Disclaimer: The following material was written for therapists to identify and manage clients with Borderline Personality Disorder while illustrating some consequences that may occur during clinical practice. Furthermore, the following hypothetical situation in no way suggests that all Borderlines are similar regarding presentation, cognition, or behavioral responses. Therapists, like others, should avoid the “No true Borderline” fallacy. This essay is not intended as a support resource or treatment recommendation for those suffering from Borderline Personality Disorder; it represents an experiential and educational guide to inform and protect therapists. Despite some of the behavioral depictions, occasional humor, and seemingly derogatory vernacular, there is no motivation by the author to show prejudice or discriminate against this controversial mental health population. Borderline Personality Disorder is a serious mental illness that negatively affects the person suffering from it, in most cases, more than it affects those who interact with them. Borderline behavior is simply a dysregulated means of survival, but therapists must learn how to recognize and survive the onslaught of such behaviors in a clinical setting.
Chaos is the score upon which reality is written. — Henry Miller
Although therapists may have the necessary academic background to assess Borderline Personality Disorder (BPD) from a vignette or comprehensive case study, they may not have worked with enough varieties of BPD experience in a clinical setting to identify the full range of behavioral manifestations. For example, therapists may learn to recognize common strains of the BPD “psychovirus,” but other strains can go completely unnoticed (it’s like not recognizing a melody because it’s being played backwards). The DSM-IV and DSM-5, with their checklists of infamous Borderline traits and diagnostic features, cannot begin to capture the experiential dynamics of being in a more direct relationship with a BPD individual (the World Health Organization’s ICD-10 defines BPD as Emotionally Unstable Personality Disorder). The complexity of this personality disorder is sometimes undetected 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 biosocial disorder and its wide array of individualized features. According to the article Subtypes of borderline personality disorder patients a cluster-analytic approach from the journal Borderline Personality Disorder and Emotion Dysregulation, 2017: “The BPD population is notably heterogeneous from a descriptive and theoretical perspective. Two hundred fifty-six possible combinations of criteria may yield the same diagnosis. Hence, two patients with a diagnosis of BPD may have only one diagnostic criterion in common.” Correspondingly, a dimensional-based severity scale for BPD should include categories for mildly disturbed, moderately disturbed, and severely disturbed—in addition to Theodore Millon’s 4 BPD subtypes: Discouraged, Impulsive, Petulant, and Self-Destructive. Regarding functionality, some Borderlines are highly self-sufficient, whereas others can be completely dependent; yet they are all emotionally dependent. BPD is considered to be the great masquerader of mental health disorders. As a characterological disorder, the symptoms of BPD are often camouflaged by the client’s Delphic presentation and myriad personal problems, thereby making the prospects of a conclusive diagnosis even more troublesome. Overall, Borderline Personality Disorder should be considered on a broad psychiatric spectrum rather than relying on common caricatures, clinical stereotypes, or hyperbolized Hollywood depictions. BPD represents approximately 2% of the general population with roughly 75% of cases being diagnosed among females. A large percentage of BPDs report a history of abuse in childhood (physical, emotional, and sexual), but 20% claim to have no memory of such encounters. But even with all of these stipulations and appraisals taken into consideration, to creatively paraphrase Richard Feynman: If you think you understand Borderline Personality Disorder, you don’t understand Borderline Personality Disorder. Considering the chronicles of mental illness, BPD is an unpredictable ontological contradiction that never fails to generate confusion for family members, loved ones, acquaintances, and caregivers.
In terms of an accessible two-tier classification system, BPD “first impressions” could be recognized as either Authoritarian or Vulnerable.
Authoritarian BPD. Interpersonal disposition: Self-sufficient, domineering, intense, mesmerizing, intrusive, anxious, dysphoric, demanding, passionate, presumptive, judgmental, perfectionistic, fearful, competitive, impatient, pessimistic, easily angered, petulant, stubborn, critical, paranoid, and envious. Attachment style: Fearful/Disorganized. Intimacy style: Erotophobic. Rationale: “I have needs for stability, predictability, and approval that were not met during childhood; therefore, I must be in charge to survive.” Valence: Assertive, flamboyant, and irritable. Parenting style: Over-involved. Objective: Control of self, others, and their environment (overtly expressed).
Vulnerable BPD. Interpersonal disposition: Dependent, charming, captivating, coercive, desperate, mercurial, seductive, playful, hapless, passionate, anxious, dysphoric, duplicitous, suspicious, fearful, affectionate, labile, docile, hypersensitive, desultory, fantasy-prone, easily disappointed, childlike, vindictive, and jealous. Attachment style: Anxious/Preoccupied. Intimacy style: Erotophilic. Rationale: “I have needs for safety, validation, and nurturing that were not met during childhood; therefore, I must be taken care of to survive.” Valence: Coy, mischievous, and enigmatic. Parenting style: Under-involved. Objective: Control of self, others, and their environment (covertly expressed).
It should be understood that these rudimentary classifications are not mutually exclusive. For example, a Vulnerable BPD could easily switch into an authoritarian mode of expression, given the volatility of their internal barometer during stressful circumstances. However, general appearances indicate a default tendency towards either one disposition or the other, and both classifications maintain fantasies of omnipotence to offset deep feelings of insecurity. For purposes of this essay, the author will focus on clinical encounters with the Vulnerable BPD. A more descriptive archetypal rubric is supplied by Christine Ann Lawson in her popular book Understanding the Borderline Mother.
In addition to the DSM’s notorious 9-point diagnostic criteria, here’s a 10-point list of the more “unspoken” elements of Borderline Personality Disorder:
- Perfectionism. Excessive attention to details with hypervigilance.
- A pervasive need for control in multiple contexts. Hyper-competitiveness and mistrust of others.
- Relying on a victim identity (learned helplessness) for obtaining sympathy and resources.
- Situational transmogrification. Shape-shifting without warning.
- Automatically seeing everything in terms of object relations and unconsciously reenacting childhood trauma during every relationship.
- Projective identification. Coercing others to become what they avow or disavow without the other person realizing that it’s happening.
- Emotional reasoning and having their own definitions for universal language while harboring ideas of reference.
- Seeking intimacy as a form of compensatory nurturing that provides safety, comfort, self-soothing, reassurance, stability, and validation rather than having an interdependent experience among two adults.
- Viewing others as need-gratifying objects while carefully evaluating them for their potential as enablers or obstacles.
- Poor listening and comprehension skills due to overwhelming emotional preoccupations. BPDs will superficially look and act like they understand you; but they often don’t, or don’t care about the content of the conversation whenever it deviates from their immediate interests.
A useful image for BPD interpretation is to picture a 3-layer cake. On the surface of the cake is the BPD’s survival-based persona; a “false self” that allows them to function in the world and feel accepted while avoiding the agony of criticism or rejection. In essence, the false self is an idealized form of identity that the pwBPD wants to present to others as if it were their authentic personality. The middle section of the cake represents a large arsenal of primitive defense mechanisms that generate the bulk of BPD symptomatology whenever a conflict of interest emerges. The bottom layer of the cake symbolizes the BPD’s traumatized and psychologically arrested inner child who is buried underneath a complicated mix of ingredients that include denial, compartmentalization, and dissociation. In therapy, clinicians must become the equivalent of psychoanalytical archaeologists who are willing to get messy in an elaborate mixing bowl of toxic cake batter to unearth the BPD’s traumatized self. Staying on the surface of the cake is what the pwBPD wants everyone to do, and they will fight like hell to maintain their protective exterior, but focusing on the frosting and its permutations only enables this evasive disorder to flourish with impunity. As a result of such confusion, therapists and other providers often take an à la carte approach to symptom evaluation and treatment before getting to the center of the BPD tootsie pop. But wait, there’s more! The therapist may assume that he or she is interacting with the BPD’s “true self,” but this is an illusion. In reality, the therapist is interacting with the BPD’s impossible-to-please inner child, and the therapist will be judged accordingly. In fact, the BPD’s true self is damaged, trapped, confused, anxious, and fearful because they never developed trust or learned to accept themselves. Likewise, the pwBPD will believe that the therapist’s true self is either an indifferent professional or an unencumbered caregiver who has the power to magically rescue, nurture, and restore their inner child. However, all therapists endorse a false self by temporarily assuming the role of a caregiver as part of their occupational identity. Whereas, the therapist’s true self is a human being with faults, problems, and limitations just like everyone else. Last but not least, most interactions in therapy rely on neurotypical forms of reasoning and interrelating; but BPDs have no reliable baseline for communication because of their unpredictable emotional states, altered memory, distorted thinking, and poor insight. What could possibly go wrong?
A conceptual view of BPD is noted by Robert B. Shulman: “The characteristics of the borderline personality include a marked and persistent identity disturbance, chronic feelings of emptiness and boredom, and intense unstable personal relationships. The borderline tends to have difficulty tolerating being alone, and will fear abandonment. They are highly impulsive, and may engage in self-mutilating behavior, have recurring suicidal threats, and manipulate others to meet their immediate needs. The borderline also tends toward having an intense affect; unstable mood; displays of inappropriate anger; perceptual distortions; and under great stress may depersonalize. They see the self as justified; since they feel intolerably bad, they are entitled to go by impulse instead of common sense, and feel entitled to soothe themselves. Their fictitious goal is to do whatever they want as they cannot be happy by how others do it. Their methods are protean, and include splitting, primitive idealization, projective identification, denial, and devaluation. The borderline personality is not a cooperator. Their impairments include affective instability, anxiety and panic, and engaging in self-harmful behaviors. These impairments may cause significant interference in social or occupational functioning. Because the borderline uses others to meet their needs, they can often be the ‘problematic patient’ that medical offices dread.”
