The Misunderstood Borderline Personality Disordered Client
> 2/21/2006 12:10:46 PM

For years the Axis II, Psychiatric diagnosis of Borderline Personality Disorder (BPDO) has been one that often strikes fear and negative reactions in clinicians of all disciplines. Clients who enter treatment previously diagnosed as Borderline, or exhibit the characteristics of the Borderline client, have been labeled as difficult patients who are draining, challenging, emotionally volatile, manipulative and unpredictable. Many clinicians refuse to treat patients who have been previously diagnosed with this disorder or who appear to exhibit the major characteristics of the disorder. For the Borderline client, failed psychotherapy is another example of disappointment, rejection and loss of relationship.

Clinicians complain that these patients are “exhausting, “defensive,” “mean,” “insatiable,” “prone to drug, alcohol and food addictions,” and are even “dangerous.” While outbursts of verbal or physical anger, cutting, suicidal threats, ideation and para-suicidal behaviors are often seen as symptoms of this disorder, the typical Borderline client is fundamentally a person with a very fragile ego who perceives the world as a dangerous place which is full of rejection, abandonment, criticism and disappointment. It is only when a borderline client senses (real or imagined) abandonment/rejection that they may become irrational and therefore reactive.

In treating hundreds of clients with Borderline Personality Disorder over the years, ranging from mild to severe on the continuum, I have come to see that this is a segment of the mental health seeking population which has been unfairly labeled, generalized and catastrophized in such a way that it greatly interferes with their ability to get good treatment and the much needed relief of positive results.

The favorite excuse among clinicians as to why this segment of the population receives little effective treatment is that it is the patient who sabotages the treatment. While I would agree that this can be true in a percentage of cases, I argue that a resolute, experienced clinician, who is without preconceived negative associations and stereotypes about this disorder, can successfully engage and treat these clients with excellent results if he or she has some basic understanding, engagement skills and essential tools.

Basic Understanding: Most patients with BPDO are suffering greatly and want to feel better emotionally (reduce mood swings, anxiety and depressive symptoms), improve their relationships (intimate, friendships and employment) and their self-control (decrease or arrest reactive acting out behaviors and impulsive actions).

Patients with BPDO feel very alone in the world and are poised for rejection and disappointment in most interpersonal relationships. These patients suffer with highly uncomfortable psychic and physical states and are ultimately seeking love, acceptance and inclusion, but tragically their symptoms and behaviors are counterproductive to their goals and needs

Engagement Skills: Initially, as with all clients, the engagement process is crucial. The BPDO client must be made to feel secure, safe and understood by the clinician. Once a client is sufficiently engaged, the clinician may begin to discuss with the patient their underlying fears of rejection and abandonment as a main theme in their lives. The clinician can illustrate their understanding of the client’s suffering and symptom otology and help the client to see how rejection and abandonment have played central roles in their lives from an early age. A clinician who expresses that he or she understands the physical anxiety, obsessive thoughts and empty feelings plaguing the client creates a connection and engagement which can promote trust and allow for further exploration and even confrontation of the client.

A clinician can then help a client to see that their actions and frantic attempts which are employed with the goal of avoiding abandonment are counterproductive to their true goal, of feeling loved and included.

Essential Tool #1: Benign interpretation is an essential tool in treating the BPDO client. Clients with BPDO tend not to interpret things as benign, but instead as quite malignant and a threat to their existence, inclusion or value. A well engaged BPDO client will be able to see that he or she cannot trust their interpretations. Clients who are well engaged and aware of their abandonment issues can start to restructure their cognitions by employing benign interpretation. Benign interpretation is the practice of interpreting things in the simplest, easiest and nicest way possible.

Example: A client’s boyfriend usually calls her every workday morning but today he has failed to call and it is 1pm. The client’s initial interpretation may be that the boyfriend is mad at her, no longer values her, has forgotten about her, or worse, that he no longer loves her and has moved on. The benign interpretation would be that he was busy at work, got stuck in a meeting, and will call as soon as he is able etc.

The more the BPDO client can practice benign interpretation the sooner he or she will see that it is much more accurate than their initial defensive interpretation. The client will also see that avoiding reactions to malignant interpretations will help them avoid unnecessary conflicts which may lead to real loss or abandonment. Slowly the client is able to recognize that their faulty interpretations, which lead to unnecessary actions/reactions, are the catalyst to their emotional and interpersonal declines.

Essential Tool #2: Externalization is a suggested method of treatment where the client is asked to externalize their symptoms and attempt to defy their past negative behavior patterns and interpretations. Externalization is useful with these clients because they can visualize fighting against their symptoms and behavior patterns without getting angry at themselves and becoming even more depressed, hopeless or desperate. Utilizing externalization does not release the client of their responsibility for their actions or symptoms but it does allow the client to see the problems as an entity that wreaks havoc on their lives and against which they can do battle without destroying themselves.

Example: A patient who acts to sabotage their relationship by continuously being negative, jealous, suspicious or even verbally attacking their partner begins to believe that they are a bad person who does mean things to the people they love. By employing externalization, the patient is able to look at the negative behaviors and see the destructive impact, yet instead of getting angry at themselves (and therefore more depressed and prone to acting out) the patient can harness their anger and get mad at their behaviors and reactions, and by doing so see their behaviors/reactions as bad as opposed to concluding that they themselves are bad. Externalization is an effective way of positively utilizing anger to defeat negative behaviors without destroying the self. Externalization is not a way to excuse behaviors or divert blame but a way to fight against symptoms without destroying the already fragile self.

Borderline Personality Disordered clients are a greatly misunderstood, avoided and neglected segment of persons seeking psychiatric help. Removing the preconceptions and prejudices widely held by mental health clinicians and empowering them with the understanding and tools necessary for successful treatment of Borderline Personality Disorder is essential to the progress of treating this disorder.

Although treatment of BPDO can be challenging and difficult endeavor (for both clinician and patient), improving understanding of the disorder, decreasing misconceptions about the disorder and enhancing effective treatment tools are the essential three elements to positive results and progress.

Suggested Further Reading

NIMH's BPDO webpage

Interview with Otto Kernberg

Severe Personality Disorders: Psychoterapeutic Strategies


I like the empathy of your post. I also like that you use the word "client" rather than the clinical term "patient."
Posted by: CindyG 2/22/2006 11:31:47 AM

Hello and Thank you for placing this information on the web. Wow I don't really know what to say except bulls-eye. I have BPDO i was diagnosed several years ago. I never went back. I was told there was nothing could be done. Since then I have gone from one bad relationship to the next. In the end I never really know who's fault it was but always suspect it was me. I fight depression and rejection everyday. So I became a salesperson then after years of selling rejection I had a breakdown after the death of my father. I have been a call girl ever since. It is easier for me. No rejection, no dissappointment. Recently, I have been trying to get back into the real world but I always feel as if everything will be gone at any moment.I am always terrified of being rejected so I hang out with the rejects but mostly I am alone.I never really know how to live only how to act.I guess I shall get a book on this since I cannot afford a Drs help. I can only afford enough time to get my script and go. Sometimes it is too hard and I cry. Sometimes I am happy but I am afarid it won't last.What a bummer, eh?Anyway thanks for the free help. It matters.Madeline
Posted by: madeline 2/1/2008 7:24:01 AM

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