Chaos is the score upon which reality is written. — Henry Miller
Although caregivers may have the necessary academic background to assess Borderline Personality Disorder (BPD) from a hypothetical vignette, they may not have worked with enough varieties of BPD clients in a clinical setting to identify the full spectrum of manifestations. The DSM-IV and DSM-5, with their checklists of infamous Borderline traits, cannot begin to capture the experiential dynamics of being in a more direct relationship with a BPD individual. The complexity of this personality disorder is sometimes incapable of being detected by even the most seasoned clinicians until a specific behavioral pattern over time suggests a definitive pathology. The danger of normalization and misdiagnosis is common with Borderlines because of the protean nature of this disorder and its wide array of individualized features.
The ways that Borderline Personality Disorder can present itself are sundry, but the traits reliably surface whenever sufficient stressors are involved in the person’s life. The problem is that notable levels of stress may not emerge in therapy sessions as they would in a family context or social setting. In some cases, the BPD’s polite demeanor, charm, style, and affable disposition, as presented in a structured setting, can create the illusion of normalcy for an extended period of time before things begin to unravel. As clinical misinterpretation progresses, the caregiver may end up pouring the equivalent of codependent jet fuel on the client’s emotional reasoning by gradually supporting their distorted views of reality, or by feeling compelled to gratify their assorted requests for special treatment.
The challenge for clinicians is when a misdiagnosed or undiagnosed BPD presents in multiple sessions with no identifiable traits or affective instability (as with a “quiet” or high-functioning Borderline). Furthermore, the elusiveness of this disorder will often escape the radar of the client’s previous clinicians—possibly because of the BPD’s ability to present themselves as calm and well-adjusted during most clinical interactions (if affective dysregulation is admitted by the client, it is often misdiagnosed as Bipolar Disorder or minimized as situational anxiety). A contradictory or confusing diagnostic history might suggest that the client is suffering from a faulty interpersonal navigation system rather than a mood-related disorder. Likewise, it’s sometimes assumed that the client has been an innocent bystander of chaotic circumstances, surrounded by personality disordered individuals, rather than being a card-carrying member themselves. In other words, objectivity can easily be lost if a clinical confirmation bias exists in thinking that the client is a victim of bad luck instead of being a potential culprit. In these circumstances, understanding the multi-generational pervasiveness of BPD in families is of key importance.
BPDs are resource and sympathy acquisition specialists—chameleons of adaptation as their lives are often in dramatic fluctuation. Assessments taken at face value may have therapists believing the client’s victim identity, which can provoke a strong rescue response, thereby enabling an unrealistic and unsustainable attachment as the therapeutic alliance develops. The BPD can surreptitiously condition others to respond to their needs, and conscientious therapists may feel heroically compelled to go the extra mile as a gesture of loyalty. Unfortunately, the therapist’s valiant rescue attempts will only reinforce the client’s dependence and further vindicate their assertions of distress. In short, the therapist might feel obligated to take care of the BPD until the caretaking fuel runs out. Subsequently, the BPD’s inevitable performance evaluation of the therapist’s efforts will result in either effusive praise or punishment.
Subconscious transference and countertransference will undoubtedly emerge from childhood associations for both the client and the therapist as sessions progress, but additional enmeshment can occur because of subjective physical allure, shared interests, historical similarities, camaraderie, and other overidentification factors. Idealization of the clinician is also a common phenomenon during various stages of therapy with BPDs, and most therapists enjoy being acknowledged or admired for their efforts—regardless of the client’s tendentious proclamations. After all, therapists are human and have their own needs for validation in an otherwise thankless and emotionally grueling profession. Nonetheless, this “admiration” may have a trapdoor that includes erotic fixation (common among BPDs). If the therapist misinterprets the client’s fixation for genuine appreciation, or if the therapist augments the fixation by also admitting auspicious feelings for the client, the misunderstanding of what is personally conveyed versus what is pathologically motivated could result in a chain of events ending with previously unintended efforts to pacify the BPD’s intense preoccupation with sensation seeking. Caregivers may rationalize exceptions to treatment and loosen boundaries as a way of surrendering to the client’s indifference towards common rules, repeated demands for attention, or to demonstrate solidarity within the therapeutic relationship. If therapy evolves from being too casual to something that resembles a familiar friendship, it’s only a matter of time before the BPD will initiate further efforts to decimate the professional power differential. Other misinterpretations may include believing the client to be a mere witness of “crazymakers” rather than investigating the client’s adult contributions to their own psychosocial predicaments.