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 during casual therapy sessions as they would in a family context, romantic relationship, or adverse situation. In many cases, the BPD’s affable demeanor, charm, and energetic magnetism—as presented in a structured setting—can create the illusion of normalcy for extended periods of time before things begin to unravel. But, to be sure, this commonly misunderstood disorder is a far cry from the “worried well” going through a seasonal spell. BPD is a form of psychological pain that cannot be attenuated by methods of normal communication; individuals with personality disorders do not realize that their emotions and behaviors diverge considerably from quotidian human experience. To be inappropriately blunt, BPD “flare-ups” are a bit like herpes simplex virus. There may be no visible outbreak of symptoms until the pwBPD encounters stress. In most cases, the crux of the disorder is environmentally triggered and exacerbated by a skewed perceptual lens. This is why those suffering from BPD can sometimes “hide” their internal suffering when the potential for emotional conflict is perceived to be at a minimum threat level. However, it’s the stress of not getting their way that really brings out the creature features of this tumultuous disorder. *It’s also important to know that not all BPDs engage in self-mutilation or suicide attempts, but they can be self-destructive in other ways that are far less obvious. As clinical misinterpretation progresses, the caregiver may end up pouring the equivalent of codependent jet fuel on the pwBPD’s emotional reasoning by gradually supporting their distorted views of reality, or by feeling compelled to gratify assorted requests for special favors. BPDs could be thought of as emotionally unstable individuals with maladaptive software programs—akin to a faulty GPS—when it comes to navigating interpersonal dynamics. Unfortunately, BPDs are not responsive to most forms of traditional psychotherapy and, therefore, must be willing to submit to specifically designed treatment programs (i.e., DBT, MBT, IFS, schema therapy) that usually require years of attendance before adequate insight is developed. Borderlines don’t know how to interact in relationships, and a relationship with their therapist is just another type of relationship.
Things are not always what they seem. — Phaedrus
The challenge for clinicians is when an undiagnosed or misdiagnosed pwBPD presents in multiple sessions with no conspicuous traits. Furthermore, the elusiveness of this disorder will often escape the radar of previous clinicians because of the BPD’s ability to superficially present themselves as well-mannered, confident, carefree, and ostensibly reasonable during brief interactions. BPDs can also appear cognitively copacetic and highly functional when engaged with specific activities that allow for structure, affirmation, control, and unambiguous results (apparent competence). If affective dysregulation is admitted by the client, it’s often misdiagnosed as Bipolar Disorder, atypical depression, or minimized as situational anxiety. Despite a plethora of comorbid considerations, a contradictory or confusing diagnostic history might well suggest that the client is suffering from pervasive patterns of psychic disturbance that transcend Axis I considerations. However, due to time constraints and other factors involved with high-maintenance clinical work, reliance on the assessments of previous caretakers often remains unquestioned. Likewise, it’s sometimes assumed that the client has been an innocent bystander of chaotic family circumstances—surrounded by personality disordered individuals—rather than being a card-carrying member themselves. In other words, objectivity can easily be lost if a confirmation bias exists in thinking that the client is an unfortunate victim or survivor of “bad luck” instead of being a potential culprit (this bias does not dispute victimization from abuse or neglect in childhood). Whenever such misguided conclusions become diagnostically solidified, the lost-in-translation therapist will assume the position of a detective chasing down the wrong suspects. In these circumstances, understanding the multi-generational and hereditary pervasiveness of BPD in families is of key importance (early diagnosis of Borderline Personality Disorder is crucial for a favorable treatment prognosis). Because of the public and mental health stigma surrounding Borderline Personality Disorder, medication management is often chosen as the sine qua non for treating symptoms rather than subjecting the client to a series of more intensive evaluations. However, psychotropic medication is only supplemental and not effective for managing the nucleus of this multi-layered disorder.
It’s the Hard Knock Life for us. — Annie
BPDs are known for being resource and sympathy acquisition specialists—chameleons of expediency and masters of mimicry with lifestyles that are frequently in dramatic fluctuation. Their stories can be captivating, and their charismatic powers of persuasion are often unrivaled. The BPD’s voyage of hardship (unrelenting crises) and methods of retelling are irresistible bait for any caretaker who cares too much. In fact, BPDs are some of the most emotionally convincing interlocutors on the planet. From a BPD’s point of view, they are soldiers of misfortune struggling for survival in a hostile world filled with untrustworthy people; ergo, survival usurps self-awareness. 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. After all, it’s considered rude for therapists to openly question the veracity of a purported victim in a treatment setting. But keep in mind, the client’s victimology list may include multiple offenders, in multiple contexts, to be blamed over an extended period of time. For example, BPDs can go from one personal or professional relationship to another while complaining about how they were grievously mistreated during their last encounter (aka “system surfers”). However, a detailed history of the client’s life will undoubtedly reveal significant contradictions while demonstrating evidence for repetition compulsion. Upon closer examination, BPDs have a remarkable capacity to inadvertently exploit others while maintaining a repeated position of victimhood—perpetuating a cycle of victim and rescuer. Consequently, this position abdicates personal responsibility while justifying the BPD’s impulsive behavior, self-aggrandizement, and mistrust of others—it’s like playing tennis without a net. BPDs are emotionally disturbed individuals who are exceedingly proficient at persuading their sympathizers that everyone else is disturbed. To be sure, giving a pwBPD the benefit of doubt will not benefit anyone (including themselves). Other diagnostic misinterpretations may include believing the client to be a mere witness or scapegoat of other “crazy makers” rather than investigating the client’s adult contributions to their own psychosocial predicaments. To make matters more convoluted, BPDs sometimes expect professional relationships to be indistinguishable from personal relationships to ensure instant bonding. Therapeutic relationships, in particular, are anticipated to become more personal if the clinician’s empathy is to be convincing. However, a pwBPD will often interpret clinical interactions to be a simulacrum of parental judgment with the potential for criticism or shame. Subsequently, BPDs will work hard to undermine and control the therapeutic process to avoid anxiety in the face of uncertainty. The process of change equals an all-too-familiar manifestation of stress and unpredictability from the BPD’s childhood. All therapeutic relationships are interdependent collaborations, but building a therapeutic relationship with a pwBPD has a much greater likelihood of becoming hostile or codependent because of their distorted perception of trust.
Love is a battlefield. — Pat Benatar
As can be expected, the pwBPD’s history of romantic relationships are characteristically unstable and stormy with evidence of intermittent reinforcement relationships. BPDs are looking for someone to love, and someone to blame, to compensate for adverse childhood experiences. BPDs often exhibit an obsessive preoccupation with love and re-parenting, under the guise of an adult romantic relationship, as the solution to all of their problems. However, long-term pair bonding is extremely difficult with BPDs because they’re predisposed towards jealousy, chronic irrationality, self-sabotage, abandonment rage, and they cannot be emotionally subdued for any substantial period of time. According to psychotherapist Ross Rosenberg, “Their [Borderlines] romantic relationships begin quickly, intensely, and with a great deal of excitement, euphoria, and sexual chemistry. Their volatile emotions move in one of two directions: love and adoration or hate and destruction. Because this person has had little-to-no experience with healthy relationships, the euphoric ‘perfect love’ feelings that occur in the beginning of the relationship are neither realistic nor lasting. The early euphoric love experience is transient as their psychological fragility leads them to an eventual emotional crash and burn. This black-and-white approach to their romances creates a teeter-totter effect of extreme behavior; they either shower their partner with love and kindness, or rage at them with disgust and violence. Their love/hate processing of relationships places an impossible burden on the partner. Often individuals diagnosed with BPD are preoccupied with real or imagined abandonment, which they frantically try to avoid. The perception of impending separation or rejection can lead to profound changes in the way they think about themselves and others, as well as in their emotional stability and behavior. Whether real or imagined, any reminder causes them to strike back at their romantic partner with rage and aggressive hostility. A mistaken comment, a benign disagreement, or an expression perceived as disappointing can quickly transform their loving feelings toward their ‘soulmate’ into a raging retribution against an enemy.”
The brain is the organ of destiny. — Wilder Penfield
The neuroscience of BPD is both fascinating and unusual. BPDs interpret their surroundings through a gallery of uncensored emotions that defy ordinary experience. It is well known that the brain’s limbic system generates the bulk of human emotions, including feelings of love, sexual desire, aggression, and hatred. However, these emotional states are normally regulated by the brain’s prefrontal cortex to ensure continuity of experience within the parameters of external reality. Without neurotypical filtering processes, an electrical storm of impulsive potential becomes as unpredictable as it is unmanageable. Excessive emotional reactivity also occurs whenever critical faculties are not functioning during periods of stress. These “filters of reason” appear relatively absent or significantly diminished in BPDs, thus resulting in a unique hyperarousal of the frontolimbic network that creates “pure” feeling states. Since the BPD’s feelings are unregulated by the brain’s usual gates and checkpoints, a wide range of emotions are experienced with incomparable intensity. In addition, the BPD’s unfiltered feelings may also be experienced by others with similar levels of intensity. For the non-borderline, witnessing these extremes of emotion can be both captivating and terrifying. The BPD’s feelings of love and desire are as unrestrained as their feelings of aggression and hatred. For example, euphoric displays of idealization and affection are compelling stimuli for the non-borderline because such emotional intensity is abnormally exciting. On the downside, disproportionate expressions of rage and hatred will be experienced by the non-borderline as highly irrational, confusing, and extremely disturbing. Furthermore, the pwBPD’s emotions during extreme stressors are not amenable to self-monitoring or self-reflection. In fact, these feeling states erratically alternate without recognizing gradations of interpersonal experience. The BPD’s manifest image at any given moment is contingent on the precarious mechanisms of a reactionary mind, and this juxtaposition will surprise anyone who tries to make sense of such counterintuitive behaviors and cognition. https://www.dana.org/article/the-frustrating-no-mans-land-of-borderline-personality-disorder/
Being a hero is about the shortest-lived profession on earth. — Will Rogers
BPDs are like runaway trains searching for someone who will save them from another crash and burn. BPDs can surreptitiously condition others to respond to their feelings of desperation through forced teaming, and conscientious therapists may feel heroically compelled to go the extra mile—like a case manager on steroids—as a gesture of loyalty. However, this expectation places too much pressure on therapists to compensate for the BPD’s desire for unconditional love, friendship, and support. Unfortunately, the therapist’s rescue attempts will only reinforce the client’s dependence and further vindicate their assertions of distress (Vulnerable BPDs often claim to be mistreated by those who are supporting them either financially or emotionally). In short, the therapist might feel obligated to take care of the pwBPD until the caretaking fuel runs out; but a clinical death trap of Faustian proportions awaits the therapist if they become the client’s go-to person (aka “favorite person”). The BPD’s favorite person is based on a fabricated image (the “distorted other”) that places the therapist on a superhuman pedestal to serve the unfulfilled needs of the client. BPDs often live in a fantasy world inhabited by heroes and villains to protect themselves from painful memories of childhood trauma. As a consequence of such unrealistic constructions, the therapist will unknowingly be subjected to tests and confirmations that either prove or disprove their caretaking worth. Subsequently, the personification of a mythological trope ensues: The therapist, like many empathic individuals before them, becomes the BPD’s latest knight in shining armor (aka negative advocate). In this treacherous association, the BPD’s need to feel loved matches perfectly with the therapist’s need to feel needed. Inevitably, the BPD’s performance evaluation of the therapist’s efforts to be an ideal caretaker will result in either effusive praise or devastating disappointment. Since the most significant goal of BPDs is to gain the unequivocal concern of caretakers, this disorder may very well be the most challenging condition for clinicians to work with when it comes to maintaining professional boundaries. BPD represents a strange inversion of reasoning. BPDs are assertive, and yet insecure. They are needy, and yet suspicious. They are demanding, and yet unappeasable. They are helpless, and yet controlling. Therapists have a job that depends on building trust with their clients; however, BPDs live in a perpetual state of mistrust. Impossible standards of care will be demanded before the pwBPD feels comfortable enough to trust their caregiver. However, attending to those demands without taking sufficient precautions is the beginning of a downward spiral. In the world of BPD communication, everything is upside down and contradictory. It’s a complicated game of semantics that has to be carefully examined before any assumption can be verified. Words like trust, relationship, friendship, love, and caring have entirely different meanings for BPDs, and any deviation from their emotionally challenged dictionary can spell trouble.
