Working with Patients with Borderline Personality Disorder (Clinician’s Perspective)

“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. Leila was alluding to Emma, described in an earlier article as “the most difficult client she has ever had to treat”

Rodis responded to this, “Let us look into this case in more detail and talk about the skills required when working with patients and clients diagnosed with Borderline Personality Disorder.” Prior to delving into these skills, we started to explore the reasons why it is crucial to possess them. We described three reasons why, from the perspective of the patient and client (see above cited article for details). And in this current article, I am going to outline, from the clinician’s perspective, 3 reasons why for acquiring the skills for working with patients and clients suffering from Borderline Personality Disorder.

Clinician and Advocate perspective

Strong countertransference

“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. “This sounds very frustrating, and patients and clients, like Emma, can bring up lots of emotions in us,” said Rodis, in a low tone of voice. “What type of feeling would you say you have been experiencing in your work with Emma, so far?” added Rodis.

“She reminds 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 and always gets into trouble and expects me to bail her out,” responded Leila, with increasing intensity in her tone of voice.

“Lots of emotions and lots of feelings are stirred when working with patients and clients suffering from Borderline Personality Disorder; they may evoke all forms of countertransference, and they often remind us of many of our past and present relationships. And this may complicate things, unless we closely monitor the whole dynamic,” stated Rodis.

Transference and countertransference are essential aspects of any therapeutic relationship. And, as it is well known, patients and clients suffering from Borderline Personality Disorder have a profound fear of abandonment, which they often exhibit in the, “I will leave you first” phenomenon, at the slightest perception that they may become less important, less loved, or less cared for in a relationship. The clinician is not spared from this coping mechanism, which is often characterized by rejection or dismissal of any type of recommendations made in treatment, and that can simply engender additional strong feelings in us, clinicians, against our patients and clients. “Countertransference is inevitable, but how we use and respond to it is crucial and is part of the essential skills for working with this population.

Draining propensity

“Sometimes I feel like her dumping ground. Two nights ago, I was out for dinner, she called, I did not pick up, and she left a voicemail, stating she was suicidal. When I called back, she was screaming and crying on the phone, explaining how Joel, her boyfriend, had not shown up for dinner and was not returning her calls or text messages. Emma thought he had just left her. She then went on and on until the text messages from Joel started again, and she ended the call with me. I feel drained,” said Leila. This was one of her most recent events with Emma, and Leila was, indeed, drained.

A lack of purpose and direction in treatment has been one of the factors contributing to feeling drained when working with patients and clients suffering from Borderline Personality Disorder. “This draining propensity is rather common; it adds to negative countertransference and leads to clinician resistance to working with these patients and clients,” said Rodis. “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.

Splitting ability

One of the cognitive and emotional challenges for patients and clients who suffer from Borderline Personality Disorder is their inability to tolerate thoughts, alternatives, beliefs, or feelings that seem to be opposite to each other. “You are different. You take time to listen to me. You do not rush me, and I don’t think you would ever abandon me,” Emma articulated these words to Leila after a prior statement regarding her previous therapist. “My previous therapist, whom I trusted, ended up abandoning me.”

“After she started telling me how different I was, it took her only a few weeks before I became ‘just like her previous therapist.’ She even once told me that I was worse, but she was still coming to the clinic only because she thought she still had the best psychiatrist ever. Now, I am back to being her best therapist because the psychiatrist has not been willing to add that sixth medication that she has been asking for,” Leila explained. Splitting is very frequent in these groups of patients and clients, and it can also be a trap even for the best-experienced clinician.

“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. “Let us look into this case in more detail, and talk about the skills required when working with patients and clients diagnosed with Borderline Personality Disorder,” explained Rodis.

Prior to learning the skills, exploring the reasons why of the skills helps put things into context and helps prepare the terrain for a successful implementation. Strong Countertransference, Draining Propensity, and Splitting Ability are the three reasons why it is crucial for us as clinicians to learn and master the skills for working with patients and clients suffering from Borderline Personality Disorder. We have been called to serve, to make a difference, and to do no harm. But without the right skills, we may unknowingly and unintentionally be causing harm to our patients and clients. Mastering the required skills is therefore essential and agreeing on the why of mastering them is also crucial, if we are to lay a strong groundwork for successful implementation.

References

1. Gabbard GO, Wilkinson SM: Management of Countertransference With Borderline Patients. Washington, DC, American Psychiatric Press, 1994.

2. Horwitz L, Gabbard GO, Allen JG: Borderline Personality Disorder: Tailoring the Psychotherapy to the Patient. Washington, DC, American Psychiatric Press, 1996.

3. Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993.

4. Waldinger RJ: Intensive psychodynamic therapy with borderline patients: An overview. Am J Psychiatry 1987; 144:267–274.

5. Stevenson J, Meares R: An outcome study of psychotherapy for patients with borderline personality disorder. Am J Psychiatry 1992; 149:358–362.

6. Boyer LB: Working with a borderline patient. Psychoanal Q 1977; 46:386–424.

7. Grotstein JS: The analysis of a borderline patient, in Technical Factors in the Treatment of the Severely Disturbed Patient. Edited by Giovacchini PL, Boyer LB. New York, Jason Aronson, 1982, pp 261–288.

8. Masterson JF: Psychotherapy of the Borderline Adult: A Developmental Approach. New York, Brunner/Mazel, 1976.

9. Masterson JF: The Personality Disorders: A New Look at the Developmental Self and Object Relations Approach. Phoenix, Ariz, Zeig, Tucker, 2000.

10. Meares R: Metaphor of Play: Disruption and Restoration in the Borderline Experience. Northvale, NJ, Jason Aronson, 1993.