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The difficulties experienced by individuals with BPD are varied and they often exhibit different patterns of behavior throughout their lives.Their predisposition towards emotional vulnerability leads to extreme, long-lasting emotional reactions to life events and a slow return to a normal emotional state.The main findings reported in the PACE trial were that cognitive behavioral therapy (CBT) and graded exercise therapy (GET) were moderately effective treatments for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and fear avoidance beliefs constituted the strongest mediator of both therapies.These findings have been challenged by patients and, more recently, a number of top scientists, after public health expert Tuller, highlighted methodological problems in the trial.As a doctor who has been bedridden with severe ME for a long period, I analyzed the PACE trial and its follow-up articles from the perspectives of a doctor and a patient.During the PACE trial the eligibility criteria, both subjective primary outcomes, and most of the recovery criteria were altered, creating an overlap of the eligibility and recovery criteria; consequently, 13% of patients were considered “recovered,” with respect to 1 or 2 primary outcomes, as soon as they entered the trial.Individuals with BPD commonly invalidate their own emotional experiences by ignoring, suppressing, judging, or discounting them.

Marsha Linehan, the founder of Dialectical Behavioral Therapy (DBT), contends this is a typical and unfortunate result of attempting to manage a client with BPD using traditional methods. Linehan, traditional therapies, especially Cognitive-Behavioral Therapies, may actually exacerbate the client’s issues because the client experiences the techniques as invalidating. A well-meaning therapist may and suggest reasonable and helpful behavioral changes and associated strategies.In addition, 46% of patients reported an increase in ME/CFS symptoms, 31% reported musculoskeletal and 19% reported neurological adverse events.Therefore the proportion negatively affected by CBT and GET would be between 46% and 96%, most likely estimated at 74%, as shown in a large survey recently conducted by the ME Association.Validation builds strong rapport, which allows the therapist to suggest behavioral change in a way the client can accept.Finding Balance Effective therapists must balance validation and acceptance with behavioral change.

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