Treating patients with BPD: Do’s and Dont’s between therapist and client –
With Borderline patients being some of the most challenging and complex to treat, an extensive knowledge of the disorder and how it manifests is essential. Without this a therapist is likely to cause more damage than benefit to someone struggling with BPD, especially as it is within this therapeutic relationship, where many core issues will arise, that a significant bulk of the healing can occur. If a therapist is unaware of how the disorder presents and is ineffective in their approach, it can lead to the further complex trauma, for example in relation to issues of trust, abandonment and blame.
A core issue with Borderline patients is that of boundaries and related struggles. I am yet to meet an individual with BPD who hasn’t experienced some sort of major difficulty around boundaries in some way, and usually from an early age. It is therefore essential that a therapist treating Borderline clients is vigilant and consistent in their boundaries – and that these boundaries are clear from the get-go. Remember that this client-therapist relationship could very well be the first relationship an individual has experienced which has (or at least has the potential to have) those healthy and necessary boundaries. This consistency and rigidity, though perhaps challenging at first, will actually lead to an increased sense of safety and trust from a client to their therapist, especially over prolonged periods of time.
Boundaries within a therapeutic context can also be as much for the therapist as they are for the client. With attachment difficulties rife amongst the Borderline population, and themes such as internet stalking and information seeking a common occurrence, these boundaries remain as much a protection for the therapist as they are a necessity for the client. It is not the therapist’s job to rescue or fix a client, as much as a client may provoke or evoke this reaction. Boundaries help lead to long-term empowerment for the client as they learn to meet their own needs and take care of themselves. To be a part of this journey with them and to extend oneself in this way is an act of kindness and dedication in and of itself as a therapist. As a therapist, remember that it is possible to show empathy and genuine care and concern towards a client whilst maintaining an appropriate level of personal detachment through the implementation of such boundaries.
Consistency & structure –
If a therapist works according to a specific structured approach, as one does within the realm of DBT, it is generally advisable to not stray from this structure. It can be understandably challenging not to become swayed by a client’s mood, momentary experiences, or perhaps even fall into enabling their resistance. However, in doing so, a message is relayed to the client that their emotional and mental experiences have the power to alter their environment and those around them; essentially providing evidence that their emotions are in control of them and the people around them, and not the other way around. It is essential that a therapist shows their client that they are able to deal with whatever it is that is being experienced by their client, and maintaining a structured and consistent approach that is unswayed by momentary difficulties, (whilst simultaneously working with current presenting issues), is a key way of showing this.
Sharing responsibility and role determining –
The work done between a client and therapist relies on a two-way relationship. Both client and therapist will have their own expectations and responsibilities within the relationship. If a therapist takes too much responsibility for a client’s recovery, they are taking away from the client the tool of empowerment which may otherwise encourage a sustained remission. Conversely, if a therapist puts too much responsibility onto a client and puts little investment in of their own, it is unlikely the proposed expectations will be realistically achievable for the client to manage alone. The relationship and process needs to remain collaborative in order to lead to healthy and lasting changes. Both client and therapist need to pull their weight, and any ambiguity spoken about as soon as it arises.
Falling into reassurance-seeking traps –
“Are you angry with me?”, “Have I disappointed you?”, “I’m too much for you to deal with”, “Everybody hates me” – These are just some familiar things a BPD client will ask or state especially within a therapeutic relationship. Much of the time the intention of these statements is for reassurance-seeking purposes. In my opinion, even though it has been very difficult for me when on the receiving end, the most beneficial approach to take is to answer the client’s questions once and once only, with a short and simple response that is clear and concise.
Client: Are you disappointed with me?
Therapist: No, I am not disappointed with you. I am sad that…..
If the client then continues to ask questions that vary along the same theme, the best way to move forward is for the therapist to block oneself from continuing to reassure them. The therapist has already answered, and continuing to engage in this anxious and fearful ‘dance’ will only perpetuate the client’s reliance on the therapist for a continued though unsustainable external locus of reassurance and regulation. It is likely, anyhow, that in these moments no amount of reassurance will be enough to assure a Borderline client. Additionally, with the long-term aim being for the client to one day be able to rely on themselves for this comfort, the process of constant reassurance-giving will only hinder this self-reliance and emotional independence from being achieved.
Remembering important information –
Many Borderline patients will be hyper-vigilant and analytical of their therapist to the nth degree. If a client’s therapist forgets or erroneously expresses information a client has previously shared, it is likely to lead the client to feelings of anger, resentment, inadequacy and hurt at the thought that their therapist “doesn’t care enough” to remember these fine details of their life. With more menial details such as the precise age of a sibling or the name of a neutral acquaintance, it may feel easier for a client to give their therapist some leeway. For the bigger issues however – such as in relation to traumatic events, family dynamics, or even smaller but recently-asked questions of importance – when a therapist is able to keep track of this material, it fosters a sense of trust, faith, safety and even appreciation within the client, which otherwise may be compromised.
