Studies show that up to 20% of all hospitalizations for psychiatric reasons are diagnosed as Borderline Personality Disorder. In layman's terms, they have a nervous breakdown. Anyone who works in the mental health profession will sooner or later come across the Borderline Personality Disorder and the experience will often leave the new therapist baffled and confused, and hungry, even desperate, for more knowledge about the disorder.
The Diagnosis of Borderline Personality Disorder
A full clinical diagnosis of Borderline Personality Disorder can be found in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. The disorder is thought to originate in early childhood. They are often young females with a history of abuse, but not always. Typically they are tormented by disturbed moods most often associated with disturbances in relationships. Their sense of self is quite thin or lacking altogether; in fact one of the questions I ask in diagnosing this disorder is “How would you describe yourself?” The question makes them squirm. Their answer is rambling or often simply, “I don’t know.” It may even make them angry.
Anger is well known to the Borderline, and the therapist will soon understand the intense frustration and overwhelming rage of a person who must endure so much rejection and self-loathing, much of it brought about by their patterns of behavior, making for a very sad situation that can even be frightening to friends, family and even therapists. In fact, the diagnosis came to be named “Borderline” because the patient was thought to be at the borderline of insanity. Indeed, Borderlines can become so distraught that they may experience periodic breakdowns that may require hospitalization until they are stable.
The Typical Pattern of the Client/Therapist Relationship
The inexperienced therapist will often find themselves eager to help these clients, typically a young female, who often presents with self abuse, suicidal ideation, incidents of drug and/or alcohol abuse, issues around sexual identity or promiscuity, and very often reports a history of mistreatment by others. These clients scream vulnerability, their emotions are highly unstable and close to the surface, they tend to be guilt-ridden, and they often display very little insight regarding the high drama played out in their lives or that they are most often causing it. Our hearts go out to them. They are attractive in their suffering. They are intense as people and their intensity excites the therapist.
The client is initially eager to please the therapist. They have found a new savior, and the relationship develops like any friendship. The therapist becomes caught up in their desire to do good, to help, and the case seems simple and straightforward. But as the therapist draws the inevitable boundaries, the client becomes disappointed and unruly. The client will tend to test the therapist in ways that the therapist is bound to fail. This failure proves to the client that the therapist is no better than all those other people who have failed them. Now the therapist realizes that they are being caught up in the very drama they wish to treat and their first reaction is fear and confusion as to what to do. The therapist feels they have been tricked or turned on for no good reason. That attractive intensity now seems draining, even frightening.
The Beginning of Therapy is the Recognition of Transference
But this is when the therapy can begin, for now the therapist has experienced the very transference that will guide the treatment. The thing to do is to engage the client in examining the therapeutic relationship, gently in order to avoid more layers of anger and confusion. The therapist must carefully explain to the client the differences of a client/therapist relationship, explaining boundaries, and expectations of therapy, even dynamics of the therapy if the client is psychologically sophisticated. The therapist must explain how their therapeutic relationship is similar to other relationships experienced by the client. Combined with this is the examination of how relationships in the past and present may be similar in their dynamics, showing connections and exposing the truth. The client must be taught that their emotions over real and perceived trauma can be tolerated as emotions arise in therapy, while taking a rational view of what is actually happening. The therapist must also be capable of sitting with and enduring this emotional labyrinth.
Projection and the Borderline Personality Disorder
Borderlines are difficult to work with because they are not only extremely defensive but tend to attribute harsh or damaging words, actions and behaviors onto other people without any basis. This is called projection, whereby words, actions and behaviors of people in the past are projected onto people in the present without any foundation in reality; they are seeing attacks, even instigating them, where there are none. Reality is distorted; even time may be distorted. Confronting these projections is an extremely difficult undertaking and so do not be surprised if the client vociferously rejects such observations by the therapist; they may become quite angry with the therapist for siding with the accused.
Much depends on the ability of the therapist to help the client overcome their projections onto the therapist as they help the client to accept and understand that this process of projecting is part of their illness. Then both can explore how to recognize when projection is taking place and find ways in which to mitigate and/or overcome it. All of this is quite taxing on the nerves of both parties, requiring a trusting relationship with the therapist and much courage on the part of the client to work through intense anger and frustration.
A Difficult and Long-Term Teaching Process
Working together in a trusting relationship is something the Borderline is not accustomed to, and they are initially surprised and confused over not being rejected by the therapist, often in spite of their efforts to make the therapist reject them. But they soon learn there is a price to pay for this acceptance, and that is looking at their relationships with a clearer vision, giving up and taking responsibility for certain patterns of behavior, and tolerating unsettling emotions without overreacting to them. Reinforcement and praise from the therapist over the smallest success is extremely important.
In time, sometimes a very long time, as the therapist can expect rough periods where no progress or even regression takes place, the client will begin to understand that the therapist is only trying to help them. This is very difficult for the therapist as well, and issues of abandonment will often crop up, especially when the therapist is perceived as too harsh. This reminds the therapist that the Borderline’s sense of connectivity to others is very frail. Even so, the same issues will come up again and again and the therapist must be able to tactfully point these out without becoming frustrated or impatient.
Unfortunately, some Borderlines will have to go through a number of therapists before they are willing to tolerate this process of gaining insight and taking responsibility. Fortunately, their symptoms tend to mellow as they mature. There may also be times when the client may need to be prescribed medication to help them cope during difficult periods, therefore it is important to have a working relationship with a psychiatrist who well understands your case.
Never easy, always challenging, the Borderline Personality Disorder will test any therapist's skills to the utmost. But through knowledge, empathy and persistence, therapeutic efforts will pay off in time. These insights and tips are based upon my own practice in the field and should not be considered the last word on the subject. Research is ongoing into this disorder and the practitioner should apprise themselves of the latest knowledge base.
The reader may also enjoy Beware the Narcissitic Personality Disorder, Therapy and Transference with Personality Disorders and/or How to Utilize Uncertainty in the Practice of Psychotherapy.
Michael Winston - Author of 4 exciting historical fiction novels that depict various aspects of the American Revolution: "Independent Action" and "Uprising" ...
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