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Borderline Personality Disorder: 2 Commandments to Follow

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW

This is the most difficult client I have ever had to treat. She calls me multiple times a day, at any time, expecting me to just pick up. I don’t know what to do anymore.” Leila was quite irritated, as she articulated these words to Rodis, the consultant to the HOPE Clinic.

This was the first introduction to Leila and her client, in the first article series on Working with Clients with Borderline Personality Disorder. “Let us look into this case in more detail and talk about the skills required when working with patients and clients who are diagnosed with Borderline Personality Disorder,” responded Rodis.

Prior to looking into the skills required to working with patients and clients suffering from Borderline Personality Disorder, some needs, reasons, and perspectives have been explored , looking at the perspective of patients and clients, clinicians, and that of agencies and the system, as a whole. A total of nine factors have been described:

  1. Need to be understood

  2. Relationship repair

  3. Victim and subject of biases

  4. Strong countertransference

  5. Draining propensity

  6. Splitting ability

  7. Burnout prevention

  8. Successful integration of care

  9. Waste containment

For further reading, see the previous articles in this series entitled;

During her work with Emma, Leila has been reacting instead of responding, which has been adding to her challenges of working with someone suffering from Borderline Personality Disorder.

Strong and negative countertransference has been evoked, in addition to projective identification (“I don’t know what to do anymore”), and Leila has been feeling drained and experiencing burnout. “However, it does not need to be this way. There are well established skills for working effectively with this population, and we will learn them, together,” added Rodis.

There are 10 Commandments to follow when working with patients and clients suffering from Borderline Personality Disorder. Below are the first two:

Remain stable and prevent burnout

“Sometimes I feel like her dumping ground… I feel drained,” uttered Leila, who has been feeling overwhelmed and experiencing burnout; she has had little guidance prior to Rodis consulting at the Hope Care Center. Remaining stable means keeping one’s judgment in check, staying away from projecting one’s own values, and refraining from enacting one’s patient’s and client’s unconscious wishes for rejection. Remaining stable also means seeking guidance and supervision regarding feelings and emotions, ensuring the understanding of countertransference and using it positively and for the benefit of our patients or clients. “She just reminded me of my sister, who rarely answers my calls, yet expects me to pick up as soon as she calls, even when it is two in the morning. She is so demanding, always getting into trouble and expects me to bail her out,” stated Leila, with increasing intensity in her tone of voice, responding to Rodis’ question, “What type of feeling would you say you have been experiencing in your work with Emma, so far?”

Preventing burnout is accomplished by remaining stable, by mastering the skills required to effectively work with this population, and by having access and taking advantage of the emotional support offered through co-workers, supervisors, and the agency and system, as a whole. An article-series have been dedicated to the topic of preventing burnout and promoting self-care. (For further reading on this, see: Preventing Burnout: Self-care for Clinicians and Advocates).

Psycho-educate

Hesitation about either making a diagnosis or educating patients and clients with regards to Borderline Personality Disorder is common. It starts with proper symptom contextualization, using a bio-psycho-social and cultural based approach, conducting a proper diagnostic and differential diagnostic formulation, clarifying the comorbidities, and reconciling your formulation with the explanatory model of illness from your patients and clients. All this entails proper collateral information, an effective and comprehensive mental health assessment (See articles series entitled, New Strategies for Mental Health Assessment), and maintaining a holistic view of your patient and client.

Once you have done all of this, you should feel confident explaining to your patient and client his or her likely diagnosis and what this means for them, both in the short and long-term. As a principle, as you psycho-educate, always remember to first find out what your patient and client may already know. From there, you should proceed and talk about available treatment, the risks and benefits associated with each, and the different options, including the success rate for each. You ought also to discuss the duration and stages of treatment and the possible consequences, and what he or she may expect during the duration of treatment.

“This is the most difficult client I have ever had to treat…I don’t know what to do anymore.” Leila was quite irritated, as she initially articulated these feelings. With guidance and support, she subsequently changed to, “Thank you, Rodis, I feel I now have a roadmap to work with Emma.”

Rodis has been meeting with Leila, going over the 10 Commandments of Working with Clients with Borderline Personality Disorder, the principles, the techniques, the Do’s and Don’ts of working with this patient population. With these new strategies, one can go from unknowingly or unintentionally doing harm to guiding one’s patients and clients towards full recovery that they all deserve.

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