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Depathologizing The Borderline Client

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PNMJ13-3Learning to Manage Our Fears

By Richard Schwartz

Inevitably, given their history of trauma, many borderline clients will trigger their therapists from time to time. But forgoing the urge to blame these clients and taking responsibility for what’s happening inside you can become a turning point in therapy.

I’ve specialized in treating survivors of severe sexual abuse for many years, which means that many of my clients fit the diagnostic profile of borderline personality disorder. Therapists typically dread these clients since they can be among their most difficult, unpredictable, and unnerving. My clients have often been highly suicidal—some threatening suicide to manipulate me, and others making serious attempts to kill themselves. Many have been prone to self-harm, cutting their arms or torsos and showing me the raw, open wounds. I’ve known them to binge on alcohol to the point of ruining their health, to drive under the influence, and to show up drunk for sessions. Sometimes they’ve acted out by stealing and getting caught or exploding into such rage in traffic or on the street that lives were actually in danger.

At times, they’ve formed a childlike dependence on me, wanting—and sometimes demanding—not only my continual personal reassurance, but also my help in making even small decisions, like whether to get a driver’s license. Some have had tantrums when I’ve left town. Others have wanted regular contact between sessions and asked to know in detail how I felt about them and what my personal life was like. They’ve continually tried to stretch my boundaries by demanding special treatment—such as free sessions and extra time on the phone to talk about every detail of their lives—or violating my privacy by finding out where I live and dropping by unannounced. When I’ve set limits on my availability by telling them when or if they could call me at home, some have responded by implying or stating outright that they might cut or kill themselves.

Sometimes I’ve been idealized—“You’re the only person in the world who can help me!" Other times, I’ve been attacked with head-spinning unpredictability—“You’re the most insensitive person I’ve ever known!” During therapy, some clients have suddenly shifted into behaving as if scared young children had just taken over their bodies; others have erupted in almost murderous rage at seemingly small provocations. Repeatedly, progress in therapy has been followed by self-sabotage or a backlash against me that’s made treatment seem like a Sisyphean nightmare.

Early in my career, I'd react to such behaviors as I'd been taught: correct the client’s misperceptions about the world or about me, firmly enforce my boundaries by allowing little contact between our weekly sessions and refusing to disclose my own feelings, and make contracts for them to help them refrain from harming themselves or acting out. Not only did this rational, impeccably “professional” approach typically not work, it usually made things worse. My careful, neutral responses seemed to turbocharge client dramas, and I spent large chunks of my life preoccupied with clients who never seemed to get better.

In retrospect, I can see that despite my best intentions, I was subjecting too many of my clients to a form of therapeutic torture. By interpreting some behaviors that scared me as signs of severe pathology and others as forms of manipulation, I often made matters worse. I hardened my heart against these troubled clients, and they sensed it. They felt that I’d abandoned them emotionally, especially during crises, when they most needed a loving presence. My well-intentioned attempts to control their risky behaviors frequently convinced them that I didn’t get it, and even that I was dangerous, no different from their coercive perpetrator.

Of course, I’m not alone in having these experiences. Many therapists become detached, defensive, and directive when confronted with the extreme thoughts and behaviors of their borderline clients. It’s hard not to have these reactions when you’re responsible for protecting someone who seems out of control. Alternatively, some therapists react by trying to be even better caretakers, expanding their boundaries beyond their comfort level until they grow so overwhelmed and resentful that they end up unloading their clients onto someone else.

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11 comments

  • Comment Link Monday, 18 November 2013 18:45 posted by OLAF HOLM

    Magnificent article from Dr. Schwartz; for us IFS people it´s a big plus for our daily work

  • Comment Link Monday, 04 November 2013 19:48 posted by Jeff Kayes, LPCC

    I don't think I will apply for sainthood anytime soon! Your article was humbling for sure. I found that I had to remind myself (quickly!) that I do succeed with some of my clients. Thank you for your brutal honesty with your internal reactions in working with these two women.

  • Comment Link Friday, 27 September 2013 18:02 posted by Sherry J. Zitter LICSW

    This is a moving, skillful and superbly helpful article to me. It ha shifted my relationship to 2 of my clients who have a huge amount of self-hate and a tough time holding onto the work we do in between sessions.
    The most useful part for me, of course, is the focus on noticing my own parts and how they can take over my natural compassion and wisdom. When I unblock my own heart, and open it toward any client is any situation with deep curiosity, miracles can happen -- as Dick shows us time and again.

