anxiety and fears around interpersonal relationships. It thereby creates a greater sense of safety and security in the world, and makes it also a more predictable place. Insight and understanding communication, as well as engaging in it, is the key to this.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
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Haverkampf, C. J. (2010c). Inner Communication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Haverkampf, C. J. (2017a). Attachment and Psychotherapy (1). Retrieved from https://www.jonathanhaverkampf.com/
Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
Haverkampf, C. J. (2018). Building Meaning – Communication and Creativity (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.
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