Alpf Medical Research Personality Disorders

Borderlines are notoriously difficult patients. Most experienced therapists are likely to have several stories to share about borderline personalities who caused no end of problems. Because borderlines often appear at first glance healthier than they really are, therapy often focuses on some apparently simple issue, only to become increasingly complex over time. In fact, simply establishing an alliance can prove extraordinarily difficult. A large proportion just quit therapy, citing problems with the therapist, who is then devalued just like many others. Those who do continue may require repeated hospitalization as indicated by the strength of the impulse for self-mutilation or suicide. Nevertheless, it is also true that borderline pathology is a matter of degree, and treatment with less severe patients is often highly gratifying. Many borderlines have a range of highly developed social skills, along with an intrinsic motivation to restrain contrary and troublesome impulses. Therapeutic gains can lead to extended periods of productive functioning and interpersonal harmony, which provide the therapist with an unusual opportunity to see therapeutic goals realized.

Therapeutic Traps

One of the fundamental principles of therapy holds that interpersonal pathologies are recaptured in the therapeutic relationship itself. For the borderline personality, this means high expectations for nurturance from the therapist, inevitably followed by distorted perceptions of the therapeutic relationship and periods of intense anger and manipulation. Borderlines not only idealize and then devalue the therapist but also bring into therapy threats of suicide and, sometimes, frequent and repeated self-mutilation, dramatic physical evidence of psychopathology. Clinicians who treat borderlines should carefully monitor their own countertransference feelings to maintain a healthy level of detachment from the emotional lability and intensity to which every session is susceptible. In fact, many clinicians find it necessary to limit the number of borderline patients in their caseload. Otherwise, they risk therapeutic burnout, dreading sessions with their borderline patients and even finding that their countertransference feelings overflow into other subsequent therapy sessions. Another common trap is failure to maintain personal boundaries, creating a vicious circle of chronic giving-in to the borderline's demands for increased attention and nurturance (Benjamin, 1996).

Another potential problem lies in neglecting the importance of comorbid personality disorders. In the DSM, the borderline personality disorder is a heterogeneous collection defined by both symptoms and personality traits. Subjects often present as a more severe variant of some other personality disorder, particularly the negativistic, depressive, histrionic, and avoidant. Because the borderline personality can be considered a level of personality organization, for any given individual, the meaning of his of her particular symptoms and Axis I disorders is often decipherable only in the context of comorbid personality disorders. In other words, self-mutilation in a borderline client with dependent and masochistic features may have a different meaning than self-mutilation in a borderline client with histrionic features. Because the borderline category is less homogeneous than other personality disorders, treatment cannot as easily proceed on the basis of a borderline diagnosis alone.

Many therapists worry that depression and explosive hostility, which often signify acute breaks with reality, can lead to a more permanent decompensatory process. Among the early signs of a growing breakdown are marked periods of discouragement and persistent dejection. At this phase, therapists are advised to shift into a more supportive mode, while maintaining boundaries and avoiding blatant manipulations. Because many therapists feel burdened and frustrated by their borderline subjects, they may be tempted to react dismis-sively, with the implicit message to "just snap out of it." Such reactions represent a snapshot of the borderline's history and current interpersonal relationships, where demands are made to function, whatever the individual's mental state (Linehan, 1993). If the therapist is perceived in the same way, regression may accelerate. A consistent and appropriate level

Focus on Therapy

Getting to Know Anxiety

Getting to Know Anxiety

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