Dealing with borderline patients

[grapefruit17]

---

Members do not see this ad.

Any tips? I work super hard in my program. Currenrly on inpatient psych. I get a good feeling when I help my manics stabilize somewhat, or when I improve family dynamics for the older post stroke pt with signs of dementia.

But man, dealing with this one patient has been a bit painful. She has a formal dx of borderline and even without knowning that it was very easy to see she was borderline given how vague her story was, and how she would change parts of it often. Not too mention several other things..

How do you guys approach the borderline patients with multiple "suicide attempts"?

 

[Nasrudin]

I'm assuming you know what transference/counter-transference is... but if not. This is your introduction to it as an embodied and witnessed phenomenon embedded in your question. Also... vagueness and migration of self-narrative do not serve formulation of Borderline character structure in an of themselves, but if you mean difficulty reflecting on and making sense of internal states and volatility of self-states then yes.

The thing you might think of is. This thing that I'm feeling with this patient. What does it mean? Does this person elicit this type of reaction from other relationships outside the therapeutic one? And in that way... you take a step towards understanding your relationship with this patient as being important for modeling, problem solving, formulating, and hopefully changing the way this patient relates to all of the people in their life. You have to stay centered. The patient's pull for you to react in uncomfortable or hostile ways can be looked at as a terrible state of being in which they do not have reprieve from and have sadly learned that dramatic interplay is relating in some confused way. How would you like to be them? Perpetually confused by your interactions with people. Oscillating between anger and fear of abandonment.

So you have to model an impassive, higher form of relating. Calm, reassuring. Supporting, affirming, but not caught up in dramatic interplay with them. Let them hate you, overly identify with you, overly attach to you, hate you again, all manner of erratic confused, emotionally charged self-states. And you buddha like. Constant. Even tempered. Helping them cycle through emotional self-states in less and less intense ways.

If you hate them. Perhaps you're too attached to the notion of being loved or looked up to by your patients in the first place. Or.. perhaps you've had a bad experience with someone in the past that they recall you to and invite you to inhabit again. Whatever the case may be.

The importance of your understanding of your own internal states cannot be underestimated. But don't despair. There is a kung-fu of dealing with this sort of patient and other sorts that you learn by doing. Which you are...

It does help to be given proper training in those arts though. My program rotates us through several months of a personality disorder clinic which I think was invaluable. I'm going back this year to advance to brown belt status, after 6 months of co-leading a DBT group in my outpatient year. So.. it takes time. And patience... lots of patience. haha.

 

[Shikima]

They need to be directed to IOP/PHP rather than inpatient. Better outcomes as the quality of therapy is leaps better.
It's not about medications for that group - skills over pills.

And don't make the mistake to think you can medicate the symptoms and reactionary behaviors out of the person. You'll end up with more side effects than progress.

 

[thoffen]

I think the title sums it up. It is not really dealing with the patients, though. On paper treating them is not hard. Not full of hope often, but given a clinical narrative I have faith you'll come up with a good answer. The real problem is dealing with your feelings. And the answer is get supervision. But also keep in mind that those feelings are very much an expected and important product of the treatment and unavoidable. Yes countertransference is the correct label, but more specifically these feelings are likely a product of projective identification. If you can appreciate that the likely scenario is that this degree of intense instability, anger, and lack of trust in self control and external environment are what your patient feels all the time, and that such projective identification defense is the best their ego can do in the moment, perhaps you can generate a little empathy.

That notwithstanding, sometimes such behavior is not due to more severe dysregulation and instead more of an exploitative narcissistic dynamic or consciously directed for primary or secondary gain. And those are very much different in understanding and approach to treatment.

 

[grapefruit17]

A lot of wise and helpful insight here. Thanks!

 

[OldPsychDoc]

Remember that they didn't ask to be that way...these primitive defense mechanisms are just them doing the best they can to cope. They can learn better ways...eventually. Be patient and don't take $h1t personally.

 

[smalltownpsych]

The advice of staying centered and resisting the pushes and pulls is spot on. Just to clarify though, it doesn't mean being detached or distant or avoidant of emotional response. The challenge is to be able to respond genuinely and modulate your own emotional reactions. The emotional intensity of the rage, the fear, the hopelessness of this damaged personality has to be mirrored in a modulated way or we just become one more invalidating object.