Commitment long-term –
A therapist treating someone with BPD needs to be aware of the longevity and investment needed for a client’s long-term recovery and needs. There is no quick-fix and no temporary solution. A long-term therapeutic relationship is the way to go, and the therapist needs to know, expect and commit to this from the onset.
Even if a presenting issue feels baffling, strange or negligible to a therapist, if a client is expressing discomfort or distress, they need to be taken seriously. Even if a therapist cannot empathise fully with a client’s internal world, they need to be able to imagine what it could be like for them, including acknowledging the extent of the pain their client is going through, no matter what the trigger or cause. An individual’s experience and pain is their own – it is what it is, and it is their truth and their reality. No one can take that away.
Views on medication –
Whilst some therapists will be more opinionated on the issues of medication than others, it is important that they do not overly project their own views onto a client to the extent it informs potentially life-changing decisions and actions. Although it may be appropriate or even helpful to discuss certain feelings and facts around medication in therapy, any final decisions and changes surrounding psychiatric medicine need to be taken to a psychiatrist (or other medical professional).
Minimising, shaming and judgments –
There are no ‘shoulds’ or ‘shouldnts’ allowed in a therapeutic milieu with regards to the subjective experiences of a client. Of course, naturally, a therapist will have expectations of their clients within certain contexts, but when it comes to the emotional content of a client’s experiences, whatever is going on for the client is valid and worth exploring. Nothing is ‘too small’ an issue, no feeling is ‘bad’ or ‘wrong’, and everything shared in the session is valuable. Shaming in any form is unacceptable, and judgments are totally inappropriate unless they are entirely discerning as opposed to a direct evaluation of the client’s experiences.
Following through with promises –
If a therapist says that they are going to do something, it is essential that they carry this promise out within the time-frame they have committed to. Borderlines take promises very seriously, and are likely to remember what has been said by their therapist word for word. If certain commitments are not followed through, it is likely to result in feelings of inadequacy, anger, upset and distrust for the client, who – with this opportunity – will possibly be testing their therapist out by seeing how strongly they keep to their word. Because trust is something that can be grown with evidence and outcomes, if a therapist makes a commitment, it is preferable that they follow through, in order to avoid creating further trust-related problems with their clients. Similarly, if a therapist sticks to what they say they are going to do, a client is more likely to feel motivated to do the same. After all, the therapist-client relationship is a two-way street. Why should a client feel they ought to continue completing their homework or assignments, if their therapist often fails to complete theirs?!
“No touch” policy –
This is pretty simple. A therapist must not touch their client unless within a few circumstances: If a client initiates contact via asking through a hug, if appropriate, the therapist can agree to this as long as it is brief (lasting no long than a few seconds, says the BPS!), and as long as it is not an overly regular occurrence. Additionally, in the treatment of certain conditions such as anxiety, panic or trauma, certain therapies include touching in the form of tapping or via placing a hand on their client’s back or head. In these circumstances, it is still necessary to ask permission from the client before touching them. In most other circumstances, a therapist should not touch their client at all, especially not before asking, or without informing the client of their intentions. This is especially important when considering the trauma histories and levels of anxiety different clients experience. During an episode of panic, being touched for one person may be reassuring, whereas for another client it may spark off a trauma reaction and full-blown panic attack. If the therapist asks first, then this can be easily avoided. As a bottom-line, no self-initiated touching is a therapist’s best bet; safest for both client and practitioner.
Crisis management –
Some therapists allow telephone calls during crises outside of usual therapeutic hours. If a therapist’s hours are 9am until 10pm (for example), then it is essential that these are the hours they stick to. No matter what texts, voicemails or emails a therapist may receive from a client, it is not the responsibility of the therapist to take on every single crisis of a client, especially if this puts them under stress or strain and goes beyond their call of duty, both practically and emotionally. It is important that therapist and client have a crisis plan in place, for times when it is inappropriate or unfeasible for a client to contact their therapist within a crisis. Ideally, the client should be provided with the hotlines of local crisis teams, charities or services, as well as know the formalities and whereabouts of their local hospital and emergency psychiatric services. Again, this comes back to the concept of boundaries – both in protecting the therapist and the client.
Prioritising effectively –
Patients with BPD often present with a range of behavioural manifestations which can be life-interfering or even life-threatening. It is essential that a therapist targets these behaviours first and foremost to help the client get to a place of management and containment of symptoms, before the deeper psychotherapeutic and trauma elements of therapy can begin. After all, if a client becomes institutionalised, hospitalised or even dead, what good is the deeper work whilst the physical life of an individual is at such risk? When it comes to Borderline patients, safety has to be the therapist’s number one priority. Of course, once an individual is stable enough to progress to the next level of therapeutic work, it is totally necessary to work through the core childhood, traumatic, deepest and perhaps most complex issues presenting. All in appropriate time, relative stability and effectiveness.