Givers need to set limits because takers rarely do. — Rachel Wolchin
Therapists may rationalize exceptions to treatment and loosen boundaries as a way of surrendering to the client’s demands for undivided attention, or to demonstrate solidarity within the therapeutic relationship. BPDs instinctively perceive boundaries as representations of disapproval, so they expect therapists to ignore these inconvenient barriers to bonding. It’s a precarious predicament, because BPDs often think of themselves as being entitled to customized experiences that cater to their immediate emotional needs. BPDs generally expect constant contact with their caregivers and loved ones via email, phone calls, texts, and emergency visits. However, not wanting to alienate or hurt the feelings of the pwBPD in the short term may result in confusion and resentment for both parties when boundaries are no longer amenable to remediation. If therapy evolves from being professional to becoming more casual or “friendly,” it’s only a matter of time before the pwBPD will initiate further efforts to decimate the remaining power differential. The BPD’s urgency to have their needs prioritized can lead to multiple role endorsements by caregivers, such as becoming a voluntary apologist, advocate, family interventionist, avenger, personal secretary, friend, emotional support ambassador, babysitter, affection supply, and emergency manager. It must be understood that BPDs will elicit strong emotional responses from caregivers, and these responses are sometimes experienced as intensified concern (i.e., feelings of pity, outrage, endearment, or moral panic). The therapist must trust their professional instincts more than the emotionally driven impulses of the pwBPD, but clients who are in distress can be difficult to assess with neutrality. Precipitously, the dynamics of the therapist-client relationship can become organized around the client’s capricious emotional needs instead of being effectively redirected or challenged by the therapist. BPDs are in the molding business as they search for others who are willing to become malleable acolytes in service of their “id without a grid.” The BPD’s basic message is: If you care for me, you will do something to make it better right now. A therapist’s protective instinct will automatically be innervated by such displays of desperation, because no caregiver wants to be seen as uncaring. Therapists are in a Catch-22 situation. Like the parable of Thales, therapists can fall into a bottomless well of boundary violations if they focus on attending to the client’s constellation of insurmountable needs. What was once an analytic space, is now forever lost in space.
Psychotherapists face an unavoidable paradox: They must immerse themselves in the moment to empathize with patients and emotionally distance themselves to maintain boundaries or offer perspectives to foster change (Bateman & Fonagy, 2006). Philosophically, therapists strive to adopt a dialectical stance in which they simultaneously accept the patient while facilitating change in the patient (Koerner, 2012). From a practical standpoint this means switching between validation and change during a session, often in the same intervention, and flexibly navigating this contradiction (Koerner, 2012). Gabbard & Wilkinson (1994) argued that therapists typically react by becoming either over-involved to “save” the patient or under-involved to emotionally distance themselves.
Controlling my environment was still a compelling need for me. I did everything I could to not be surprised by anything. Looking back, I think that my need to predict how my day was going to unfold was a direct response to the amount of chaos in my childhood. — Olga Trujillo
It’s important to be aware of the BPD’s requirements for validation, proximity, and reassurance. They cannot tolerate being alone (autophobia) any more than they can tolerate stressful or challenging situations. Without self-acceptance, BPDs perpetually rely on acceptance from their environment. BPDs will identify characteristics in others, such as generosity or agreeableness, to get their needs met—appearing retrospectively as premeditated manipulation, albeit unintended. Incidentally, the longer a pwBPD has gone undiagnosed and untreated, the more refined their survival mechanisms will become. In layman’s terms, BPDs are less interested in change than changing others to get what they need. Other people (aka need-gratifying objects) are in a position to provide services, but if those services fail to meet the BPD’s expectations, calamity will likely ensue. Therapists, by definition, are trained to be of service to those in need; however, BPDs will take advantage of every accommodation offered while cataloging these susceptibilities for future interactions. They will subjugate challenging interpersonal encounters because it makes them feel uncomfortable, and spatial distance is perceived as a sign of rejection. BPDs simultaneously seek and reject help, because accepting help that requires significant change makes them feel out of control. Notice the inherent contradiction: A helpless victim who needs to be in control. Perfectionism, a common BPD attribute, is another manifestation of control that acts as a substitute for external validation (i.e., “when I’m perfect, then I’ll be loved”). Counterintuitively, perfectionism also serves as a form of self-invalidation because these unrealistically high standards are self-imposed. It has also been argued that BPD perfectionism is a symbolic representation of “emotional cutting.” The Borderline lives in fear, but control makes them feel safe. BPDs will try to obtain as much control and power as they are allowed in adulthood to compensate for the lack of control they experienced in childhood. Control of themselves and others is the BPD’s primary method for fear management. Meanwhile, they’ll continue to dispatch a decoy of ineptitude for maximum effect as they demand unreasonable levels of emotional and/or material support from anyone who gets too close to them. As a result of appearing victimized, the pwBPD’s stated concerns can be misinterpreted as legitimate complaints rather than pathological patterns of dependence. With BPDs, you cannot separate personal motivation from psychopathology; it’s a distinction without a difference. Consequently, any therapist who accepts the pwBPD’s assertions of helplessness at face value is headed for an imminent clinical disaster. The BPD’s victim identity provides a more secure attachment to caregivers, but this attachment is unendurable. Subsequently, therapists will lose objectivity by allowing themselves to become emotionally influenced by the pwBPD’s ongoing quagmires.
Listed below is the Borderline’s Tyrannical Toolkit for obtaining recognition, support, resources and allegiance from family, friends, romantic partners, or caregivers. Commanding the will of others is the BPD’s primary goal to mitigate their insecurities and fear of abandonment. Weaponizing emotions is the bailiwick of the emotionally unstable. These survival-based methods of control are strategically effective because they demand impassioned responses from the BPD’s “target” or intended audience.
- Anger/hostility: Anger evokes a sense of urgency and fear in others, which may result in attempts to de-escalate the pwBPD through appeasement and various efforts to soothe their rage. Although it usually has the opposite effect, hostility can sometimes induce deference and accommodation. Disappointment, entitlement, and devaluation belong in this camp.
- Seduction/charm/flattery: BPDs sometimes use seduction as a form of currency for gaining approval, or as a defense mechanism to avoid further scrutiny. BPDs may flirt and flatter until others acquiesce to their requests and desire to be validated. To acquire secure attachments, BPDs can become whatever they think you want them to become, or they will tell you whatever they think you want to hear. Either way, these approaches to persuasion can be very effective. Idealization and “love bombing” fall into this category.
- Incentivizing: Gifts and/or financial control. Gifts can be used as a form of coercion under the guise of generosity. Receiving gifts compels others to respond with attentiveness and appreciation while feeling obligated to reciprocate. Subsequently, others will feel valued and willing to do more for the pwBPD. In a similar, but more extreme way, financial control implies a position of ownership to ensure that all eyes are focused on the donor.
- Pity: Portraying victimization to solicit support and affirmation of suffering. Appeals for sympathy can be extremely powerful, because most people do not want to be seen as indifferent to the suffering of others. Threats of self-harm or suicide can engender compassion and compliance from loved ones. Martyrdom is another method for obtaining concern, whereas malingering evokes pity and avoids responsibility altogether.
- Guilt: Shaming through guilt can make others feel negligent, insufficient, or incompetent. Apologies and offers of compensation will be made by those who succumb to blameworthiness. Criticism and disapproval also causes others to feel self-conscious, or question their own experiences, thereby becoming more amenable to BPD influence. Gaslighting belongs in the garage of internalized guilt.
- Blackmail: An effective way to intimidate others into compliance is by posing unmerciful ultimatums. Punishment often awaits those who disappoint the BPD. The message is: “Do it or lose it!” This strategy reminds others that the BPD is always in control. Double binds and other threats belong in this category.
- Entrapment: Obligation through legal ties (e.g., marital, financial, children, or professional endeavors). BPDs will work quickly to secure contractual commitments from others, but this association can result in consequential involvement with the court system whenever that commitment sours. More importantly, high-conflict personalities will use the legal system as a way to obtain resources, gain attention, or to seek revenge.
