Ten Erroneous Therapist Beliefs, Ten Optimistic Therapist Beliefs, and Ten Hopeful Patient Beliefs in Treating Borderline Personality Disorder

When I first meet with a patient who, somewhere along the path of life has been diagnosed with borderline personality disorder (BPD), my heart goes out to them and to their family. Before I learn the details of their unique family history and what has brought them into my office, I know that they have suffered a great deal. They have suffered as their family has tried o make sense of this seemingly incomprehensible disorder. They have suffered as they have tried to meet the demands of school, work, or societal roles. They have sometimes even suffered at the hands of fellow mental health professionals, who have, with good intention, attempted to treat the patient’s Axis I presenting problems, but lacked the experience or awareness of the force and drive of the Axis II subterrain – the infrastructure underlying many Axis I diagnoses. Most of all – these good people have long suffered in their own minds, hearts, and souls – struggling to understand who they are, and why they are the way they are.

The most sobering and cutting description of BPD that I have ever seen is not contained within the DSM-IV list of diagnostic criteria. It actually is spoken about one of the main characters in a Jonathan Kellerman novel, “Silent Partner”:

“The borderline patient is a therapist’s nightmare…because borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology. At first glance, they look normal, sometimes even supernormal, holding down high- pressure jobs and excelling. But they walk a constant tightrope between madness and sanity, unable to form relationships, incapable of achieving insight, never free from a deep, corroding sense of worthlessness and rage that spills over, inevitably, into self-destruction. They’re the chronically depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed-hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench sitters with arms stitched up like footballs and psychic wounds that can never be sutured. Their egos are as fragile as spun sugar, like a jigsaw puzzle with crucial pieces missing. They play roles with alacrity, excel at being anyone but themselves, crave intimacy but repel it when they find it. Some of them gravitate towards stage or screen; others do their acting in more subtle ways.

No one knows how or why a borderline becomes a borderline. The Freudians claim it’s due to emotional deprivation during the first two years of life; the biochemical engineers blame faulty wiring. Neither school claims to be able to help them much.

Borderlines go from therapist to therapist, hoping to fine a magic bullet for their crushing feelings of emptiness. They turn to chemical bullets, gobble tranquiliers and antidepressants, alcohol and cocaine. Embrace gurus and heaven-hucksters, ant charismatic creep promise a quick fix of the pain. And they end up taking temporary vacations in psychiatric wards and prison cells, emerge looking good, raining everyone’s hopes. Until the next letdown, real or imagined, the next excursion into self-damage.

What they don’t do is change.

When encountering such an individual, in real life or as a therapist, one immediately registers that this individual is very different – even more so than the average person who has encountered their fair share of conflicts on the road of life. In my professional training in the early 1970s, I was taught that borderlines were not treatable, that they did not get better, and that they only sucked the life blood out of the best intentioned therapist. It was common practice to hear from my supervisors back then that if a therapist decided to treat a BPD patient, than only one patient at a time should be treated in a single practice. Needless to say, as I began my own practice in 1987, there was a certain amount of conditioned fear that I experienced when encountering a young person who seemed to fit most or all of the DSM-IV criteria. The negative schemas that plagued me back then included most, if not all of the following:

1. 1. I will burn out if I decide to treat BPD.
2. I will run up my malpractice premiums and face denial of insurance.
3. I will not be able to manage the never-ending demands of my patients.
4. I will not have the necessary skill set to treat this population.
5. I will not have sufficient support to deal with all of the conflicts my patients bring to my door.
6. My borderline patients will take over my practice and leave insufficient time for my other patients.
7. Sooner or later, I will be the subject of a lawsuit.
8. What would I hope to gain from attempting treatment with such a difficult population?
9. Would the effort be worth the emotional cost, to the patient or to myself?
10. Does my attraction to working with this population really tap into sort of underlying need on my part to play the hero and save the damsel in distress, so to speak?

Fortunately, much has changed over the past forty years. With the seminal work of Marsha Linehan and the genesis of Dialectical Behavior Therapy, Jeff Young’s groundbreaking contributions in the field of schema therapy, and Jon Kabat-Zinn’s revolution in the introduction of mindfulness to the Western world of psychotherapy, therapists today need not fear the diagnosis of BPD. While it is true that treating this population may require a different skill set than required in treating non-BPs, there is also the good news that they DO get better, that they CAN lead productive lives, and that those therapists who decide to treat them WILL – with determination and a great deal of patience – be able to witness positive change and good therapy outcomes over time.