Sharing personal information –
Although in some forms of therapy a therapist may loosely give information about themselves to their clients, within the context of a Borderline-client-and-therapist relationship, it is important to find an appropriate balance and be aware of the varying needs of individual patients. For some, sharing too much personal information can play into the attachment needs of the client who may seek to know and learn aspects of their therapist’s life which may not be appropriate. Because BPD patients tend to carry a lot of attachment-related trauma and challenges, it is common that some clients will possess more than just an “element of curiosity” regarding their therapist. For others patients, having personal information shared with them may help nurture trust and security within the relationship. As long as this is done appropriately, and in line with the client’s best interests and long-term goals, either approach can be effective. Whilst the therapeutic domain needs to be as much about the client and their life experience as possible, with little (or no) emphasis on that of the therapist’s, some instances of self-disclosure are encouraged with Borderlines, especially in DBT. Specifically, therapists’ self-disclosure which is related directly to the patient can be beneficial in creating incentives and using helpful reinforcement strategies within certain contexts. Examples of this type of self-disclosure include being honest with a client about how their behaviours (both effective and ineffective) affect the therapist (both positively and negatively). It can be helpful to hear from a therapist their excitement and pride when as a client you have been skilful and are working hard in therapy. Equally it can be beneficial to get feedback about how certain behaviours can act to push one’s therapist away. Learning what behaviours make the therapist feel more motivated and drawn to the relationship is as helpful as hearing what behaviours serve to push them away. Though challenging, this feeds in to the concept of reinforcement for positive behaviours alongside a lack of reinforcement for negative behaviours, which together act to increase the likelihood of long-term changes for the better, as well as gains for both the patient, therapist and the therapeutic relationship.
Enabling ineffective behaviours –
In DBT, the primary treatment for patients with BPD, there is emphasis on how unhelpful it can be to provide positive reinforcement for ineffective behaviours. If a client engages in an ineffective behaviour, and they are met with an increased interest, level of concern, and given more attention by their therapist, then they are only likely to continue engaging in these behaviours in order to achieve the same effect. It is important not to enable ineffective behaviours, but instead to remain as cool and dettached as possible so that a client does not perceive their therapist’s reaction as an invitation to re-engage in the behaviour. Even if a client’s behaviour escalates in an attempt to grab their therapist’s attention, it is vital that the therapist does not give in. If they do, it only increases the likelihood of the client’s negative behaviours reoccurring. If this goes on and on, there is a possibility the therapy or approach is not working.
Reinforcement v.s. Punishment –
Now whilst we have discussed why it is unhelpful for a therapist to (whether unintentionally or not) enable an ineffective behaviour through various means of reinforcement, it is neither helpful to use the method of punishment. It can actually be more damaging than it is beneficial to approach ineffective behaviours with punishments, and there is empirical evidence to suggest this. For example, taking a session away because a client has self-harmed is totally inappropriate. On the contrary, rewarding a client with an extra session as a reward for engaging in skilful behaviours can be a great incentive and useful DBT approach for motivating the continuation of effective symptom management through healthily ‘conditioning’ the client. It is known that punishment is not an effective way of treating the Borderline population – please bear this in mind as it can actually be more damaging than expected.
Maintaining professionality, projection and counter-transference –
As BPD clients can be incredibly emotionally reactive, it is important that a therapist is able to meet their clients’ struggles in a way that does not mean they fall victim within difficult interactions. If a therapist is unable to maintain some semblance of personal detachment where necessary, and instead takes on their clients’ issues as their own, it is unlikely they will be able to remain effective for long. As soon as a therapist starts taking on their clients’ issues as personal attacks, perhaps projecting their own insecurities onto the therapist-client relationship, the therapy becomes no longer centered around the needs of the client – and their process may become lost amid or enmeshed with the therapist’s own difficulties. This has happened to me and I have ended up feeling responsible for my (ex) therapists and their emotions, because they were unable to maintain, once again, appropriate boundaries.
Attitude: Compassion, empathy, patience, flexibility and a sense of humour –
Perhaps one of the most fundamental bullets of this post: because without a certain flexibility and empathy in a therapist’s approach, the relationship is unlikely to get very far. Remember that it takes time and positive evidence for a client to start building up a trusting connection with their therapist, and so naturally the personality and demeanor of a therapist has a pivotal role in the growth of this potentially life-changing interactive relationship.
Intention and forward-thinking –
If you are a therapist treating clients with BPD, continue to ask yourself what you are trying to achieve long-term with your client, and ensure that what you are doing is in line with those goals, every singly step of the way.