When your practice situation permits, it’s appropriate to inform the patient that you charge for after hours phone contacts as well as for extended phone contacts during office hours. These are professional services which the patient should expect to pay for, just as you would expect to pay for the furnace man to come and relight your burner on a cold winter’s night. Offering unlimited free support at all hours of the day or night is a recipe for therapist burnout and for a major betrayal of the patient’s trust, because you will not be able to keep it up, and a burned-out therapist is both unhappy and dangerous.
Since many of you work for not-for-profit agencies, let me take a moment here to disparage certain dysfunctional attitudes that seem to pervade such organizations. You probably went into this sort of work because you enjoy helping people, and you feel real compassion for those less fortunate. These traits make you willing to work long hours for low pay, and your professional reputation depends on your willingness to go the extra mile for your clients. When an entire organization is staffed from top to bottom with professionals who share the value of self-sacrifice, there’s an opportunity for the best intentions to lead to the worst outcomes.
Not only does your borderline patient need to see that relationships can have limits and still be rewarding, she also needs to believe that she can survive on her own adult resources in this world. The therapist who can’t limit the patient in her quest for constant reassurance is saying, “Yes, you really are just as incompetent as you feel!”
The most challenging aspect of therapy with BPD is knowing how to set and enforce limits. This is a matter of therapeutic art, and cannot be taught in a lecture or manual. We all make errors in judgement when it comes to enforcing limits and providing optimal levels of support in therapy. More experienced therapists are less likely to make these errors, and should be sought as mentors by less experienced therapists. Therapeutic technique is not perfectible, only subject to endless improvement. Borderlines are those patients who show us where we have room to grow in our technical skills.
Important areas for limit setting in BPD:
1. rules for outside contacts
2. abusive behavior in sessions
3. client must agree to attend one more session before quitting (implies no impulsive suicide)
4. missed sessions must be planned (charging for no-shows and late cancels, except in extraordinary circumstances, is good for the patient)
5. patient must contact therapist before destructive acting out
6. “If you make me hospitalize you involuntarily, I won’t work with you after discharge”
Note that the threatened loss of the therapeutic relationship, once established, is the most potent adverse consequence available.
Dealing with the borderline in crisis:
a. find out what mode they’re in and respond appropriately
b. increase visits, even a few minutes every other day can help
c. assess suicidality: plan, intent, timetable, available means, any steps taken, past history, substance abuse
d. get permission to talk to significant others and arrange increased support
e. consult with another professional and document it
f. consider referral for medical therapy
g. consider day hospital or support group
h. consider brief hospitalization
If you’re interested in a more complete protocol for the treatment of BPD, and one with some actual outcome research to recommend it, you should look at two books published in 1993 by Guilford Press, both written by Marsha M Linehan: Cognitive-Behavioral Treatment of Borderline Personality Disorder, and Skills Training Manual for Treating Borderline Personality Disorder. Linehan’s method is briefly outlined in Guilford’s Clinical Handbook of Psychological Disorders.
Linehan calls her method Dialectical Behavior Therapy, because she emphasizes training the patient to abandon simplistic ways of thinking. She correctly points out that reality is complex and multifaceted, and that we all have to deal with situations involving conflicting and ambiguous data. An overall therapeutic goal of Linehan is to teach the patient to avoid rigid thinking and extreme behavior.
Linehan emphasizes that the therapist must respond hierarchically to the many challenges presented by borderlines. Suicidal behaviors have the highest priority for therapist attention, followed by therapy-interfering behaviors, then quality-of-life interfering behaviors. Important behavioral skills taught in Linehan’s method:
1. distress tolerance (desensitization, using the therapist to reduce anxiety)
2. emotion regulation (including affect identification and management)
3. interpersonal effectiveness (conflict resolution and empathy)
4. self-management (learning how to increase chances of success in meeting ones goals)
5. mindfulness (non-judgmental awareness)
These skills can be taught in individual sessions, but it’s more cost-effective to offer weekly didactic groups to teach basic skills while the individual therapy focuses on the problem areas most relevant to the particular patient.
Both Linehan and Young, in common with most therapists who work with trauma survivors, delay dealing with traumatic memories until the patient has sufficient trust in herself and in the therapist to withstand the high levels of emotional arousal that commonly accompany a focus on past trauma. It may require many months of preparation before a patient can reliably resist self-destructive impulses, maintain a stable lifestyle, and show significant progress in the basic skills addressed in Linehan’s Stage I.
