A site visitor who signed with the name “Jay” recently left an interesting comment to my earlier post on borderline personality disorder. As this bears on the issue of rage and the sense of entitlement, I’ll quote his remarks at length. He’s a young mental health professional, working at an in-patient facility:
“I have one BPD patient. Just one and the stress is starting to get to me. It is becoming a nightmare. She cuts, threatens suicide, hits her peers, urinates on the floor and yells at the top of her lungs when she does not get her way. She pulled the fire alarm during her tour of the building because she wanted to be let in the music room. That room was under construction. I explained to her why she could not go in there, her answer was “how do you know?” I pointed to the “under construction keep out” sign. She replied “well you still don’t know that.” She then proceeded to yell at me for not taking her side.
Another example, she ordered cereal for breakfast the night before. She woke up and asked for oatmeal and bananas. We did not have any oatmeal. We offered cereal and bananas. She flipped a few chairs, threw her tray at the kitchen staff, threatened to kill herself and burn the place down. That lasted 3 hours. There was no talking with her, no pacifying her. Finally she was placed in restraints and medicated. She sleeps 10 hours.
Empathy does not work, group therapy, one on one, drawing, meditating, bribery, nothing . Yes, I bribed her with snacks, tried a few reward systems. She’s in her early 20s, as I am. I can not reach that girl. She hates me one day and can not live without me the next. My colleagues are all sick of her. Being the youngest of the staff, she’s is mine until she leaves. I am seriously considering switching to hospice care. She has no boundaries and does not respect mine. For example, I stated that I am uncomfortable with kissing on the cheeks, hugging, holding hands and such. However I do shake hands. She will try to hug me every time I see her, or touch my clothes, hair, to touch my papers. I’d say “please don’t”, she’d say “but I want to see what it is” or “they are just papers”. Yes papers that are on my lap . That make my blood boil.”
In this comment, Jay dramatically illustrates the emotional challenge of working with someone who suffers from borderline personality disorder. His reactions are not unusual; I have felt very similar ways during sessions with my own clients. His account also reminds me of other such stories I’ve heard, about the way bpd patients affect their ward staff. They are highly provocative and evocative; they inspire feelings of hostility and resentment. They make you want to quit the profession.
In order to help someone like this young woman, you first have to get clear on the difference between empathy vs sympathy. Jay states that “empathy does not work,” but I doubt he or anyone else on the staff is truly empathizing with her … at least they’re not aware that they are. She fills them (via projection) with all her own unbearable emotions of rage and anger; the way she treats her caretakers evokes the same feelings within them that she is struggling with. Jay says her behaviors make his “blood boil” — that’s where the empathy comes in. The problem is that, for the most part, we mental health professionals believe it’s inappropriate to have such feelings, and when we’re forced to admit that we do have them, we want to blame the patient.
What I recommend instead is to use those feelings to connect with her. In my response to Jay, I suggested that he say something to his patient like this: “When you can’t force me do what you want, it makes you so furious you hate my fucking guts and want to kill me.” It’s clear from what Jay writes that she’s struggling with murderous rage and it’s important to name it for her, to articulate the emotions and impulses she’s feeling. It’s easy to assume that she knows what she’s feeling; the truth is, her mind is continually blown apart by the violence of her feelings; she doesn’t really know what they are in any way you or I would recognize. It’s the job of the therapist to help her bear with those feelings and learn to understand them — very difficult work.
This young woman also finds any kind of frustration unbearable; she’s goes into a rage whenever she feels it. In part, this reflects the sense of entitlement you so often find with borderlines; it also betrays the limits of her capacity to bear any kind of pain. She demands to be treated as if she were an infant, really — ministered to by a perfect mother who would tend to her every need and never let frustration become an issue. It would be important to address this with the patient: “I think you find any kind of frustration unbearably painful; when you feel it, you just want to kill somebody.” With my own clients, I’ve also said things like: “You expect me to understand and gratify your every need without you having to say a single word.”
Neither can she bear the experience of separateness; those boundary-crossing behaviors that understandably annoy Jay represent her attempt to take possession of him, to own him, and to deny the separation between them. When the experience of need, separateness and frustration is unbearable, fantasies of merger often come to the rescue. If she “owns” Jay by merging with him, then on some level, she believes she won’t have to feel frustration, or become enraged when he doesn’t instantly do what she wants him to do. When she feels “at one” with Jay, she “loves” him (it’s not really love, of course); when she experiences him as separate and frustrating, she wants to kill him. To me, these are familiar borderline dynamics.
I feel for Jay. His comment is overflowing with all the unbearable emotion she inspires in him. Using those feelings as a guide to the patient’s emotional experience (countertransference in the broad sense) is the only way to make the work bearable for the therapist, and the only way you can truly help someone this troubled. In my experience, it also helps you feel more compassionate toward their suffering. It is painful and often terrifying to feel murderous rage. If Jay, with his healthier mind and greater mental capacities, finds it so difficult, imagine how hard it must be for his patient to bear with her experience. By using your reactions as a guide to understanding your client (instead of feeling quietly guilty because you hate her), you’ll truly empathize with her experience, and probably feel a lot more sympathy as well.