It’s important to recognize the BPD’s disproportionate requirements for attention, proximity, affection, and reassurance. They can cleverly uncover personal weaknesses in others, such as generosity or agreeableness, and skillfully exploit them to get their emotional needs met (appearing as premeditated manipulation). BPDs will generally capitalize on a caregiver’s commitment to compassion⸻taking full advantage of every accommodation offered while cataloging these vulnerabilities for future interactions. They will subjugate any challenging interpersonal system that they’re interacting with because individuation makes them feel uncomfortable and spatial distance is seen as a threat. It’s like host manipulation by parasite. The BPD’s intrusiveness virtually guarantees a more secure attachment to the caregiver, but this attachment is ephemeral and unsustainable. Subsequently, the therapist can lose their sense of objectivity and autonomy by allowing themselves to be more open and vulnerable to the BPD’s overpowering emotional needs, but this progressive transformation is extremely treacherous. Too much self-disclosure and overindulgent styles of caregiving are equally dangerous when working with BPDs. Once the bargaining stage of sacrificing the self for the sake of the other begins, the therapist is headed for an impossible task of perpetual mollification. Over time, trying to successfully manage one BPD on your caseload could feel as emotionally draining as managing hundreds of other clients (this is a telltale sign that someone could be hitting home runs in the Cluster B ballpark). The fragmented sense of self and emotional greediness of the Borderline is an equal-opportunity seeker.
Addressing the relentless demands of an excessively needy BPD is like experiencing The Myth of Sisyphus on crystal meth. Lacking in object permanence, there are never enough words of reassurance or altruistic gestures to placate the BPD’s fragile sense of self. You might as well be sweeping a dirt road. A veritable recipe for disaster also awaits the therapist if he or she is coping with issues of their own, such as work stress, family problems, anxiety, burnout, and depression. A reliable axis of balance is needed before being able to properly notice degrees of imbalance in others. Losing one’s proverbial mind can sometimes occur as a byproduct of working with others who have already “lost” theirs. Without proper self-care, the ability to care about the cohesiveness of the therapeutic frame will be less significant—resulting in a slippery slope of potential transgressions. BPDs have a second sense for spotting those who appear emotionally repressed or disenchanted, such as therapists suffering from compassion fatigue, and may use flattery to create an infectious atmosphere of lighthearted disinhibition. Likewise, without knowing that the client is a rank-and-file BPD contender, the chances for course correction in therapy become more untenable over time (this is why ongoing supervision must be prioritized). Without proper training for the early identification and management of BPD, the therapist is potentially lost in a sea of misapprehensions and clinical missteps (it’s like conducting therapy in Plato’s Cave). In these circumstances, the therapist may become a reluctant participant or a willing accomplice in the BPD’s eternal quest for enmeshment.
The BPD valence is that of a perennial victim perpetually in fear of abandonment, but keeping this fear from being exposed may prevent or indefinitely postpone diagnosis. The BPD may also employ subtle or overt forms of seduction as a means of strategic survival to acquire unambiguous commitment from their caregivers while using this emotional attachment to solidify their immense desire for control. Just like an ungrounded wire seeks a neutral source for proper conduction, the BPD craves the reliability and perceived stability of others to resolve feelings of erratic discontent. In addition, the BPD will subconsciously use the therapist as a self-object for needs unmet in childhood (the perfect mother/father) or fantasies unattainable in adulthood (the perfect partner). A therapist can inadvertently enable or exacerbate the behavioral patterns of a Borderline by automatically catering to their frequent demands, obsessive requests for attention, and impatient sense of entitlement—especially if the BPD’s concerns are misinterpreted as legitimate personal complaints rather than psychopathological reactions. As a result, the clinician’s temptation to become a “fixer” will allow the BPD to avoid being confronted or challenged. BPDs can easily coerce others into becoming their “psychosocial saviors” if purported tales of victimization are not thoroughly investigated during early stages of the therapeutic relationship. The helping profession of psychotherapy encourages the development of an effective relationship to help the client, but it’s the professional aspect of the relationship that must remain especially predominant when working with Borderlines. In the BPD motorcade, the wheels of impulsivity are always out of brake fluid. It’s like having a hyper-reactive limbic system for an engine without access to a steering mechanism. If the therapist mistakenly hands the car keys of therapy over to the client, the BPD will drive everyone off the nearest cliff.