Skillful treatment of PTSD is a complex, challenging, and contentious area. The basic goals are:
1. remembering and accepting the facts of earlier traumatic events, or learning to live with perpetual uncertainty about what actually happened; and
2. reducing stigmatization and self-blame
Arthur Freeman chairs the psychology department at the Philadelphia College of Osteopathic Medicine and also directs the Cognitive Therapy Training Program at the Adler School of Professional Psychology in Chicago. Among his many relevant publications is a book called Cognitive Therapy of Borderline Personality Disorder.
At a recent symposium on BPD, Dr. Freeman gave some pointers on here-and-now focus in the treatment of PTSD. In his view, “The preferred intervention is the least intensive, least extensive, least intrusive, and least costly alternative that will provide what the patient requires at that time.”
Focusing on Cognitive treatment of intrusive recollections and flashbacks, Freeman suggests the therapist’s initial focus should be on assisting the patient to precisely characterize the experience so as to make it more concrete and less eerie for the patient. He asks for
1. A complete description of the thoughts or perceptions which constitute the episode;
2. Identification of anything in the current life situation which may have triggered the episode, with specificity as to the particular aspect of the current situation which was a trigger;
3. A description of emotions, thoughts, sensations, and behaviors which followed the episode.
Dr. Freeman’s approach shares with the majority of therapists working in this area the basic technique of converting emotions into words, which seems to assist the patient in gaining a sense of mastery over the strong emotions involved. He also encourages journaling for this purpose, and teaches relaxation and imagery as tools for self-soothing.
Traumatic nightmares are handled similarly to flashbacks; writing down the nightmare upon arousal is useful because some of the most important images will not be remembered the next day. Freeman emphasizes reinforcing the patient for gaining control over the intrusive recollections.
With reference to the specific problem of flashbacks which occur during sexual activity, Dr. Freeman suggests that sexual activity be interrupted until both partners are comfortable with its resumption; to close one’s eyes and wait for him to finish would tend to reinforce dissociation through reenactment of the trauma. Communication with the partner about what’s happening is encouraged, as is asking for the partner’s support. The patient can also train herself to pay attention to important differences between the current partner and the original perpetrator, including both differences in appearance and differences in the quality of the relationship. In some cases, the partner may need professional assistance to become more comfortable with the patient’s special needs; in others, the problem in need of attention may be the patient’s inappropriate choice of partner.
Linehan’s third stage puts appropriate focus on the patient learning how to maintain improvement without so much help from the therapist. Goals of this stage are:
1. non-defensive self-appraisal that will resist unreasonable attacks on one’s self-esteem; and,
2. trust in one’s ability to cope with stress.
In her discussion of telephone contacts between sessions, Linehan emphasizes the need to repair the relationship. Borderline patients often experience delayed emotional reactions to something the therapist said or did during a session. Often, the next call after a session relates in some way to such a delayed reaction. The therapists’s ability to accurately hear the underlying concern and to respond with empathy can substantially improve the chances for the patient to stay in therapy. Arthur Freeman suggests that each session end with an invitation for the patient to give the therapist some feedback, thus reducing the probability of rumination and after hours phone calls.
Linehan characterizes the skillful therapist as “able to balance a high degree of nurturing with benevolent demanding.” This is one of a number of paradoxical elements of the therapy situation to which she refers in her writing. Others are
a. Clients are free to choose their own behavior, but they cannot stay in therapy if they do not work at changing their behavior.
b. Clients are taught to achieve greater independence by becoming more skilled at asking for help from others.
c. Clients have a right to kill themselves, but if they ever convince the therapist that suicide is imminent they may be locked up
d. Clients are not responsible for being the way they are, but they are responsible for what they become
Such paradoxical elements can be presented to a patient at the appropriate time and in an appropriate manner, to stimulate reflection and to help the patient move beyond simplistic thinking. Linehan also recommends skillful use of metaphor, stories, parables, and myth in therapy. These techniques require a certain literary bent and much skill to apply; their strength is that they circumvent the patient’s logical resistance to new ways of thinking about the world.
Another advanced therapeutic technique recommended by Linehan, and applicable in any therapy, is to take the patient’s absurd position and logically extend it until even the patient sees the absurdity. This has to be done with exquisite sensitivity or the patient will feel mocked. Two examples cited by Linehan are:
1. The patient would rather die than gain weight; if being dead is preferable to being overweight, the overweight therapist is within reason to offer to join the patient in a suicide pact.