One favorite example of a poor interaction with a patient with Borderline was seeing her hitting herself, the wall, tears flowing, and screaming in rage all after a typical interpersonal conflict and saying in a calm and detached voice, "You seem pretty angry right now. " Her response was a sarcastic and caustic, "No ****". Main reason I was so far off was because I was a bit nervous already because I was responding to my own need to "fix the situation" and be the hero since the staff had come looking for me to do something to descalate the situation and I was the boss.

Don't get me wrong, I still enjoy being the hero and it is good to have the mastery and skills to deescalate an angry patient with Borderline or an agitated and paranoid patient with schizophrenia or get a resistant patient with addiction to shift. I think that is where the real challenges of this profession lie and that part is so much harder than coming up with a DSM label and administering a sedative or hoping that a new medication will "fix it" either.

 

[randomdoc1]

Trust me, there is hope. I have seen DBT work. It takes time, it takes patience, it can seem unrelenting. But overtime, many patients with borderline personality disorder even reach a point where they experience remission of symptoms and that is incredibly rewarding. But yes, the countertransference some cases can create out of us is legendary.

 

[MacDonaldTriad]

I'm not anti-DBT, but it does have a lot of requirements that can exclude something like half of those who need it. You will still need to gain experience with more insight oriented approaches with these patients. I wonder if someone looked at doing traditional therapy with a group of patients with BPD who meet all of the same commitment and attendance requirements DBT needs, if outcomes would be that different. I have seen impressive results with DBT, but it remains true that patients with BPD are never doing as well as you think when they are doing well, and they are never doing as poorly as you think when they are doing poorly.

 

[Shikima]

I'm not anti-DBT, but it does have a lot of requirements that can exclude something like half of those who need it. You will still need to gain experience with more insight oriented approaches with these patients. I wonder if someone looked at doing traditional therapy with a group of patients with BPD who meet all of the same commitment and attendance requirements DBT needs, if outcomes would be that different. I have seen impressive results with DBT, but it remains true that patients with BPD are never doing as well as you think when they are doing well, and they are never doing as poorly as you think when they are doing poorly.

To make the study super effective, it should be designed as a randomized, double-blind study.

 

[thoffen]

To make the study super effective, it should be designed as a randomized, double-blind study.

How could a therapy provider be blinded to what kind of therapy they are providing? (Or patient for that matter...)

 

[Shikima]

How could a therapy provider be blinded to what kind of therapy they are providing? (Or patient for that matter...)

A joke?

 

[smalltownpsych]

I'm not anti-DBT, but it does have a lot of requirements that can exclude something like half of those who need it. You will still need to gain experience with more insight oriented approaches with these patients. I wonder if someone looked at doing traditional therapy with a group of patients with BPD who meet all of the same commitment and attendance requirements DBT needs, if outcomes would be that different. I have seen impressive results with DBT, but it remains true that patients with BPD are never doing as well as you think when they are doing well, and they are never doing as poorly as you think when they are doing poorly.

Agreed about the requirements being beyond what can typically be applied in most settings. Just wanted to clarify that DBT as designed and conducted by Dr. Linehan in her studies includes insight oriented therapy in addition to the skills component. She also contends that most standard psychotherapeutic approaches suffice to provide the therapy component so long as the psychotherapeutic frame is adhered to. Adherence to the frame is probably a key component and is also found in Kernbergs tranference focused psychotherapy. I think that corresponds to what you are stating.

 

[NickNaylor]

And don't make the mistake to think you can medicate the symptoms and reactionary behaviors out of the person. You'll end up with more side effects than progress.

What, you doubt the "borderline quadfecta" of antipsychotic, mood stabilizer, benzo, and antidepressant?

I find your lack of faith... disturbing.

 

[smalltownpsych]

What, you doubt the "borderline quadfecta" of antipsychotic, mood stabilizer, benzo, and antidepressant?

I find your lack of faith... disturbing.

I think you missed their attention and focusing problems. 😛

 

[MacDonaldTriad]

Agreed about the requirements being beyond what can typically be applied in most settings. Just wanted to clarify that DBT as designed and conducted by Dr. Linehan in her studies includes insight oriented therapy in addition to the skills component. She also contends that most standard psychotherapeutic approaches suffice to provide the therapy component so long as the psychotherapeutic frame is adhered to. Adherence to the frame is probably a key component and is also found in Kernbergs tranference focused psychotherapy. I think that corresponds to what you are stating.

I agree, you are just much more articulate than I am. You hint at the bottom line of any therapy framework. The patient has to trust you and want to please you enough to get better. Now given the volumes of books written about this, I might be oversimplifying a bit but maybe not as much as you think.