Skills for Working with Clients with Borderline Personality Disorder: 2 Commandments
“This is the most difficult client I have ever had to treat. She calls me multiple times a day, at any time, expecting me to just pick up. I don’t know what to do anymore.” Leila was quite irritated, as she articulated these words to Rodis, the consultant to the HOPE Clinic.
This was our first introduction to Leila and her client, in the first of our article series on Working with Clients with Borderline Personality Disorder. "Let us look into this case in more detail and talk about the skills required when working with patients and clients who are diagnosed with Borderline Personality Disorder,” responded Rodis.
Prior to looking into the skills required to working with patients and clients suffering from Borderline Personality Disorder, we have explored the reasons why it is crucial to possess these skills. We delved into these reasons from the perspective of our patients or clients, our clinicians, and that of our agencies and the system, as a whole. We have described a total of nine reasons:
Need to be understood
Victim and subject of biases
Successful integration of care
For further reading, see the previous articles in this series entitled;
During her work with Emma, Leila has been reacting instead of responding, which has been adding to her challenges of working with someone suffering from Borderline Personality Disorder.
Strong and negative countertransference has been evoked, in addition to projective identification (“I don’t know what to do anymore”), and Leila has been feeling drained and experiencing burnout. “However, it does not need to be this way. There are well established skills for working effectively with this population, and we will learn them, together,” added Rodis.
There are 10 Commandments to follow when working with patients and clients suffering from Borderline Personality Disorder. Below are the first two:
Remain stable and prevent burnout
“Sometimes I feel like her dumping ground… I feel drained,” uttered Leila, who has been feeling overwhelmed and experiencing burnout; she has had little guidance prior to Rodis consulting at the Hope Care Center. Remaining stable means keeping our judgments in check, staying away from projecting our own values, and refraining from enacting our patient’s and client’s unconscious wishes for rejection. Remaining stable also means seeking guidance and supervision regarding our feelings and emotions, ensuring we understand our countertransference and using it positively and for the benefit of our patients or clients. “She just reminded me of my sister, who rarely answers my calls, yet expects me to pick up as soon as she calls, even when it is two in the morning. She is so demanding, always getting into trouble and expects me to bail her out,” stated Leila, with increasing intensity in her tone of voice, responding to Rodis’ question, “What type of feeling would you say you have been experiencing in your work with Emma, so far?”
Preventing burnout is accomplished by remaining stable, by mastering the skills required to effectively work with this population, and by having access and taking advantage of the emotional support offered through co-workers, supervisors, and the agency and system, as a whole. An article-series have been dedicated to the topic of preventing burnout and promoting self-care. (For further reading on this, see: Preventing Burnout: Self-care for Clinicians and Advocates).
When supervising clinicians, I often hear the hesitation about either making a diagnosis or educating patients and clients with regards to Borderline Personality Disorder. It starts with proper symptom contextualization, using a bio-psycho-social and cultural based approach, conducting a proper diagnostic and differential diagnostic formulation, clarifying the comorbidities, and reconciling your formulation with the explanatory model of illness from your patients and clients. All this entails proper collateral information, an effective and comprehensive mental health assessment (See articles series entitled, New Strategies for Mental Health Assessment), and maintaining a holistic view of your patient and client.
Once you have done all of this, you should feel confident explaining to your patient and client his or her likely diagnosis and what this means for them, both in the short and long-term. As a principle, as you psycho-educate, always remember to first find out what your patient and client may already know. From there, you should proceed and talk about available treatment, the risks and benefits associated with each, and the different options, including the success rate for each. You ought also to discuss the duration and stages of treatment and the possible consequences, and what he or she may expect during the duration of treatment.
“This is the most difficult client I have ever had to treat…I don’t know what to do anymore.” Leila was quite irritated, as she initially articulated these feelings. With guidance and support, she subsequently changed to, “Thank you, Rodis, I feel I now have a roadmap to work with Emma.”
Rodis has been meeting with Leila, going over the 10 Commandments of Working with Clients with Borderline Personality Disorder, the principles, the techniques, the Do’s and Don’ts of working with this patient population. With these new strategies, one can go from unknowingly or unintentionally doing harm to guiding one’s patients and clients towards full recovery that they all deserve.
For more in this series of articles, check below!
Dr. Sidor is quadruple board certified in psychiatry, with board certification in General adult, Child and adolescent, Addiction, and Forensic, psychiatry. He also has additional training in public psychiatry, in several treatment modalities, in addition to his teaching, supervision, mentorship, coaching, and management, experience. Some of his passions are public speaking, leadership, entrepreneurship, and research, in addition to program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the past-Medical Director for CASES (Center for Alternative Sentencing and employment Services), and he speaks and writes fluently in six (4) languages—French, English, Spanish, Creole, and has intermediate proficiency in Portuguese and Italian.
American Psychiatric Association: Practice Guideline for Psychiatric Evaluation of Adults. Am J Psychiatry 1995; 152 (Nov suppl).
Sederer LI, Ellison J, Keyes C: Guidelines for prescribing psychiatrists in consultative, collaborative, and supervisory relationships. Psychiatr Serv 1998; 49:1197–1202.
Bateman A, Fonagy P: Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. Am J Psychiatry 1999; 156:1563–1569.
Waldinger RJ: Intensive psychodynamic therapy with borderline patients: An overview. Am J Psychiatry 1987; 144:267–274.
Beck AT, Freeman AM: Cognitive Therapy of Personality Disorders. New York, Guilford, 1990.
Rinsley DB: Developmental Pathogenesis and Treatment of Borderline and Narcissistic Personalities. Northvale, NJ, Jason Aronson, 1989.
Searles HF: My Work With Borderline Patients. Northvale, NJ, Jason Aronson, 1986.
Stone MH: The Borderline Syndromes: Constitution, Personality, and Adaptation. New York, McGraw-Hill, 1980.
Seeman M, Edwardes-Evans B: Marital therapy with borderline patients: Is it beneficial? J Clin Psychiatry 1979; 40:308–312.
Shapiro ER: Family dynamics and borderline personality disorder, in Handbook of Borderline Disorders. Edited by Silver D, Rosenbluth M. Madison, Conn, International Universities Press, 1992, pp 471–493.
Siever LJ, Trestman R: The serotonin system and aggressive personality disorder. Int Clin Psychopharmacol 1993; 8:33–39.
Soloff PH, George A, Nathan RS, Schulz PM: Characterizing depression in borderline patients. J Clin Psychiatry 1987; 48:155–157
Paris J, Zweig-Frank H: Dissociation in patients with borderline personality disorder (letter). Am J Psychiatry 1997; 154:137–138.