As a cognitive therapist by training, and as a student of mindfulness in recent years, there is a certain set of beliefs that has helped me in treating my BPD patients with the respect and care that they deserve. This list is a work in progress, and I welcome the wisdom and life experiences of those therapists who have done this work for many years in adding to this list. The more optimistic outlook that I carry with me into my work with borderline patients today includes the following:

1. Before you treat a patient thought to meet criteria forBPD, make certain that the diagnosis is accurate. BPD sometimes can be the wastebasket diagnosis du jour, especially within an adolescent population, but it may not be so. On the other hand, with all respect to the DSM-IV, it has been my experience that younger adolescents may meet full criteria for a diagnosis of BPD and should be treated. Do not be afraid to use the diagnosis and begin to educate parents early on.
2. Explain to patients that the treatment protocol of BPD does not so much mean we are ascending a mountain seeking to make them perfect, so much as we are seeking the path to make them whole once again.
3. Expect phone calls during moments of crisis – sometimes more than one in a day. This is normal with BPD patients, but may be their first step in avoiding self-injury. Keep your expectations reasonable and expect setbacks. They are part of the learning process. Treating BPD is an educational process that involves the teaching of more skillful behaviors. We all have very different learning curves when acquiring new skills.
4. Do not internalize the inevitable anger that patients will direct towards you. Find a good support group of colleagues or become involved in DBT training which will make peer supervision a part of the treatment protocol.
5. Remember that in BPD more than in any other diagnosis, make time and seek permission from the patient to work with individual or multiple family members, or significant others. They are hurting too and more than likely seeking more effective means to heal and better the relationship with the patient.
6. Remember to use your liability plan wisely. If you encounter a situation where your patient is non-compliant beyond reason, consult with your plan advisor to take necessary steps to protect yourself and your patient. Dr. Eric Harrris of the American Psychological Association Trust Risk Management Plan is an excellent resource for patient management with this population.
7. More than with the average patient that you treat, develop a means for allowing yourself the time to re-energize. A daily meditation practice will work wonders, and will be a lifestyle that you may teach and model for your patients.
8. Become a student of Buddhist psychology. The teachings of the Buddha will not challenge you to step away from your own faith, if you have one. Rather, the teachings will enhance your faith, and give you a set of practices gleaned from a 2500 year-old tradition that may have an extraordinary impact on how you as a therapist teach about human suffering and how to overcome it. I would highly recommend our colleagues Jack Kornfield, Tara Brach, and Mark Epstein as three wonderful teachers.
9. Success will never be defined as a defined end-point in working with BPD patients.

Success will be defined, as so eloquently defined by Marsha Linehan, in helping to restore our patients’ lives to lives worth living.

Finally, I offer a new set of hopeful beliefs to BPD patients themselves:

1. You are NOT your diagnosis. You are a human being first and foremost and you are never defined by the diagnostic traits of BPD. These are a shorthand means for therapists to communicate and describe a style of personality more than a physical diagnosis like cancer.
2. You can get better and manifest less of these traits with proper treatment.
3. If you take the time to learn where this came from and how it developed in your life, you will shed the guilt and the blame and accept the cards that life has dealt you so that you can move on with your head held high.
4. Allow yourself to nurture the spiritual side of yourself, however you define this. There is more inside of you that is healing than in any bottle of prescription meds.
5. See your therapist as a guide. A good guide knows the way but may occasionally become lost too.
6. Do not be afraid to step out into your community and offer your support, your skills, and your caring. In helping others, you may find the secret to healing yourself. For all that your emotional vulnerability may have been a source of hurt in the past, may it now serve as a source of strength now in your recovery to assist the hurt of fellow travelers.
7. Remember that those who have accuse you of being a master manipulator could not understand that all you were really trying to do was survive a world that you did not always understand. Forgive them.
8. Get used to the uncertainty of life, but take heart in that we know more about how to help you than the rest of the world may believe. Let them believe what they like. You just need to stick with your plan.
9. Remember that a hospital may help to stabilize you if needed, but it will not be a place you need to visit any longer for the most part.
10. Always remind yourself that in the end, it will all have been worth it.