When they discover the center of the universe, a lot of people will be disappointed to discover they are not it. — Bernard Bailey
BPDs share many similarities with those suffering from attention-deficit disorders, but they primarily feel that not enough people are paying attention to their needs for support and validation. Most BPDs were not paid enough attention to in childhood, so they will try to over-compensate for this lack of developmental stimulation in adulthood. In fact, this is why BPDs are seen by others as self-absorbed and universally impatient. BPDs are on a subconscious mission to course correct for childhood deprivation, and they expect loved ones to be compliant and sympathetic to their need for reclaiming recognition. “People with BPD often derive their sense of worth from how much other people are serving them,” says psychologist Daniel S. Lobel. Harboring enormous levels of self-doubt, BPDs experience a sort of “prosopagnosia of the soul” (identity diffusion) and rely on others to stabilize their fragile sense of self-worth. Otto Kernberg, a psychiatrist who pioneered a new understanding of Borderline Personality Disorder, believed that pervasive feelings of loneliness and the need to belong to something were the driving forces behind all of the other behaviors associated with BPD. For the BPD, other people unwittingly serve as props to help them achieve emotional stability while quenching their thirst for propinquity. Therapists learn that successful therapy requires patient engagement by developing a strong therapeutic alliance, but too much obsequious interaction with BPDs will create an avalanche of starry-eyed expectations. The Borderline is an equal-opportunity seeker whenever emotional propitiation is on tap. Compliance with the fanciful expectations of the BPD is expected, but don’t expect the BPD to comply to the rules and expectations of others. Over time, trying to successfully manage such clinical complexity will become overwhelming for the therapist (this is a telltale sign that someone could be hitting home runs in the Cluster B ballpark). BPDs often assume that their therapist should be available on demand to soothe their feelings of desolation and anxiety. The BPD’s hypersensitivity to criticism and mistrust of others can also make therapy exceptionally challenging without triggering their inferiority/superiority complex. BPD’s are generally thought of as covert narcissists (aka “failed” or “shy” narcissists) who can easily convert others into seeing things as they see it. Therapists who don’t suspect BPD psychopathology will eventually be caught by surprise (like an off-duty police officer during happy hour) whenever they say or do something “wrong.”
It is the fool who thinks he cannot be fooled. — Joey Skaggs
The valence of Borderline Personality Disorder is perennial pathos and desperation, but keeping the underlying fear from being fully exposed may prevent or indefinitely postpone diagnosis. Likewise, to appear vulnerable can suggest that there’s something about the client that therapists should protect and pacify, although vulnerability among BPDs is seldom revealed as a form of subterfuge. BPDs will modify their behavior and appearance to please others, and these alterations are contingent on caprice as much as they are on context. The BPD’s shape-shifting capacity to present themselves in a carefully assembled manner is a survival-based façade (aka “false self)” that increases their ability to receive social acceptance while appearing normal, relaxed, or glamorous (predominant among BPDs with histrionic traits). Not being allowed to individuate during childhood, BPDs will pretend to be someone who they believe others will admire to avoid feelings of being flawed. However, therapists must learn to ignore the client’s window dressing (aka supernormal stimuli) and pay closer attention to how the furniture is arranged inside the building. Underneath the BPD’s veneer of well-crafted composure lies a cauldron of festering resentment, fear, insecurity, and hostility from unprocessed frustrations. According to psychoanalyst Donald Winnicott, there are five degrees of the false self. In the worst-case scenarios (i.e., extreme cases), the true self is completely hidden. The false self is required to become so strong that it appears to be the true self. To be sure, BPDs can be very successful in life, but typically their intimate lives suffer. At the other end of the scale, the “nearly normal cases” still retain a false self but meet ordinary social expectations. However, once the BPD’s false self begins to crack, an unexpected display of extreme euphoria or intense anger can overwhelm and confuse therapists. BPDs may also incorporate emotional blackmail and double binds to acquire unambiguous commitment from their caregivers. Counterintuitively, these behaviors are defense mechanisms to preemptively avoid feelings of abandonment by preemptively asserting dominance. Just as live wires require neutral sources for proper conduction, BPDs crave the perceived stability of others to resolve feelings of discontent and emptiness. Likewise, the BPD’s fragmented identity is a foreboding klaxon for therapists who attempt to undergo the monumental task of core restoration without producing enmeshment. BPDs also have a preternatural antenna for spotting those who appear charitable, such as caregivers who are committed to making a difference, and may use flattery through attribute mining to create an atmosphere of revelry. As a result, the therapist’s temptation to become more friendly allows the pwBPD to avoid being confronted or challenged in ways that could reveal maladaptive patterns of interaction that were previously unnoticed.
Voices carry. — Amiee Mann
Too much self-disclosure and overindulgent styles of caregiving are equally dangerous when working with BPDs. Once the bargaining stage of self-sacrifice for the sake of the BPD begins (masochistic surrender), the therapist is headed for an impossible task of perpetual mollification. Most therapists do not possess the power of prescription. What do they have? The power of conversation, encouragement, reassurance, and emotional support. However, the very qualities that make therapists good at what they do (i.e., being attentive, considerate, empathic, and accommodating) are the very qualities that can work against them when interacting with BPDs. Therapeutic conversations that focus on shared experiences are necessary for establishing trust with BPDs, but certain forms of trauma bonding may reinfocre a rescuer-victim paradigm that is internalized by both participants. Avoiding early discussions about the limitations of therapy with a pwBPD only postpones the inevitability of future disappointment. Talk is cheap, but the consequences of misguided communication are not. Volunteering to become a clinical marionette at the BPD’s disposal is a form of professional self-abnegation that can gradually occur as a consequence of trying to please the unpleasable. For example, repeatedly soothing a cancerous outbreak with corticosteroids will temporarily reduce pain and inflammation, but it will not remove the patient’s tumor. A therapist’s compulsion to comfort the pwBPD may also occur if they are reminded of urgent demands imposed upon them by their own family of origin. However, BPDs identify with suffering because pain was often associated with receiving attention and nurturing from a caregiver during childhood. Although BPDs may plead with others to resolve their emotional pain, they’re ultimately too afraid to let go of what they know best. In addition, BPDs will unconsciously use therapists as objects to fulfill needs unmet in childhood (i.e., the ideal mother/father), or fantasies unattainable in adulthood (i.e., the ideal loving partner). Likewise, the therapist may unknowingly respond to such needs for purposes of correcting former attachments gone awry in their own life, or to receive affirmations of caretaking competency. The chemistry of familiarity is a strange brew indeed.
Lookin’ for love in too many faces. — Johnny Lee
Subconscious transference by the pwBPD and countertransference reactions by the therapist will undoubtedly emerge as sessions progress. Additional therapist-client intrigue can occur because of shared interests, trauma bonding, family of origin similarities, and other forms of overidentification. Similarly, the intimate nature of one-on-one therapy is magnified whenever working with Borderlines because of their intense need for caring and attachment (an infectious intensity). Interacting with BPDs is a bewildering lesson in psychological hermeneutics, and understanding what’s really being communicated requires a great deal of careful analysis. For example, idealization (aka “love bombing”) of the clinician is a common phenomenon with BPDs who become overly attached. Not surprisingly, most therapists enjoy being admired for their efforts to provide comfort, advice, and reassurance—regardless of the client’s tendentious proclamations. After all, therapists are human beings who have their own needs for validation in an otherwise thankless and emotionally grueling profession. Nonetheless, this “admiration” via idealization may have a trapdoor that includes eroticized transference (an intense, vivid, irrational erotic preoccupation with the therapist characterized by overt, seemingly egosyntonic demands for love and sexual fulfillment to compensate for emotional neglect and/or abuse in childhood). This transference dynamic can intensify because the therapist is literally paid to pay attention to their clients through empathic attunement and unconditional positive regard. If, for example, the therapist misinterprets the BPD’s fixation for genuine appreciation, or if the therapist augments this transference-based reenactment by also admitting auspicious feelings for the pwBPD, a misunderstanding of what is personally conveyed versus what is pathologically motivated could result in a chain of events ending with the BPD’s need for establishing a corrective relationship. In such cases, the therapist may feel simultaneously drawn to the BPD’s needy persona and express malignant eroticized countertransference to acknowledge the client’s amorous disposition, especially if the therapist is not able to productively displace their own unconscious frustrations. Fantasies of “making up” for the client’s dismal past can also occur if the therapist’s desire to be seen as a paragon of benevolence (unobjectionable positive countertransference) is not self-monitored with sufficient reality testing. As therapeutic dialogue resumes, the BPD’s need for acceptance can become increasingly problematic for therapists who are not effectively managing countertransference reactions. For the pwBPD, caring is conflated with intimacy. It turns out that Freud was right after all.
You are special too, don’t lose yourself. — Ernest Hemingway
BPDs have a unique ability among mental health clients to uncover repressed aspects of the therapist’s self through systematic transference. Once the Kool-Aid of projective identification (to induce the other to become) is properly ingested, the ability to sustain mentalization (separation of identities) quickly evaporates. BPDs expect caregivers to meet them at their frustrated level of psychological development, or else the caregiver is just another asshole like everybody else. And, to be sure, no caregiver wants to be thought of as an asshole. Therapists may become equally puerile, irrational, and impulsive as they attempt to appear more accessible, trustworthy, and convincing to the BPD via introjection (internalizing various aspects of the client’s values, feelings, and behaviors) and projective counteridentification (endorsing symbolic roles that the pwBPD avows or disavows via projective identification). The therapist, in essence, becomes whatever the BPD needs them to become in a transmogrifying maze of psychodrama-infused cosplay (un couple malade). For example, this equalization process can cause therapists to regress—literally losing themselves—in order to accommodate the BPD’s regression rather than maintaining a detached objectivity. It’s like host manipulation by parasite, replete with layers of rationalization that succumb to an emotionally charged form of subliminal programming. BPDs are hostages of their own impulsivity, but they have an incredible gift for sharing the voltage of those impulses with other potential targets. Once the defensive sensibilities of the therapist are effectively neutralized, the therapist may no longer think of the client as a subject of observation.