2. The patient will kill herself if the therapist won’t see her immediately; the therapist expresses great anxiety and offers to call an ambulance so the patient can be hospitalized for her own protection.
These are tricky techniques, in which the therapist both joins with the patient and proposes a therapeutic ordeal.
Linehan’s method, like Young’s, emphasizes the therapeutic relationship as the ultimate reinforcer of patient behavior. It is essential that the therapist pay a lot of attention to the patient’s progress and minimize attention to negative behaviors. The therapist may find herself in a dilemma when it comes to responding adequately to the patient’s self-destructive behaviors without reinforcing them. It may be helpful to frankly share this dilemma with the patient.
In her discussion of limit-setting, Linehan stresses that the therapist must understand the limits of his or her own tolerance for the patient’s bad behavior, and clearly communicate this information to the patient. “Therapists who do not do this will eventually burn out, terminate therapy, or otherwise harm the client.” She suggests the therapist be frank and unapologetic about some limits being for the good of the therapist.
Linehan chooses to instruct her patients that cognitive distortions are frequently a consequence of emotional arousal. This is a departure from a purely cognitive framework, in which dysfunctional cognitions are seen as the cause of turbulent emotion. None the less, Linehan shares with therapists all the way back to Sigmund Freud the basic idea that pausing for rational analysis is better than allowing one’s rawest emotions to govern one’s behavior. She also shares with most mainstream therapists a preference for techniques which encourage the patient to desensitize herself to the fear of emotion by repeatedly experiencing these emotions in the therapy sessions while the therapist assists her to delay any behavioral response.
In her discussion of therapist style, Linehan suggests that the therapist’s negative emotional reactions to the patient can be used to educate the patient about her impact on others. For example, “When you demand warmth from me, it pushes me away and makes it harder to be warm.” I’m a bit uncomfortable with this intervention because it contains embedded YOU statements: “you demand… you push me away….” A more authentic statement might be, “Sometimes I feel more distant from you at the very times when I sense you wanting me to show warmth to you. I wonder if others around you sometimes have the same response, and if there’s anything you could do differently to increase the chances of getting the response you want.”
Linehan also recommends the therapist try to stay in a consultant-to-the-client role, except when the patient is clearly overwhelmed. This helps to avoid infantilizing the patient, and also helps the therapist to avoid being sucked into confrontation with others over what’s “best” for the patient.
It’s important to remember that you can’t save every patient, especially the chronically suicidal ones, without locking them up for several years at a time. This means that if you don’t have the strength to bear the loss of an occasional patient to suicide, even the ones you really care about, you shouldn’t be in this business.
When you do lose one, it should be a learning opportunity. You as therapist should insist on case consultations from consultants chosen for their expertise rather than for friendship. This process is scary, but also uniquely growth promoting.
CONCLUDING REMARKS:
In summary, Borderline Personality Disorder is one of the most challenging entities for today’s therapist; in fact, this category originated as a repository for patients who fail to improve with ordinary treatment methods and whose particular pathology is most likely to provoke a negative emotional reaction in the therapist. Comfort and effectiveness in the treatment of BPD implies mastery both of one’s own emotions and of therapeutic techniques in general. It is not realistic to expect success in every case, and successful treatments are usually long and stormy.
Borderlines ARE treatable. Linehan’s study of 44 severely affected women, treated over one year with either Dialectical Behavior Therapy or “treatment as usual”, showed an attrition rate of only 17%, with reductions in frequency and severity of self-injury, and fewer hospital days for the patients treated with DBT. A second study showed improvements in anger management, social adjustment, work performance, and anxiety with DBT. These results were maintained at 6 and 12 month follow-ups. The original study was published in the Archives of General Psychiatry, vol 48(1991) pp 1060 ff.
The major open question is whether current restrictions on payment for psychotherapy will permit many borderlines to have effective treatment. No satisfactory brief therapy for BPD has been reported. In many settings, the best we can hope for is to deal with a series of crises in ways that may have a favorable cumulative impact on the patient. We must assist borderline patients to get their emotional needs met without their having to resort to grossly self-destructive behavior. The current tendency to provide acute medical treatment and outpatient referral rather than inpatient admission, and to keep inpatient stays very short, may actually be helpful in this regard, because it avoids reinforcing the patient’s dysfunctional behavior.