The Therapist and the Borderline; doing therapy with an Axis II Disorder

Most of the therapists I know do not want to work with Axis II disorders. They find them very resistant to treatment and very emotionally exhausting for the therapist. Among these Axis II disorders is what we call Borderline Personality Disorder, BPD.

Probably the most outstanding characteristic of someone with BPD is emotional volatility. One minute this person idealizes you and tells you that you are their anchor and that they are happy, successful, capable, even alive, because you are in their life. They credit your impact on them as making them successful in all facets of their life. Almost immediately and without warning, these same individuals will turn on you in a very Dr. Jekell/Mr. Hyde way to attack you with their negativity. They tell you that you are nothing, you have failed them, you are inadequate and uncaring and they cannot depend on you. They say that you hate them and you are trying to destroy them.

Therapists find this type of attitude swing within a session or a conversation to be very disruptive and difficult to deal with. Now, imagine having this individual in your personal life. Without the training that a therapist has, how would you deal with someone who goes back and forth like this from very loving, almost idealizing you to someone who attacks you with vicious emotional rage? Would you end the relationship? Would you work to appease them so that you don’t have to be afraid of their anger? Would you just give them whatever they want because you don’t have the energy or resources to “guess” which one of them you will see and you just want peace?

I have probably spent as much of the last thirty years doing therapy with friends and families of people with BPD as I have with people that were diagnosed with BPD. All of them are a challenge. In the abstract, it is very easy to have compassion and understanding for the individual stricken with this disorder. In the specific moment, it is hard to keep your boundaries in place and work with them in an intentional and ultimately therapeutic or beneficial way because they are such an emotional rollercoaster.

The basic underlying issue for people with borderline personality disorder is that they have a chronic and constant fear of abandonment. They experience waves of anxiety whenever they perceive any distancing by the people to whom they have anchored themselves. It can be the end of the therapy hour, the end of a “friendly” dinner date, a friend going on a vacation for a week, someone not answering their phone call whenever or why-ever they call. When these individuals become aware that you are not there for them (accurately or inaccurately) they panic and their panic causes them to rage. They attack, either you or themselves. They frequently self-mutilate and they threaten suicide. Eight to ten percent of them actually do commit suicide. Many of them do some kind of self-mutilation, such as cutting.

As a therapist, or a family member, you may not see this coming. You do not anticipate it because you are just going about your life. Maybe it is time for your vacation. Perhaps your mother is ill, and you need to spend a few days taking care of her and are not available for your borderline friend/neighbor. The paradox is that the borderline can show empathy, compassion and support for you, but there is an unstated expectation that whenever they need you, you will drop everything and be there for them no matter what is going on in your life. If you fail them in this, then they will rage at you and attack you because you have abandoned them. You have been the unfaithful friend or lover. You have not returned their affection and furthermore, it is because you know at your core that they are really bad people. How dare you think that they are bad? They have done nothing wrong, they have only loved and cared for you and been a good friend. Why can’t you stop being selfish long enough to do just one little thing for them. What an ungrateful, unlikeable, unworthy friend you are, after all they have done. They are not bad, you are bad, and they won’t love you any more. Even when you understand that this outburst is not about you, it can be difficult to listen to.

When a person with BPD is in the throes of this emotional cycle, they will act out in some form. Often they do something very risky like have unsafe, inappropriate sex with someone, or gamble or drive recklessly (if no one really loves them and they have an accident and die, then surely God must have wanted this for them!) Fortunately, these episodes usually only last a few hours, or a few days at most. Then the mood swings almost like a pendulum and they are happy and friendly again. They will come back to you as if nothing ever happened and be very seductive in their loving friendship. It takes you on a real rollercoaster ride.

As a therapist, you will get phone calls to your answering machine so that they can hear your voice. They usually do not leave a message, they just need to hear your voice. They have difficulty remembering that you are real. By the time they get in their car to go home after a session, they already need assurance that you are real and they really had a session with you. They will write long, emotional rants between sessions pouring out their hearts about whatever fears and anxieties they have. They will rage on paper against whomever their focus is on and whomever they fear the loss of. The general rule of thumb for these notes is not to open them. Save them for the next session and then invite the client to open and read it to you so you can talk to them about their feelings as they read it. They will hate this and attack you for it, but it is the way to establish and keep the therapeutic boundary.

We do not know why this disorder happens, the good news is that many people who are diagnosed with this disorder when they are young adults actually evolve out of it in their late thirties or early forties, and become no longer diagnosable with this label. The bad news is that it is so difficult to work with and care about them while they are on this journey because the emotional volatility is just such a strain for most people. The challenge for the therapist is to keep good boundaries. Work with the borderline is always and most importantly about boundaries. These individuals constantly push the envelope in an attempt to get inside your defenses. They will figure out what car you drive and park next to it. They will drive by your house and then later comment on your flowers or your children at play. They will memorize your office and know if a picture is out of alignment or has been changed. They read the same books you do so that they can talk about them to you. They learn when you have breaks and want the appointment on the front end of the break so they can squeeze a few extra minutes. They want the last appointment of the day so that they can “walk to the car” with you. They are constantly pushing for some sign that they are not “just a client” to you, but they are special. They need to know that they are different and you care more about them than you do your “real clients.” This is seductive and stressful. You have to learn how to respond to this and when you tell them, “No, I can’t walk to the car with you I have some work to do and some calls to make,” be prepared for their anger and their rage. You will get calls and letters about how inhumane you are and how you are a ‘paid friend’ who really does not care about them. They will assault you with their anger. When the pendulum has swung just far enough that they fear you will stop seeing them, they will have a crisis and need you. They will overwhelm you with gifts, both tangible and gifts of their affection. They will try to seduce you into not abandoning them. The individual with this disorder does not have the ability to trust that you are real, that they have not just imagined you, and that you care about them. They fear your loss. They rage about that and punish you for it, even before it happens. What is going on clinically is that they are setting up a situation where there will be an opportunity (justly deserved) for you to fire them and thereby reenact their abandonment by the object (historically the mother) and prove once again that they are unworthy and doomed in their relationships, but that it is really not their fault.

Your job (should you accept it before the tape self-destructs) is to have boundaries, be consistent, be genuine, and respond to them with caring accuracy. You must articulate your boundaries with love and gentleness in the face of their hostility. You must refuse their gifts. Do not let them be the first client of the day and bring you coffee and doughnuts. Do not let them be the client scheduled before your lunch break who has a crisis where you have to stay through your lunch and be with them. Do not let them walk you to the car at the end of the day and do not let them call you with suicidal ideations in the middle of your night or during your child’s birthday party. They will do all these things.

Once you know you are working with a borderline case, you have to emphasize boundaries. You have to be conscious of them, you must articulate them and you must defend them against a very subtle and consistently strategic assault. This is hard work, but it is worthwhile. These people can change over time and get better. It is truly a blessing to be able to take that journey with them and watch them heal. When they grow in their ability to be in relationships because their self-identity is stronger and more safely grounded, there is incredible satisfaction and humility for the therapist. This is a very difficult population to treat and many therapists do not have the stamina or the characterological orientation to work with this population. If you choose to work with this population, please do the work because it is worthwhile and gratifying for you and life-saving for your clients.

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One Response to The Therapist and the Borderline; doing therapy with an Axis II Disorder

  1. melissa cook says:

    Lovely article. Very well written!I work with borderlines and your article validated what I do.

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