Pervasive patterns of acting out conveniently thwart BPDs from recognizing inner turmoil and deep emotional wounds. For this reason, interpersonal boundaries are constantly being tested or crossed. Borderlines, if they are anything, are accomplished opportunists capable of theatrical performances by appearing distraught or claiming to be constantly mistreated by others. If the therapist is not careful, the temptation to violate additional boundaries for the sake of appeasing the client becomes more likely (BPDs must be approached with adequate interpersonal restrictions due to their inherent emotional immaturity and inability to delay gratification). Similarly, caregivers can become collateral damage in the path of a Borderline’s hurricane of emotional instability. BPDs will often choose to attach to that which is either idealized or inaccessible, but when the attachment is disrupted, the object of love quickly becomes the object of aversion. Ironically, the therapist may still be enamored with the image of helplessness that the BPD once presented. The BPD wants love to be a possession, whereas the therapist may become lovesick in their pursuit of healing the client. Once the Kool-Aid of projective identification is properly ingested, the ability to sustain mentalization (separation of identities) quickly evaporates. Therapists may become equally immature and impulsive as they attempt to become more accessible, trusted, and convincing to the client. The psychic fusion of the BPD and therapist can quickly become a tangled web of quid-pro-quo arrangements to quell the client’s urgency for devotion and to satiate their intense yearning for unambiguous intimacy.
No matter how sympathetic or considerate the clinician is in relation to their client’s ongoing needs, they will inevitably disappoint the BPD’s unrealistic expectations. The resulting devaluation period will likely include dramatic displays of anger, rage, exaggerated accusations, and vindictive forms of retribution. For better or worse, the therapist will realize that being a mental health caretaker, despite all intentions, cannot include the responsibilities of completely taking care of someone. Specialized training programs for therapists to rapidly diagnose and facilitate the effective management of BPDs should be mandatory as a preventive measure. Self-efficacy is encouraged, but not guaranteed through association (for either the client or the therapist). It’s up to the BPD to develop the necessary ego strength for achieving autonomy by understanding how an overreliance on others prevents accountability and self-reflection. Similarly, it’s up to the therapist to understand the importance of setting firm limits, being intrepid in the face of boundary testing, and following ethical guidelines to ensure a professional therapeutic relationship for the sake of the client’s intrinsic well-being. The anodyne of affection may satisfy unfulfilled needs on both sides of the couch, but the therapist will never be able to find their way back once the process of BPD pacification begins. Codependent quicksand is a formidable force. In the end, the BPD will pull the rug from underneath their caregiver whenever the emotional gravy train runs out. By using whatever means necessary to assign blame while denying accountability, the focus of all future concern will be conveniently relocated to the BPD’s elaborate amphitheater of victimhood. The therapist, no matter how personally compromised or professionally misguided, must have been part of the conspiracy! It’s not enough for the BPD to suffer from a failed outcome due to unrealistic expectations, they must spread their tragic surplus of misfortune to their chosen target of opprobrium.
Working through childhood experiences, both good and bad, and understanding how this affects adult decision making is what matters in the end. Deeply embedded triggers from interacting with our families of origin are reactivated for both the therapist and the client in every therapy session. Many therapists have not done enough of this exploratory work to properly recognize or manage transference or countertransference, and their client may be equally unaware or uninterested in considering the influential depth of such dynamics in relation to their current psychological motivations. Unprepared therapists could unwittingly be treading water in an ocean of Cluster B bathwater before waking up to find themselves circling the drain. Likewise, the caretaker may become the latest scapegoat in the BPD’s retaliate-against-everyone-who-has-ever-disappointed-me project as their self-fulfilling prophecy of abandonment continues unabated. As a consequence, overly attentive responses by the therapist (i.e., projective counteridentification) to the accumulating desires and fantasies of the BPD will incrementally raise the stakes whenever interacting in such an intimate setting as therapy. At the end of the abandonment rainbow, the disillusioned BPD will be encouraged by their sympathetic allies to collect misadventure bonus points as they reclaim victimization. However, the clinician will suffer a much greater loss if professional boundaries aren’t cautiously maintained before entering into such an unassailable therapeutic landscape.
Stacking a house of unstable cards is naturally going to collapse if you don’t understand the true nature of what you’re stacked up against. The therapist who prematurely folds their boundaries in the face of something they don’t yet understand will lose the pot every time. Betting against a Borderline’s nature is impossible, because they can always read the hand of accommodation that you’re holding. Even when the mysteries of chaos are finally revealed, the embers from that loaded deck will continue to burn.