“The patient’s use of projective identification exerts subtle and powerful pressure on the analyst to fulfill the patient’s unconscious expectations that are embodied in these fantasies. Thus the impingement upon the analyst’s thinking, feelings, and actions is not an incidental side-effect of the patient’s projections, nor necessarily a manifestation of the analyst’s own conflicts and anxieties, but seems often to be an essential component in the effective use of projective identification by the patient. Therefore, a patient’s projective identification efforts are most likely to bring about some type of result if they affect the therapist. Often, if a patient feels that the therapist ignores these efforts, the patient may redouble them or may give up and try elsewhere, acting out in other relationships. The projective identification mechanism may bring the therapist in touch with core fantasies of a particular type of relationship that lives within the patient’s mental structure. The urge for the therapist is to become an active participant and act out the according feelings and behaviors,” writes Dr. M. Feldman. Similarly, the therapist may project whatever they want to believe about the client rather than scrupulously analyzing the incongruous reality of the client’s psyche. We are now reminded that the sleep of reason really does produce monsters. The psychic fusion of the client and therapist can rapidly morph into a tangled web of quid-pro-quo arrangements to quell the BPD’s urgency for devotion and to satiate their intense yearning for affection (BPDs are extremely adept at attachment seeking, although they simultaneously mistrust those attachments). The BPD’s libidinal intrusiveness via eroticized transference can present as disorienting and overwhelmingly arousing for any therapist who is misinterpreting their client’s subconscious messaging. As a result, the therapist might end up getting their own needs met by feeling indispensable in the face of attending to such challenging inducements (i.e., falling in love with the idea of making the client feel loved). Likewise, the therapist may confuse responding to the client’s psychopathology with the experience of establishing an unparalleled emotional connection. It’s a textbook example of folie à deux.
“Because of the centrality of projective identification in the experience of treating borderline patients, therapists often feel invaded and transformed into someone other than who they are. Attempting to resist this transformative process can be a formidable problem. Firm boundaries and reasonable limits will eventually reduce the patient’s infantile demands. When the therapist refuses to be the idealized, perfect parent, patients will ultimately learn that they must become their own mothers—the wish to fuse and be fed must be turned inward,” says Dr. Glen Gabbard. As Masterson (1976) noted, “Probably the single most difficult skill to acquire in psychotherapy of borderline patients is the ability to recognize and control one’s own identification with their projections.” Rule of thumb: Never go full-transference gratification.
We’re far from the shallows now. — Lady Gaga
BPDs can pressure therapists into becoming “psychosocial saviors” if their purported tales of victimization and historical discrepancies are not thoroughly investigated. Fear and denial keep the pwBPD from having to do any of the emotional heavy lifting, so they become experts at deflection by reorganizing factual accounts to avoid personal responsibility or feelings of shame (experiential avoidance). As a result, therapists might feel responsible for doing more than they should if they become swept away by the BPD’s anecdotes of adversity. Unfortunately, the more the therapist does, the more will be expected by the pwBPD. In fact, the therapist may be responding like everyone else in the BPD’s life by attending to the never-ending needs of a desperate foundling in search of a supportive audience. However, the more the therapist tries to solve the BPD’s problems, the more difficult these problems become (aka the tar-baby dilemma). The therapist may unknowingly represent the most recent target in heavy rotation on the BPD’s take-care-of-me carousel. From the American Addiction Centers: “People with BPD have relationship issues with nearly everyone in their lives, and significant relationship issues will often develop with therapists as a result of the therapeutic process of change. The patient may first idolize the therapist and then later totally demonized them (splitting), or may attempt to manipulate different therapists against each other in order to manipulate the overall treatment. Professionals who treat people diagnosed with BPD must be aware of these potentialities and even expect them to occur. Unstable personal relationships within treatment itself as well as outside treatment contribute to the difficulty of helping these individuals adjust.” However, the limited time frame of therapy is not equipped to withstand such relentless permutations of stratagem. As a consequence, the therapist may begin entertaining taboo fantasies of attending to the client’s psychosocial “emergencies” outside of a clinical context. Without maintaining boundaries, the therapist will no longer be able to maintain objectivity; without maintaining objectivity, the therapist will forever be trying to extinguish the pwBPD’s peripheral complaints instead of addressing the client’s core issues. BPDs subconsciously manufacture their own misery, but they can make anyone who attempts to fix their problems even more miserable. Like a swiftwater first responder, the therapist will drift farther and farther down the gauntlet of BPD appeasement until the rescue raft of good intentions finally capsizes. The helping profession of psychotherapy encourages the development of a genuine relationship to help the client, but it’s the professional aspect of the relationship that must be prioritized whenever 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 pwBPD will drive everyone off the nearest cliff with their busload of needs. Meanwhile, the therapist should prepare to be thrown under the bus whenever those “needs” are no longer being gratified.
Change begets change as much as repetition reinforces repetition. — Bill Drayton
Addressing the continuous demands of a BPD is like experiencing The Myth of Sisyphus on methamphetamines; it’s utterly exhausting. BPDs will make six impossible demands before breakfast, but any effort to obey these demands will result in six more impossible demands before lunch and dinner. BPDs largely identify with the drama of their problems, so any attempt at remediation will threaten the BPD’s identification through externalization. Lacking in object permanence, there are never enough words of reassurance or altruistic gestures to placate the BPD’s need for consolation—you might as well be sweeping a dirt road. In such circumstances, the therapist may find themselves making promises equivalent to the emergency demands of the BPD in an effort to de-escalate emotional reactivity; attenuate impatience; soothe anxiety; or to continue receiving encomiums as an intrepid caretaker. As this temerarious gambit commences, the pwBPD will invariably become more dependent on the therapist’s attempts to stabilize their compromised sense of self. Meanwhile, therapists may become addicted to eliciting positive changes in the BPD’s emotional state. The BPD’s ability to reshape the therapist into becoming a more responsive caretaker provides an insurance policy for maintaining centrality. Predictably, the unwitting therapist may feel authenticated by the BPD’s gestures of lavish appreciation—willing to risk more and more for the sake of accommodating their client. Therapists who allow BPDs to take advantage of their generosity are conditioned to be uncritically sympathetic to those in need. As one could imagine, it’s easy in these situations for therapists to feel revitalized by offering levels of emotional support and reassurance that are unavailable to the client in other contexts. After all, if positive psychology teaches us that finding a sense of meaning and engagement is curative, nothing could feel more meaningful for a caregiver than assisting a client who appears helpless and unambiguously appreciative. However, the BPD’s veneration of the therapist is always contingent on a continuation of appeasement within the therapist-client validation pyramid scheme. No matter how intoxicating the back-and-forth of validation can feel during the ascending honeymoon period, the end result will invariably lead to emotional bankruptcy and disappointment. Although idealization is a potent dopamine generator, therapists should be suspicious if they become the subject of excessive pedestalization. Borderlines and assiduous caretakers are lock-and-key participants in therapeutic relationships, but this indelicate union involves countless caveats. BPDs will use perspicacity based luminol to expose the blood stains of anyone who is willing to be subservient to their needs. Once the lifeblood of caregiving capitulation is located, BPDs become merger-hungry hemovores of opportunism.
I went down, down, down and the flames went higher. — June Carter Cash
The therapist might regrettably believe that professional boundaries aren’t going to be manageable or effective for addressing *this* particular client’s needs. In fact, the therapist may have never encountered a client who is so oblivious to standard rules of engagement (BPDs are often raised in households without any sense of interpersonal boundaries). If the therapist is intimidated by the client’s assertive and impulsive demeanor, a “Borderline Without Borders” situation will eventually consume the therapeutic frame. Additional fears of being perceived as uncaring or inaccessible during therapeutic interactions may cause the therapist to feel guilty. As a result, exceptions to standards of care are reluctantly made to keep the client engaged (aka VIP syndrome). BPDs occupy a privileged position as mental health clients because they often respond in therapy according to the whims of a child while being granted the respect and rights of an adult. In some cases, therapists may become self-conscious and feel as if they are being emotionally negligent by upholding professional standards. BPDs also have an aptitude for making other people feel responsible for their feelings, and the gravity of this burden can turn caregivers into deferential doormats or rescuers to avoid conflict. The BPD’s psychological pull has the capacity to draw therapists into their kaleidoscopic world of emotional mayhem if the therapeutic alliance is threatened. Furthermore, an erroneous belief can be endorsed that acquiescence and improvisation must dictate the direction of all future interactions to compensate for the BPD’s unresponsiveness to protocol. In other words, the standard rules of therapist-client engagement become secondary to changes in the therapist’s subjectivity as they are provoked by the experience of working with BPDs. By this point, an over-involved therapist has already dug their own clinical grave site. To be sure, BPDs will defy boundaries without compunction while expecting therapists to suspend the reigns of professionalism whenever therapy is perceived to be uncomfortable, uncaring, or impersonal. BPDs can play nice, but only if you’re following their rules. Once a boundary free zone is established, therapists should expect an escalation of efforts by the pwBPD to dominate the direction of all subsequent interactions. Whenever the floodgates of unconditional acceptance open up, BPDs become Dionysian tornadoes bent on annihilating the Apollonian structures of psychotherapy. BPDs can be intense and rewarding to work with during therapy, but you must always be aware of the fine print. The only predictable variable when working with a pwBPD is unpredictability.
