Over the years, I’ve worked long-term with a number of clients who presented as borderline personality disorder symptoms, and also short-term (i.e., unsuccessfully) with many more. As a graduate student, early in my internship, the director of our clinic identified me as someone who could work with the more difficult and disturbed clients who came for treatment. Even after I earned my license and went into private practice, my colleagues sent me such cases. Low person on the totem pole often gets the least desirable referrals — that is, the ones who can’t afford to pay your full fee and at the same time make you work ten times as hard.
If I have a speciality, it is borderline personality disorder treatment; it’s the type of work I find most rewarding, despite its challenges, and where I do my best work. I suspect that most therapists prefer to work with the YAVIS client (an acronym that stands for Young, Attractive, Verbal, Intelligent and Successful), but I find I don’t do as well with such people. In part, it’s because their defenses work so much better at blocking out the really difficult emotions and conflicts (the sort of issues I usually address); it takes much longer to shed light on those feelings, even when I can detect them, and I often push too hard too soon. I work in the transference, and with the YAVIS client, it usually takes much longer to develop.
With borderline personality disorder treatment, the transference begins when you open the door on the very first day you meet (it may also begin that way with other clients, but it’s less obvious and harder to detect). For example, at the clinic where I first worked as an intern, I went out to greet a new client for her second or third session and she said, passing by me into the corridor that led to my office, “She’s back there waiting for you.” As I understood it, she had instantly split off and expelled the needy party of herself and left her behind in the waiting room. (The YAVIS client would never say such a thing!) This client had developed an instant, intense and unbearable attachment to me though we’d met just once or twice before; after only a session or two, the breaks between sessions felt like unbearable abandonment.
Another client at the same clinic, a young man who balked at paying even $5 per session, began our third or fourth hour describing a book he was reading, about a girl and the wealthy man who “kept” her in exchange for sexual favors. I suggested to him that he might have been having such fantasies in relation to me, given the financial difficulties of paying for therapy we’d been discussing last time; he said that yes, he wondered if I would be willing to give him treatment in exchange for blow-jobs. (My supervisor criticized me for going “too deep too fast,” but to me, it wasn’t “deep” at all — it was just below the surface, obvious to my client and to me.) This client attached very quickly; when I took a planned break for vacation, he found the abandonment intolerable and terminated.
The client with borderline personality disorder symptoms may also become hostile right at the outset, since intolerable anger and hatred are often core issues. One such client came for an early session and when I said something that felt to her like a narcissistic injury, she began to scream and continued to scream at me for the rest of the hour. She left a very polite phone message the following day, informing me that she had decided to seek treatment elsewhere. I didn’t understand shame at that point in my career and couldn’t reach out to her; she no doubt felt so ashamed after losing her mind with rage in session that she had to terminate in order to escape that shame. With other clients, I’ve been able to bear with their hostility, make them feel I could tolerate such violence; this often came as a huge relief and felt to them as if it was exactly what they needed. I’m good at tolerating anger and hatred.
I believe this is because my own therapist was also good at tolerating hatred; he spent years helping me learn to understand and cope with my hostility, the part of me with several features of borderline personality disorder. I’ve written about him before, referring to him as my inner brat; in my post on the kind of psychological transformation that is actually possible, I tried to describe what it’s like to cope with this part of myself.
Borderline Joe is easily wounded; he may become enraged when he feels slighted by a friend. He may react to what feels like abandonment with a “I’m going to reject you first” kind of rage. Borderline Joe doesn’t call the shots and rarely has access to my voice box. He often makes his presence known but I usually know how to handle him. I know how to stop his ranting and strive for quiet so that other feelings can emerge. My long-term clients have a similar relationship with their inner borderlines.
More than anything else, I want this website to help people understand what it means to change in psychotherapy. The self-help field offers hopelessly idealized “solutions”; even among my colleagues, we almost never talk honestly and freely about what it means to be “post-treatment”, what we’re really like “after psychotherapy.” For me, for many people I know and clients I’ve worked with, what I’ve described about my own inner life is how
successful change appears. Borderline personality disorder doesn’t disappear; it becomes manageable, a part of you that you must monitor and curtail so that the healthier parts of you that have grown in treatment can have their say.
Finding Your Own Way:
Do you have an inner borderline? Does he at first over-react to minor slights before you realize no offense was intended? Does she have abandonment issues and feels panicky without justiable cause? Maybe you attach very quickly and intensely to new acquaintances.
I’ve known many people (not clients) with these issues who pretend it isn’t true, try to act as if they were “normal” (whatever that means). It’s difficult talking to such people because what they’re saying often has nothing to do with the emotions they convey — for example, using calm and reasonable language while emanating anger or resentment. Do you feel ashamed of the borderline personality disorder inside of you? Do you feel the need to hide him, make her appear “normal”?
If you’re a therapist, do you feel alone in your professional community (as I often do) because it doesn’t feel safe to reveal the truth about your post-therapeutic self? Do you ever feel alienated by the “I’m so together” way your colleagues try to appear in public?
If you do, drop a comment, send me an email — maybe we’ll both feel less alone.