  • Comment Link Tuesday, 06 August 2013 15:03 posted by Terri

    I am a Borderline. I have been having a terrible time adjusting to a new therapist, after the retirement of a much loved and cared for counselor. The feelings of abandonment and loss have been horrible. Thanks for a great article that has helped me understand more about myself than years of therapy ever have.

  • Comment Link Sunday, 30 June 2013 13:03 posted by Stana Paulauskas PhD

    Excellent article and highly attuned compassion for self and client!!

  • Comment Link Wednesday, 19 June 2013 23:49 posted by Cecille del Gallego, LCSW, CEAP

    So spot on and very well articulated....I think the article captures the complexity of working with those who have had enormous pain and who have been violated on so many levels. It gives voice to the deepest yearning that is essentially in all of us - to be seen, heard, accepted and believed in. Great job humanizing this "population"...

  • Comment Link Sunday, 16 June 2013 20:57 posted by Jake Eagle

    Dick, I really appreciate your article this month, Depathologizing the Borderline Client. The specific details you shared about using IFS—both in dealing with parts of your client as well as dealing with parts of yourself—were illuminating.

    This may not surprise you, but I recently experienced remarkable success using IFS with a client struggling with multiple parts—I don't label my clients—but she most certainly would be labeled with multiple personalty disorder by most in our profession.

    I think what may have be unique in my approach is that I had her read the first 60 pages of Internal Family Systems after our first session. I asked her not to read any more of the book because I didn't want her to get caught up in the details, but the first 60 pages provided a context for our work. She immediately recognized herself reading your book and felt hopeful for the first time in her life. No one had previously been able to explain her confusion and internal conflict, but after reading your book she felt seen.

    During the six months of working with my client she has identified all of her parts, engaged in conversation with all of them, and now talks openly about her family and how they are learning to live together and love each other. It's been a remarkable and relatively quick transformation. I don't think it would have been possible without your IFS model.

    Hope you're well and maybe I'll see you again in Tulum.

    Jake

  • Comment Link Monday, 10 June 2013 16:23 posted by Kimberly April (not my real name)

    Thank you for humanizing the reality of the results of adult survivors of childhood abuse, and for specific ways to help therapists effectively relate to, treat, and heal those affected by this senseless horror. I am a survivor, and yes, I saw parts of myself in your dialogue. I am almost finished with my therapeutic journey of 4 long and sometimes painful years, yet also colored by unequivocal joy encontered through the ability to finally feel and deeply connect to another human being, my therapist. I appreciate all of your research and practical steps with parts work designed to help heal a shattered self. Doing parts work was one of the most painful yet healing parts of therapy after the much feared phase of establishing safety and trust, which took a very long time, and was filled with a lot of acting out in many forms.
    Thanks again for this article and your work which has given those of us who have survived destructive secrets of the past much hope for unibiased treatment and point us to a live worth living, full of connecting with others. I am not out of the woods yet as the termination part of therapy seems to be a difficult one full of loss and pain, because although I intellectually realize that my therapist is not my father, all my little girl wants to do is take her blankie and climb up on the couch and sit next to him, because he helped me feel safe and finally alive. (This definitely is embarrassing for me because I am older than he is, and part of the baby boomer generation.)I am sure I will get through this because my therapist has given me coping skills, and I know he will walk with me to show me the way. Although he will not walk for me, he will walk with me, and that for me makes all the difference!

  • Comment Link Monday, 20 May 2013 18:22 posted by toni aguilar

    this article has excellent advice for the therapist whose "parts" get too reactive and take things personally. (one of my clients taught me the term "QTIP"--quit taking it personally.) the rage (coming at us or simply to us)that some of these clients can exhibit is very difficult for some of us to handle w/o getting weary, no matter how compassionate or skilled we are. i DO believe in and use the idea of internal family systems, and i teach all my clients that all human behavior is purposive, geared toward whatever the subconscious THINKS it needs for survival. so i try to hang onto curiosity and that compassion at my core....but whew! i find it to be very hard work sometimes, choosing just the right words, the right tone, the right demeanor to help those protectors accept all of us who are in the room! thanks for running the article.

  • Comment Link Saturday, 18 May 2013 22:02 posted by Gary Brown

    though I am not a therapist, nor a phsychologist or anything like that, I have been reading and enjoying this magazine for five or six years. I found this article to be very interesting and if I might dare to say, insightful. I talk with a lot of people and many of them ask me questions similar to those a therapist might receive.
    I like to relate back to different articles I have read in this magazine to suggest things to those people. Many times I find that those to whom I speak find the way we interact to be thoughtful and insightful, I suspect this article will lead to further insights I might be able to share with those who ask for my input.
    Thank you for the article, I feel it was a very worthwhile read.

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