Yeah, yeah, my shit’s fucked up; it has to happen to the best of us. — Warren Zevon
A veritable recipe for disaster also awaits if therapists are coping with issues of their own, such as compassion fatigue, major life transitions, marital discord, family problems, work stress, anxiety, or depression. Improving the lives of others leaves little time to improve one’s own life, and working with a misdiagnosed pwBPD can be a career killer if the therapist is not operating on all cylinders. Therapists must suppress their emotions due to the nature of their work, but this occupational necessity can make working with BPDs exponentially more problematic. Contrary to professional ideals, therapists are not emotionally impervious automatons. As a reminder, a therapist’s unresolved psychological conflicts become magnified to an enormous extent through transference-induced provocations whenever interacting with BPDs. Because BPDs relate to the world through a landscape of dysregulated emotions, the therapist must work even harder to manage theirs. A reliable axis of balance for one’s own mental health is required before being able to identify degrees of imbalance in others. Likewise, losing one’s proverbial mind can sometimes occur as a byproduct of working with those who have already “lost” theirs (e.g., vicarious trauma and burnout). Therapists need therapists too. Without proper self-care, the ability to care about the cohesiveness of the therapeutic frame will be less significant—resulting in a ripple effect of potential transgressions. Well-Functioning is defined as the enduring quality in the therapist’s professional functioning over time, and in the face of professional and personal stressors (Coster & Scwebel, 1997). Therapists have many factors to contend with in life and practice aside from the dynamics of working with borderline patients. The most common personal problems interfering with therapist well-functioning are emotional exhaustion and fatigue (Mahoney, 1997). For the clinician, it may be just another day at the office; but for the Borderline, it’s about survival of the neediest (this is why ongoing supervision and consultation are essential, including the willingness to admit a need for such objective interventions). In fast-paced clinical settings, there may be insufficient bandwidth for in-depth analysis of complicated psychiatric patients. Demanding clients condition therapists to become multitasking fire extinguishers, and no client is better at starting fires than a pwBPD. Emotional exhaustion is difficult enough without having to manage an emotionally unstable and unpredictable client. Without proper training for the early identification and comprehensive management of BPD, therapists are potentially lost in an ocean of misapprehensions and clinical missteps. Working with a misdiagnosed pwBPD is like conducting therapy in Plato’s Cave, because the client’s fractured identity and duplicitous nature will present itself as an ongoing enigma. If the therapist’s critical thinking is disabled, the BPD’s regressive tendencies will quickly capture the limelight (reason and logic are mortal enemies of the emotionally impaired). Consequently, the therapist may become a reluctant participant, or a willing accomplice, in the pwBPD’s quest for enmeshment and control. Soon thereafter, a bizarre array of rationalizations are incorporated by the therapist to maintain denial about their growing sense of fear, obligation, and guilt (FOG). Therapists spend their days trying to transform the lives of their clients, but BPDs have the power to transform therapists. With BPDs, the Rogerian maxim should be carefully reconsidered with a strong dose of the conditional.
And you may ask yourself, am I right? Am I wrong? And you may say to yourself, ‘My God! What have I done?’ — David Bryne
Pervasive patterns of acting out conveniently thwart BPDs from recognizing high levels of neuroticism, or learning to effectively cope with deep emotional wounds. Although thought suppression keeps BPDs from feeling emotional pain, it ultimately prevents self-reflection and results in sensation-seeking behaviors. Borderlines, if they are anything, are invariably misunderstood by others. Similarly, BPDs detest personal criticism and do not appreciate humor at their expense. The pwBPD believes that other people must acknowledge their persistent feelings of emptiness, suffering, and desperation. BPDs are not always looking for solution-based therapy as much as they are looking for someone to recognize and attend to their emotional needs. In addition, Borderlines will rely on other adults as parental figures for advice that is seldom integrated in any meaningful sense (solution implementation is an obstacle due to active passivity). If the therapist is not careful, the inclination to violate boundaries for the sake of “repairing” the pwBPD becomes more likely.
“The ongoing temptation in the psychotherapy of borderline patients is to try to provide gratification for longings that cannot possibly be satisfied in a professional relationship. Indulging the patient’s wishes is a strategy bound to fail and also bound to engender regression by reinforcing infantile expectations, which will only intensify the patient’s eventual rage,” states Dr. Glen Gabbard. Despite their age, BPDs must be approached with adequate restrictions because of their emotional instability, immaturity, and inability to delay gratification. BPDs want to outsource the necessary task of growing up by avoiding self-reflection. The biggest mistake a therapist can make with a pwBPD is to interact with them as if they were rational adults with reasonable levels of self-awareness and personal responsibility. No therapist wants to infantilize an adult client, but BPDs sometimes require referees more than collaborators. As a defensive response, some therapists may become overly rigid to compensate for the Borderline’s occasional hostility. However, being too reserved could lead to accusations of appearing distant, cold, uncaring, or judgmental. This oleaginous tightrope is even more hazardous if the therapist is unaware that such boundary testing maneuvers are part of the BPD’s need for unambiguous acceptance. What initially felt like a once-in-a-lifetime clinical challenge could result in occupational suicide if accidentally mishandled.
But then you let me down, when I look around; baby, you just can’t be found. — Madonna
BPDs will sometimes attach to those who are inaccessible, but whenever the attachment is disrupted, the object of love will quickly become the object of aversion. Borderlines view separation as betrayal, and perceived rejection by a caregiver can evoke abandonment rage. Without the availability of a compliant object for emotional support, the former adoration of the therapist magically evaporates as the BPD’s existential fear begins to surface. BPDs will perceive malicious intent where none actually exists, and their primary mode of communicating disappointment is through reactionary rage. Without being able to control their emotions, vilification quickly follows adoration. Sadly, the therapist may still be enamored with the BPD’s former displays of enthusiasm and the warm glow of being idealized. The emotionally starved and competitive BPD wants love to be a possession, whereas the therapist may become lovesick in their pursuit of healing the client. BPD relationships alternate between gluttony and starvation; it’s all or nothing. Ironically, interacting with a BPD can initially feel like an invigorating portal of escapism for the therapist; the rest of the world seems to disappear as the caregiving lens focuses on rescuing the unrescuable. However, the therapeutic lifeboat may need to hit an iceberg of BPD indignation before the caregiver comes to their senses. BPDs prefer codependency instead of being challenged, and they’re remarkably proficient in achieving such ends. Any ambiguity in the BPD’s search for enmeshment is terrifying, and the prospect of change is unbearable. BPDs seek stability, reassurance, approval, and unambiguous gestures of affection, but it ends up being at the expense of everyone around them.
Dr. Perry D. Hoffman, president and co-founder of the National Education Alliance for Borderline Personality Disorder, explained one of the defining aspects of the disorder: “It occurs in the context of relationships. Unlike other psychiatric diagnoses, if you put someone with schizophrenia on an island all by themselves, their mental illness would still be evident. If you put someone with BPD on an island, you wouldn’t necessarily see the symptoms—whatever happens, happens in the context of [interacting] with someone else.” Instead of becoming a storm chaser, it’s better for therapists to understand the nature of the storm.
I’ve waited hours for this; I’ve made myself so sick. — Robert Smith
Because BPD is essentially an attachment deficit disorder, the client’s approval-seeking behavior and search for unconditional love is often insurmountable. However, overly attentive responses to the accumulating demands of BPDs will result in an unavoidable crash landing. The problem is that therapists have been issued the caregiving equivalent of a pilot’s license and will be held accountable for any loss in therapeutic altitude. However, if BPDs could rewind the flight recorder, and muster a modicum of self-reflection, they would discover themselves bombarding the analytic cabin space and taking over the control panel. Just as the therapist has misinterpreted the BPD’s emotional reasoning as justifiable, the pwBPD will undoubtedly misinterpret the therapist’s efforts towards appeasement and feel betrayed if caretaking promises aren’t kept. This high-conflict personality can become extremely volatile if their chosen “protector” appears to have forsaken them on purpose. After all, the therapist has been providing a steady supply of validation, reassurance, and emotional support in a safe holding environment. Unprepared therapists could be marinating in a clawfoot tub of Cluster B bathwater before waking up to find themselves circling the drain. If the BPD’s sense of identity is experienced as being dependent upon a stable relationship, the therapist who withholds validation by reinforcing boundaries has just abrogated the client’s recognition of self (it’s like denying refills on medication). The therapist has unwittingly been serving as the BPD’s missing internal part, and now that part is wearing out. In the end, BPDs will pull the rug of congeniality from underneath their caregivers whenever the gravy train of unsustainable support goes off the rails (cessation trauma). The BPD’s dichotomy of self will vacillate as the previously dependent victim quickly becomes an avenger. In such situations, the former idealization of the therapist is replaced by a 180-degree devaluation phase. A critical threshold of stress has been reached and the Borderline within has been unleashed. What was once an entirely “good” object is now a completely “bad” object (splitting), because there is no middle ground in the BPD’s world of internalized object-representations. An overwhelming desire to feel safe again compels the pwBPD to bifurcate people, messages, and situations into simple categories. BPDs consistently puts their needs at the forefront, so any sudden reduction in attentiveness (aka narcissistic supply) will always end badly. The resulting devaluation period will likely include displays of intense anger, paranoia, resentment, blame, and retribution as the BPD’s self-fulfilling prophecy of abandonment continues unabated. Most disturbingly, BPDs are generally unable to recognize their own accountability before, during, or after such contentious interactions.
“Borderlines display a signature trait, poor observing ego, which is a dense denial of vital aspects of reality and irrationality to a degree that almost has to be seen to be believed,” says Dr. Daniel J. Zimmerman. Identity disturbance is evidenced by the BPD’s intense and tumultuous attachment to their love object. They yearn for affection, yet may eventually wish to destroy the love object, or at least significantly devalue the person’s life. The gratifying sensation of vengeance makes resentment feel justified as the “bad” parent is symbolically punished in a dramatic fort/da reenactment. In order to protect themselves from such unbearable disappointment, the BPD will attempt to regain a sense of control over what they perceive to be an invalidating experience (impulsive BPD subtypes with antisocial and narcissistic traits are particularly prone towards destructive recrimination whenever enmeshment is threatened). The angry/impulsive child is experienced by the BPD’s intense rage that is rooted in childhood resentment for not receiving proper parental care. BPDs control what they want, but they often destroy what they cannot have.
“The spoiler child refuses to grow up, remains dependent in some way on the parent or a parent surrogate, and ruins and/or denigrates everything the parents try to do for them,” states Dr. David M. Allen. “The spoiler role is difficult to maintain, so the child needs to continually practice it with other people. The usual candidates for them to practice on are lovers, spouses, and of course therapists. No one else will continue to put up with them.” The phrase no good deed goes unpunished has come home to roost.
