borderline-personality-disorder.com
While studying to become a therapist, I had been warned about borderline personality disorder (BPD)—a condition that is considered notoriously difficult to treat. Borderlines, as some burnt-out professionals refer to people struggling with this disorder, have great difficulty regulating emotions. Often labeled drama kings or queens, tears, shouting, threats, physical violence and self-harm were all reported to be part and parcel of a weekly session with a borderline client. Alcohol or substance abuse, domestic violence and intensely unstable interpersonal relationships, I was told, were common with these clients, and “real work” with them was all but impossible. I dreaded my first encounter.
The suggestions most mentors, psychiatrists, professors and supervisors came up with for achieving success with clients that have been diagnosed with BPD included referring them to a different program, or referring them to a specialist—a seasoned veteran therapist preferably, older and unflappable. I was scarcely 30 years old and was a brand new hire in my first job with a baby at home when I entered into a treatment relationship with a woman who was eventually diagnosed with borderline personality disorder. I felt like I couldn’t have been a worse choice of a therapist for her.
“Sherry” was older than me and had two older children, both of whom were living in foster care. She came to be my client because she had fired her previous therapists. All of them. She had been discharged from her fourth hospitalization in less than a year, and was checking off the box by keeping her initial appointment with me. She was angry, exhausted, frustrated and suspicious. She had been sent home with a stack of prescriptions, a diagnosis she claimed didn’t fit, and terrible insomnia. She was resentful and wary of all treatment professionals, and I didn’t blame her one bit
We started with symptoms and medications: she was struggling with a very inconsistent sleep cycle and low mood; she would have terrible insomnia for days, then sleep 20 hours a day for several days in a row. She struggled to get to therapy appointments and canceled because she just could not get out of bed several times in those first few weeks. She complained that her medication was not helping. I listened and helped her access the doctor in our clinic. I attended her medication appointments with her, acting as an external hard drive, reminding her of what she had planned to tell the doctor, and helping her stay focused when her emotions threatened to derail her. We were slowly building up a little bit of trust.
Sherry lived at home with her parents, in a rural location, quite far from the city in which the clinic was located. She couldn’t work and had lost custody of her children due to her suicide attempts. She also lost her driver’s license due to her drinking and driving. She would engage in binge drinking behavior, and had been labeled an alcoholic in prior treatment episodes. She was lonely and missed her children very much, she told me, and sometimes her sadness and loneliness drove her to drink. It seemed like a vicious cycle—the more she was unable to be with her children, the more emotional she became and the more her efforts to stabilize her emotions escalated into inappropriate or dangerous behaviors, such as binge drinking.
She was sad and frustrated but stable for the first few months we worked together, but crisis seemed inevitable. One Saturday night, when I was on call, Sherry called our emergency number. “I cut myself,” she screamed after I said hello. “I’m bleeding. I cut my wrists.” I called 911.
When the police arrived, Sherry started yelling, screaming, refusing to go to the hospital, but was clearly in need of medical attention. She damaged the back of the police car by kicking the seats and windows. Once at the emergency room, she destroyed equipment and was verbally abusive to staff. She was admitted to the psychiatric ward and sedated.
When she was finally discharged, after being diagnosed bipolar with psychotic features, depressed, and alcohol-dependent, she returned to outpatient treatment with me. I felt like I had failed her: in our few months together I had done nothing to prevent this crisis—I hadn’t even seen it coming. I had called the police when her suicide attempt was quite minor—and due to the escalation in her behavior, she was now in debt because of all the equipment she damaged. She was certainly no better off than when I met her and possibly much worse.
I tried to find her a better therapist. I tried to find a way to get rid of her because I was afraid of what she might do, and even worse, I hated how helpless she made me feel. My supervisor would have none of it, though. “You’re doing a good job,” she insisted. “Just keep listening and keep being real with her.”
Sherry made choices and I supported her. She wanted her children back, she wanted to work, drive and have her own apartment, and she wanted to get off her medication, as she had gained 60 pounds since starting it. The road was long and bumpy and there were sessions in which Sherry stormed out, slamming the door behind her. She yelled at me, furious when I held up the mirror and insisted that she be aware and mindful of her own behavior. She also called me in between sessions frequently, despondent after a sleepless night, or angry after a difficult phone call with her parents. Each time she made a choice that set her back, I would call her on it, pointing out the impact of her choice and exploring alternatives. At first this made her angry enough to leave the session with a few choice words, but over time she grew to tolerate constructive criticism. