Reader’s Clinical Conundrum

“Dr. Jack, one thing that makes me stress and feel guilty and incompetent is working with patients who have borderline PD, either diagnosed or with some of its features. I have one patient in particular who I ‘dread’ seeing. When I see she is on my schedule for that day, I get a sick feeling in my stomach. Even if her appointment is in the afternoon, I stress about it all day long. At the same time I feel ridiculous for being so stressed, but seem stuck in some sort of dark loop. I tell myself it will be fine, that I have nothing to fear – it’s not like she is physically intimidating or anything like that – but I find that all this self-talk just increases my thinking about her.

“I’ve been seeing her about once a month for close to two years. It seems like my negative feelings about her have been increasing. I feel resentful which leads to feeling guilty. I try to get over my stress and fail which leads to feeling incompetent and not in control.

“You asked for particulars. Here are some – 1. She always seems to bring up a topic at the very end, with a couple of minutes left, that suggests she may hurt herself or perhaps go off on other people. Usually, it makes my appt time run over by 5-15 minutes 2. She has this condescending attitude towards me that makes me feel like I’m an undertrained idiot. For example, at the last visit after I gave her some specific recommendation she said, ‘If you had any sense you know that wouldn’t work. I’ve tried that many times already which you would know if you were paying attention.’ 3. And even though she is so condescending, she’s also clingy and tells me I’m the only person she can trust.  I’m so exhausted by this. I would appreciate any advice you have. Thanks.” – Anonymous

Jack’s Response

Dear Reader,

Thanks for sharing your clinical conundrum. You’ve painted a compelling portrait that gives a lot to go on. First, know that you are not alone in your stress, frustration, feelings of incompetence, lack of control, and guilt. I’m glad we’re getting this out in the open because many people are feeling or have felt this way at some point with patients with a similar profile. Let me now get into specific ways of thinking about and handling (both proactively and reactively) patients like this. I’ll start by highlighting some aspects of BPD. I won’t repeat DSM-5 criteria but rather focus on aspects that may increase our intuitive and empathic understanding of people with BPD. Then I’ll share recommendations based on what you wrote and what I touched on in my BPD portrait.

Features of BPD

  • Broken Self: Persons with BPD have undergone invalidating experiences during development. Often these experiences were frankly physically or sexually abusive but at times were limited to a pattern of psychological invalidation. One of my patients, a highly intelligent and creative person, grew up in a large family led by parents who saw the world as a tough unforgiving place. They raised their kids to be tough, stand up for themselves, never show emotion, and especially to show no sign of weakness. They heavily criticized their kids when they deviated from this standard. My patient was the most sensitive of the bunch and often became the focus of the parents’ and siblings’ ridicule and rejection. In effect, she came to personify all that they hated and rejected. She felt alone and received no succor.If you listen long enough to a person with BPD, they will eventually share with you that they feel they are “bad” (or a close synonym), in the sense of being broken or unworthy, or of being immoral or evil.  They will also often share that they feel empty, almost as if their inner self doesn’t exist. One patient told me she feels like her “middle or insides are missing.” She was not delusional but rather tried to convey a mental and physical sensation that was with her as far back as she could remember. Another told me that her thoughts felt like they were floating in space, not really a part of herself.
  • Affective Instability: Persons with BPD often experience strong emotions they feel they can’t control and, instead, often feel they are controlled by. Varied triggers can arouse strong emotions of anger, at times manifested as homicidal rage, of sadness, at times manifested as suicidal despair, and of anxiety, at times manifested as existential fear and dread. Many of these individuals did not have the opportunity to learn to understand and identify their emotions and the triggers of emotions, nor to modulate their emotions once they arose. One patient told me that the only emotion she was allowed to display at home was “cheerifulness,” and this at a time she was repeatedly sexually abused by her father, with her mother’s complicity.
  • Limited self-soothing: Individuals with BPD move through the world beset by powerful emotions they often don’t understand and cannot control, and their ability to self-sooth is limited. They, thus, turn to drugs and to various acting out activities in their search for distraction and self-soothing. Some will engage in non-suicidal self-injurious behaviors, some in compulsive sex, some in violence or high-risk activities that may result in death because the powerful adrenaline rush temporarily overcomes their chronic dysphoria. During medical school I dated a doctor who had borderline features. (This was before I understood anything about this.) I was surprised when I first entered her apartment and saw she had a very large blown-up image of her medical school diploma on the wall opposite her front door. When I mentioned my surprise, she said the image helped to remind her each time she came home after work that she was a doctor, someone doing something good. She needed that concrete reminder because that sense of meaning and self-worth was hard to maintain within herself. (Perhaps needless to say, our relationship was stormy and didn’t last.)
  • Radical insecurity / fear of abandonment: Because of all these invalidating experiences and resulting deficits, persons with BPD often feel very vulnerable. They unsurprisingly often have low trust in others, fear being again abused or otherwise invalidated, have limited self-soothing skills, and often feel whipped by powerful emotions. This leaves them with a dilemma: they both desire to have a close trusting relationship and to fear one. If they are left all alone, they dread some terrible outcome, some form of annihilation or a ceasing to be. At the same time, when in a relationship, they fear being not only being abused by their partner but destroyed by them. The way it helps me to think about this is to imagine the patient as a small child who fears both being all alone in the world and equally fears being destroyed by their abuser. These individuals’ tragedy is that there is no safe space, there is no respite, there is no coming home from the storm.

Given what I’ve written, it is astounding and astoundingly good that persons with BPD can be helped; they can recover. They may never be whole, but they can find a way to live with greater control, safety, meaning and purpose, and a modicum of comfort and joy. They can find a way to have relationships with people that may not be ideal from our points of view, but that can bring them some degree of closeness and support.

Now let’s consider how a clinician can act to make their relationship not only less tumultuous for the clinician and patient, but also therapeutic, a demonstration of a relationship that works in the context of all of the patient’s deficits and difficulties.

  • Maintain a Professional and Learning Mindset: It always helped me to remind myself that the patient’s acting out, and displays of anger, disappointment, or condescension were not personal. The patient was stuck in a drama that played out every day and with everyone they met. I just happened to be the current player on their stage. It also helped me tremendously when I decided one day to learn from my most difficult patients. In all my years of practice and all the many psychiatric conditions I’ve treated, the patients I have absolutely learned the most from were my patients with BPD. I realized they are no different in kind from any of the rest of us; they differ in degree. We all can react with irritation or anger when invalidated, dislike being all alone, don’t always trust other people’s intentions, are surprised by the power of our emotions, etc. So, I decided that I was going to learn from every interaction with my patients, try hard to understand what triggered them and why, and figure out how my speech and actions helped or hurt the patient or did neither. After all these years, I feel genuine gratitude for having these opportunities to understand human nature better. And last, it also helped me to remind myself of the humanity of these difficult-to-get-along-with people. They are much more than their psychopathology.
  • Maintain Boundaries: Because of these patients’ twin fears of being abandoned and of being swallowed up, patients with BPD do best in a relationship that maintains clear professional boundaries. It’s easy to start making exceptions for these patients; they’re desperate and hurting people. It’s easy to stay late or come in on a day you were going to take off or allow them to run into your next appointment time because they (yet again) came in late. The problem is you are eroding those boundaries that are there to protect the two of you. It’s a smaller step than you think between agreeing to see a patient on a Saturday morning and then agreeing to an invitation “to get a bite to eat.” And it’s only a step from there until all hell breaks loose.
  • Maintain Structure in Your Sessions: All appointments have start and end times. They start with certain tasks. The focus at the start should be on life-threatening and treatment interfering behaviors that have occurred since the last appointment. That includes addressing NSSIB, suicide-related thoughts and behaviors, missed appointments, and acting out behaviors in the clinic. You can say something like, “I know these may be difficult topics to talk about but they are the most important. I want to make sure we don’t leave them until the end and then run out of time to discuss them adequately.”
  • Responding to Provocations: An important area to maintain boundaries and structure is to make clear that intimidating, insulting, or threatening speech or behaviors are not permitted. Set the parameters right from the start. When the patient oversteps, address it; nip it in the bud. You can do it in a way to minimize embarrassing or humiliating the patient. One way to raise the topic is by saying, “You know, I noticed you [fill in the behavior]. For example, “I noticed you made a comment about me that has sexual connotations. It is not unusual that different feelings come up when working with a [doctor, therapist, etc] including sexual ones at times. What we have between us is an important relationship but it is a professional one and it is important we keep it that way.” The doctor asking for the consultation wrote that the patient was condescending towards her. Use the same reflecting technique, “I noticed that you said that if I had any sense, I would have known that what I suggested wouldn’t have worked. You also questioned whether I had been paying attention to you. You were clearly irritated with me at that moment. Could you tell me more about what brought up those feelings for you?”
  • Engage with the Patient: People with BPD have an incredible radar for invalidating interactions and when they notice it in you they WILL call you out on it. This has been very helpful to me by teaching me when I’m insensitive or acting in bad faith. I recommend 1) minimizing making assumptions about them and what want and instead ask them, 2) solicit their thoughts on what they believe will help them and give them shared ownership of the treatment, 3) apologize if and when you make a mistake or lack sensitivity in your interaction. Some of my most therapeutic and simple interventions with patients with BPD was apologizing to them when I was in the wrong. For example, you mentioned the patient being angry about not paying attention. Well, maybe she was right or partially right. Who can maintain full attention over a full workday? If you did indeed miss something, own up to it and move on.
  • Be Open and Realistic: Make sure you share the diagnosis of BPD with the patient. Explain it to them. Don’t hide it nor sugar coat it. When talking with the patient alone or with family, be forthright in the risks of self-injury and suicide. Say it’s a challenging condition and that’s why it’s important to work together. Ensure you have informed consent to call appropriate family, S.O., or friends if there is evidence patient is at risk or drops from treatment without a plan.
  • Develop a Safety Plan: This is not a safety contract. A safety plan is a LIST of what to do in a crisis (or just hard times) in order to de-escalate and keep safe. Who can the patient call when in crisis? What can they do? The list can have 4, 7, or 10 stepwise interventions. The plan should be typed out and always with the patient. At the bottom of the list is always call 911 or go to ER.

There is a lot to say about BPD. If you have other advice, questions, or scenarios to share, just write back.

Dr. Jack


Today’s Quotes

“Living is a process of developing oneself. Without experiencing pain from disconcerting periods of our lives, we would be different person, perhaps a lesser person.”
Kilroy J. Oldster

“Have no fear of perfection – you’ll never reach it.”
Salvador Dali

“Success is stumbling from failure to failure with no loss of enthusiasm.”
Winston S. Churchill