The end may justify the means, as long as there is something that justifies the end. — Leon Trotsky
BPDs can ingeniously reframe events for advantageous purposes, but retrospective discrepancy identification will separate what is true from what is exaggerated or false. BPDs are poor historians, because the past is written on the pages of their emotions. Without a stable identity, it’s difficult to be self-aware enough to follow the arc of chronology. Part of this unpredictable disorder is the BPD’s inability to think of their impulsive behavior; obsession with control; and emotional reasoning as disordered. For the pwBPD, what “feels right” must be right. BPDs need to experience immediate emotional satisfaction, even if it’s irrational or devastatingly consequential. BPDs do not see their part in causing or contributing to their own problems, because admitting such involvement would require an uncomfortable awareness of deep emotional wounds. Likewise, BPDs believe that all of their problems are external, because they cannot sit with themselves long enough to accept what they are forever trying to run away from. In tandem, therapists will ignite a codependent wildfire by making attempts to soothe the BPD’s emotional flames rather than carefully analyzing the BPD’s behaviors and thought processes—transforming caregivers into volunteer firefighters searching for the next batch of smoke. Doing too much for BPDs inevitably results in doing unintended harm, simply because BPDs don’t know what’s best for them. Remember, BPDs are living in a state of arrested development and can overreact like an unruly toddler whenever confronted with a challenging situation (low frustration tolerance). BPDs see the world in terms of love and war, because there are shades of grey in the Cluster B playground. Likewise, if the therapist is unaware that the pwBPD is acting out, they won’t be focusing on appropriate treatment interventions. Instead, therapists may endorse the impossible position of becoming the client’s designated overseer (i.e., the parentification of the provider). Reparenting is an impossible task for anyone, so therapists must resist trying for purposes of self-preservation while encouraging the pwBPD to develop self-restraint. Like children, BPDs do not notice the line of demarcation where their needs stop and another person’s needs begin. Assuming that BPDs are receptive to logical reasoning and compromise, or will become receptive with enough rational persuasion, is a very bad assumption. Normalizing the abnormal, however tempting, is sometimes the most precarious decision a clinician will ever make.
“Psychoanalysts view borderline personality as arising from failure by the patient’s mother to foster coherent differentiation between self and object in the first 18 months of life, leading to the development of pathologic ego defenses. The patient does not learn to tolerate negative affects associated with separation; this continues the child’s clinging into adulthood, as if others were desperately needed parts of the self. Sexuality and dependency are confused with aggression. Needs are experienced as rage. Long-term relationships disintegrate because of an inability to find optimal interpersonal distance. Because of inadequate ego mechanisms of defense, there is little ability to master painful feelings or to channel needs or aggression into creative outlets. The patient has a fragmented mental picture of the self and views others as all bad and simultaneously all potent, a chaotic mixture of shameful and grandiose images,” states Dr. James E Groves.
There’ll be someone else where you used to be; the world don’t care and yet it clings to me. — Tom Waits
By using whatever means necessary, the focus of all future concern will be relocated to the BPD’s elaborate amphitheater of victimhood, thereby disabling all possibility of self-awareness. Misfortune will solicit sympathy from others, no matter how much misery has been manufactured by the pwBPD. In a borderline’s binary mind, you’re either for them or you’re against them. The BPD’s desperate longing to use the therapist for positive mirroring has now created an unexpected house of mirrors effect. It’s a peculiar gambit that occurs subconsciously for the BPD: “I have successfully transformed you to serve my needs, but I will use this transformation against you for rejecting me.” An old country song creeps into the frame: I turned the tables on you, now I’m eating your food. The drama of object relations role playing has gone from the victim being rescued by the rescuer; the rescuer being persecuted by the victim; the rescuer persecuting the victim; and the victim taking final revenge by persecuting the rescuer. The Karpman Drama Triangle is being played out by two participants on auto-repeat until the rescuer can no longer afford the electricity bill. Keeping up with a BPD’s endless search for emotional satisfaction is virtually impossible, and making customized adjustments to match these unwavering desires only indulges the BPD’s psychological regression and fantasies of omnipotence. The therapist, no matter how personally compromised, ethically unmoored, or professionally misguided, will eventually be considered part of a syndicated rejection conspiracy. BPDs have copyrights on the phrase: It’s you, not me. What was once an ideal caregiver for the clinging child has now become an untrustworthy demon who must be annihilated by the punitive parent (talionic revenge). The idealized savior has now become the symbol of everything that has gone wrong in the BPD’s life. As intensified rage propels the BPD down a seek-and-destroy warpath, the chances for self-reflection are negligible (some BPDs internalize their rage rather than externalize). The BPD’s selective memory, polarized thinking, projection, dissociation, and capacity for revisionism are the perfect building materials for constructing a gaslit firewall to make sure that responsibility will always be a one-way street. Deny and project; rinse and repeat. In the BPD’s extensive collection of defensive battle maneuvers, there is none more famous than blame shifting. Disappointment will not be tolerated and blame helps eradicate feelings of shame. If the therapist fails to meet such impossible standards of care, the pwBPD will lash out with the ferocity of a thousand scorpions (paradoxically, BPDs often feel embarrassed by their impulsive reactions after their rage finally subsides). BPDs sabotage the things they want most in life because they believe that it’s everyone else’s job to satisfy their emotional needs—a job that cannot be sustained by anyone. It’s not enough for the pwBPD to be discouraged by unrealized anticipations and unrealistic expectations, such disappointment means that they must spread this surplus of misfortune to their object of opprobrium. It’s a heads I win, tails you lose situation. Unreasonably impatient in their wishes for emotional fulfillment, a familiar pattern is predictably repeated. For the Borderline, the mistakes and limitations of others are intentionally designed to cause them pain. After all, it’s what they’ve learned from childhood (no one cares; love is a cruel illusion; people cannot be trusted; and the world is a dangerous place). Squaring the circle of BPD determinism doesn’t make the circumference any less reactive.
I was a peripheral visionary. I could see the future, but only way off to the side. — Steven Wright
What was once believed to be a monogram of victimization is now seen as pervasive patterns of dependence (a continuation of learned helplessness). What was formerly considered to be legitimate frustration, “bad luck,” and disenchantment can now be interpreted as manifestations of low distress tolerance and emotional reasoning. Displays of childlike exuberance, offset by periods of terrifying tantrums, have been identified as forms of age regression. What was once thought to be situational anxiety is now understood to be unresolved feelings of emptiness, fear, insecurity, paranoia, and identity disturbance. Demands for validation and intimacy have been providing cover for an overwhelming fear of abandonment. An inability to recognize the independent needs and limitations of others is now exposed as solipsism, jealousy, envy, and inadequate mentalization. Unpredictable mood shifts are retrospectively linked to the client’s perceived levels of gratification or disappointment during social interactions. Idealization and devaluation are explained by the client’s Manichean mindset with a zero-sum transactional approach to interpersonal relationships.
BPDs tend to remember others based on their last encounter: “the great moment of disappointment.” Everything that was previously done to indulge the pwBPD’s requests will suddenly be forgotten (emotional memory blocking), because holistic integration of interpersonal experiences do not register for this all-or-nothing competitor. If the pwBPD has a high “splash” response in the face of misfortune, there will be hell to pay, and the caregiver will be left holding the tab. The BPD’s distorted surveillance kit obsessively scans for potential insults, disagreements, and signs of rejection to maintain their self-fulfilling panorama of paranoia. To be fair, BPDs aren’t aware that such irrational perceptions and hypersensitive reactions are primitive defense mechanisms to avoid feelings of low self-worth and abandonment that were formed during early childhood. And, to be clinically concise, the therapist has royally screwed things up because of an initial failure to see the forest for the trees. The therapist’s miscalculations and professional deficiencies cannot be whitewashed; but one should always expect the unexpected whenever working with Borderlines.
“The Brutal Clock is a variation of the Brutal Test where the Borderline sets up impossible expectations of others. When others are unable to meet these unreasonable expectations, they are punished with emotional abuse, which is justified by the Borderline’s sense of being the victim because they did not get what they wanted,” states Dr. Daniel S. Lobel.
A final debate remains: Are the Borderline’s cataclysmic reactions to relationship triggers premeditated or intentional? No, not in any “normal” sense (some exceptions involve malignant/dark triad BPDs with high comorbidity; elements of grandiose narcissism; and Machiavellianism). There’s also a segment of clinically diagnosed individuals who undoubtedly rely on their diagnosis to justify self-aggrandizement, but this behavior would be difficult to determine with any accuracy. For the most part, BPDs are hard-wired to impulsively think and behave in ways that will allow them to get their needs met. Emotional reactivity isn’t privy to the concept of courtesy. Most BPDs have low distress tolerance, but some BPDs have no distress tolerance. As a general rule, the BPD’s automatic survival responses overrule the survival of anyone who gets in their way. However, the incalculable damage left in the wake of their disappointment and uncontrollable rage will be experienced by others as extremely personal. Hurricanes can destroy lives, regardless of a hurricane’s lack of self-awareness. To be clear, BPDs are the heavyweight champions of emotional storm systems.
The long-awaited one has come; I ask nothing more of the sea. — Madame Butterfly
A musical analogy for therapy-client relations gone wrong with a Borderline is the ebb and flow of symphonic development. In other words, the therapist’s efforts to appease the BPD were constructed from evolving variations on a simple motif: You are worthy of being loved. Unfortunately, proof of love for the BPD is contingent upon reassurance, unrealistic expectations, and commanding the will of the therapist to avoid abandonment. However, the tempo of the second movement is similar to that of the first, but subtle changes in dynamism make it more emotionally complicated than it may at first appear. The evolution of this unsustainable saga results in a rapid crescendo of dramatic fusion during the third movement towards an ecstatic final stanza. The orchestra returns to the call and response motif before a final postlude in the fourth movement—descending from the fifth to the third while the ensemble moves stepwise downward in sixths. As with therapy, it is never a single decision, but a series of misguided steps that move incrementally before resulting in a complex web of enmeshment that has to be unraveled as painstakingly as it developed. Unfortunately, the BPD demands loyalty and insists on maintaining the emotional intensity of the third movement. If the magnitude of the emotional bond is not maintained, the performer (therapist) will be punished by the BPD who feels immense anger for the abandonment of such a quixotic attachment. The therapist, who unfortunately became a volunteer performer in the BPD’s theatrical search for true devotion, forfeited the conductor’s role of mediating between order and chaos. As a result, the therapist has unwittingly usurped the structure of the compositional (therapeutic) framework, and the disheartened BPD has unleashed a cyclone of emotional turmoil throughout the concert hall.
