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Challenges of Working with Borderline Personality Disorder

M. Gerard Fromm, PhD, ABPP|
September 4, 2015

Borderline Personality Disorder: A Conversation with M. Gerard Fromm, PhD, ABPP

When it comes to borderline patients, what are the challenges for the therapist and the staff?
The big challenge is survival. You have to survive in your role. With people who are so passionate and so chaotic, the intensity of feeling toward the person who is supposed to help is dramatic and overwhelming. Often, in outpatient settings, these therapies become an endless series of managing crises. Very commonly, a borderline person is so distressed at the end of the hour that the therapist will agree to call later in the evening or see them later in the day. Pretty soon, you've devolved into almost an emergency room way of thinking, a 24-hour availability. But, in order to really be of help, therapy has to have a stable, reliable structure, and that gets easily undermined when borderline storms occur. So therapy never gets down to the person's inner experience, how they grew up, what their real troubles are. To some extent, avoiding that more unknown pain is a function of the acting out in the first place.
Of course, with every patient, a therapist has to negotiate boundaries. But for a borderline person, the risks are especially acute. The invitation to call the therapist - or to come again for an extra session - excites a feeling that, "I won't have to be alone. I have a person who will love me." And in the background of course there is the inner sense that, "Nobody can really love me because I have so much hate in me."
We see many patients at Riggs who are here because a therapy went very badly awry - not necessary a full boundary violation, but a relationship that slipped into chronicity and futility. Often, in early assessments, someone with a borderline trouble brings a false demeanor. They're on their best behavior. So you start a therapy without knowing what you're getting into. Then something goes wrong, and they need an extra session. And then another. The therapist sees it's too much, but doesn't know what to do. And sometimes they just go with it. But more becomes much less. There is an escalation of the craziness but nothing useful happens. It's as though the therapist is supposed to meet every need, and of course, they can't and shouldn't.
If one person in the patient’s life has become so important that you’re going to feel so devastated when they leave you, you’re always in danger of destroying the relationship you most need, as these escalations often do. In therapy, that’s transference — transferring to the present something about the critical relational moments from your past. We’re fortunate here in that the intensity has a chance of being managed through the clinical team. Eventually, if things go well, the feelings do get centered on the therapist, but the therapist must have help with this. For a while, the intensity of the transference can be distributed — to the nurse, who bridges the gap between therapy sessions and manages troubles between peers; to the internist, who manages the patient’s physical health; to the patient community. And the patient’s psychopharmacologist is also helping to take the edge off of the most intense feelings. So you have many people bearing bits of the feeling, and the patient begins to feel safe. The eggs are not in one basket, so to speak, and if one part of the human environment is endangered by the patient’s intensity, there is always another, who can help both the patient and the other staff member.
Therapists need this support, or else you wind up with too much intensity inside you and, meanwhile, you need to be looking at the situation clearly, not only in terms of the patient’s past but in terms of what you might have done to precipitate an attack or outburst. The potential demand from the patient can seem so unrealistic, even outrageous, that there can be a tendency in both people to write it off as simply craziness, but that is never the real deal. The real learning comes from finding what might have actually happened between patient and therapist that ignited the patient’s attack and that might relate to failures in the patient’s early relationship life.
Basically the challenge of a borderline person comes in depending on somebody — with all that that brings up, the hunger, the anxiety, the anger and the deep mistrust as to whether you can actually put your weight on the other person’s reliability. This kind of trouble challenges both people to try to sit with painful feelings, to try to put them into words. Primarily it’s the challenge of depending on somebody, somebody you can’t control. That’s where the stability of the structure and of the therapist plays a huge role.
And the therapist needs people around him to stay stable himself, because it’s going to be a passionate piece of work and a very interesting one. Many patients like this are very appealing. They’re often quite passionate people. They feel things strongly — that’s part of the problem but also part of the potential. If those feelings can be gotten hold of and sorted out, this person can bring a lot of life.
This six-part series, exploring borderline personality disorder, is taken from an interview, conducted by former Erikson Scholar Joshua Wolf Shenk in 2009, with M. Gerard Fromm, PhD, ABPP, a senior consultant to the Erikson Institute for Education and Research at the Austen Riggs Center.