Absence is a house so vast that inside you will pass through its walls and hang pictures on the air. — Pablo Neruda
At the end of the abandonment rainbow, the disillusioned BPD will be encouraged by their sympathetic allies to collect misadventure bonus points while reclaiming victimization. However, the clinician will suffer a much greater loss because professional boundaries were not cautiously maintained *before* sauntering into such a formidable therapeutic landscape. The path by which any therapist deviates from protocol can only be retraced, fittingly, by understanding how mysterious the realm of human psychology can be during unorthodox encounters. Clients with characterological disorders can sometimes elicit out-of-character responses in clinicians. All therapists have professional blind spots and personal weaknesses, but there is no client better at uncovering those vulnerabilities than a Borderline. BPDs are searching for the ultimate caregiver to remove intolerable feelings leftover from childhood, and they will go to great lengths to make this fantasy become a reality. For historical clarity, the distinction between pervasive patterns of behavior versus circumstantial aberrations must be identified for all participants.
“We often think of boundary violations and therapist misconduct as being malevolent in nature,” Dr. Bryant Welch writes. “But with a borderline patient a therapist can get into trouble by virtue of his or her wish to help and have a therapeutic effect. Under enormous pressure to prove he or she ‘really cares,’ the therapist is either going to cross boundaries and/or ‘withhold,’ thus becoming a ‘bad object.’ The grounds are fertile for BPD rage and disappointment in either direction.”
In essence, boundary violations can emerge in direct proportion to the therapist’s efforts to appease the client’s increasing demands for attachment, validation, and reassurance. To add insult to injury, it can be embarrassing for any therapist to admit that they’ve been emotionally ensnared by a client as a result of poor boundary maintenance, communication errors, and clinical misunderstandings. Replacing the parts as they break will never repair an engine that needs to be rebuilt from scratch. The German language contains a splendid word to describe this type of guilt-ridden hindsight: Treppenwitz (a devastating rejoinder thought of only after leaving the bottom of the staircase). No matter how rewarding the process of accommodation can appear in principle, taking extraordinary risks to make the client feel validated is not the same as encouraging and challenging the client to establish their own sense of emotional equanimity and independence.
Forgiveness is the fragrance that the violet sheds on the heel that has crushed it. — Samuel Clemens
Specialized training programs to diagnose and facilitate the effective management of BPDs should be mandatory as a preventive measure to avoid Type II errors in assessment. Respecting commonly understood boundaries among consenting adults is usually taken for granted, but it’s not always guaranteed during emotionally complicated and confusing clinical encounters. It’s up to the therapist to understand the importance of defining clear limits at the beginning of therapy while being intrepid in the face of aggressive boundary testing. Recognizing clinical shortcomings; admitting to personal issues; seeking consultation; and following ethical guidelines will ensure a professional therapeutic relationship for the sake of the client’s well-being. Similarly, it’s up to the pwBPD to courageously work on developing autonomy by understanding how a lifetime of dependency has prevented accountability, insight, and developmental growth. In cases involving ineffectual therapeutic dyads, understanding what went wrong should be given far more significance than determining the correct calculus of blame. We are all products of our genes and our environment. No matter how hard we try to escape our past, we can never fully escape our vulnerabilities. Motivated by misapprehensions and a desire to connect, the therapist has failed the client by becoming an enabler rather than remaining a professional guide. When working with well-documented BPDs, analyzing should never yield to appeasement; confronting should never yield to catering; and challenging should never yield to capitulation. When working with an undiagnosed or misdiagnosed pwBPD, good luck trekking through those enigmatic eggshells (armchair deductions writ large). Ultimately, therapists who are committed to pleasing others need to practice saying “no” whenever countertransference becomes overwhelming. In other words, BPDs will not respect a therapist’s sacrifices; they will expect them. Clinicians who work with BPDs must have extensive knowledge of this disorder; adequate experience working with this disorder; and an actual desire to treat those suffering from this disorder.
“Working with patients suffering from borderline personality disorder begins with an acceptance that they live in an immature psychological world, fueled by certain constitutional vulnerabilities, where they attempt to shield themselves from conflict and anxiety by splitting the world into all good and all bad. Although this produces an illusory sense of psychological safety, in fact, it renders relationships fragile and chaotic and drives away the very people who are so badly needed to stabilize the patient,” states Dr. Marcia Goin.
Now that my ladder’s gone, I must lie down where all the ladders start, in the foul rag and bone shop of the heart. — W.B. Yeats
For better or worse, the therapist will realize that being a caretaker, despite the best of intentions, cannot include the responsibilities of completely taking care of someone. Becoming a surrogate parent, unfaltering friend, love object, or omnipotent rescuer to voluntarily save someone from a lifetime of insufficient nurturing is a recipe for disaster. No single individual can successfully meet all of the emotional and physical needs of another. Likewise, the client should be discouraged from providing transference-based gratification to the therapist. The ephemeral anodyne of affection may satisfy desires for validation on both sides of the couch, but therapists will never find their way back once the process of BPD pacification begins. Codependent quicksand is a formidable force.
What’s interesting about Borderline Personality Disorder is that it represents a subset of psychopathologies that can upend therapy as a result of trying to effectively respond to it. Therapists must be very grounded to withstand the stochastic metamorphosis and strenuous provocations involved with BPD psychodynamics. As with all BPD relationships, there are only three options for therapists to consider: Avoid, challenge, or appease. For any progress to occur during therapy, BPDs need be challenged rather than appeased; however, BPDs don’t tolerate being challenged because the need for change is seen as evidence of their imperfections. Furthermore, the power of love is only powerful if the pwBPD can learn to love themselves while acknowledging the limitations and imperfections of others. It’s not that Borderlines are irredeemably “bad” people, or fundamentally unworthy of love; rather, they’re completely baffled by the give-and-take dynamics that are required for healthy relationships. To be clear, BPDs would benefit immensely from stable companionship, but they must first develop the skills that allow for mentalization, individuation, and self-regulation. Therein lies the great Borderline paradox: Part of the solution to a Borderline’s dilemma is the availability of a meaningful and stable relationship; but part of the reason why this disorder persists is because of BPD’s mercurial involvement in relationships. Granted, relationships aren’t easy for anyone. Borderlines split in relationships analogous to the ways in which therapists split regarding their opinions about those suffering from this counterintuitive disorder. Nonetheless, silver linings must exist for both the client and the therapist if psychological insights are to be realized after such emotionally charged imbroglios. In hindsight, the message and value of compassion should not be limited by the origins or magnitude of our fragility.
We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time. — T.S. Eliot
In summation, the therapist was flummoxed by the BPD’s presentation management, emotional coercion, and incomparable powers of projective identification when the therapeutic relationship was in its infancy. An underestimation of the BPD’s psychic disturbance has resulted in depathologizing what was profoundly pathological. An erroneous clinical assumption was tenaciously defended, and the therapist allowed their own emotions to undermine the protective protocols of professionalism with an emotionally unstable client. Instead of detaching and observing, the therapist has deferred and enabled; thus resulting in an indulgence of the client’s internal fantasy structure. Subsequently, the therapist’s shield of reason was systematically broken down by the BPD’s compelling need for reassurance, emotional support, and attachment. What was easily recognized in the BPD’s childhood and adult associations was unrecognized in the client until it was too late. Something that should have been obvious was regrettably overlooked, and the therapist-client enmeshment has taken its tragic toll. The appeasement to this type of mindset was preconditioned by the therapist’s own upbringing. This uncanny familiarity comes from a complicated dance that was set in motion many years before the clinician and client finally met on that fateful therapeutic stage.
Life can only be understood backwards; but it must be lived forwards. — Kierkegaard
Working through childhood experiences to understand how these events condition our behavior in adulthood is what matters in the end. Deeply embedded triggers from interacting with our families of origin are reactivated for all participants during every therapy session. Many therapists have not done enough exploratory work to properly identify the innumerable faces of transference, or to successfully manage countertransference reactions, and their clients may be equally unaware of the influential depth that these symbolic-based forms of communication have on their own psychological motivations. Misunderstood and mismanaged countertransference reactions are the Achilles’ heel for therapists who become too personally invested in establishing meaningful relationships with their clients. A good question for therapists to consider is why they chose to work in the profession of caregiving. For many, it could be related to the power of human connection, compassion, the alleviation of suffering, and not wanting others to feel alone in their experiences. Unsurprisingly, most would agree that these values embody the essence of effective altruism. But, can such noble aspirations become problematic? Are there exceptions? Some clients require impossible standards of human connection that can only be assuaged through connecting with themselves. The therapist should never abandon their professional identity or personal boundaries for the sake of alleviating another client’s fear of abandonment. As a final caveat, be careful what you care about.
There are two tragedies in life. One is to lose your heart’s desire. The other is to gain it. — George Bernard Shaw
Borderline Personality Disorder is perhaps the greatest paradox in the Analects of human psychology. It’s a disorder that craves love, but it doesn’t understand the meaning of mature love. It’s a disorder that seeks relationships, but it doesn’t grasp the dynamics and limits of healthy relationships. It’s a disorder that yearns for proximity, but it doesn’t trust the sincerity of anyone who gets too close. It’s a disorder that begs others to experience and absorb its suffering, but it cannot see that this is the very reason why it continues to suffer. It’s a disorder that desperately seeks transfiguration from the outside, but it doesn’t know that transformation comes from within. It’s an existential insecurity that cannot believe in the power of accepting itself, because it was not accepted when it began. It’s an anachronism desperately searching for the perfect resolution.
And your long-time curse hurts, but what’s worse
Is this pain in here
I can’t stay in here
Ain’t it clear?
That I just don’t fit
Yes, I believe it’s time for us to quit. — Bob Dylan
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 comprehend will lose the game 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 raging Queen of Hearts will continue to burn.
This should have been a noble creature:
A goodly frame of glorious elements,
Had they been wisely mingled; as it is,
It is an awful chaos—light and darkness,
And mind and dust, and passions and pure thoughts,
Mix’d, and contending without end or order,
All dormant or destructive. — Lord Byron
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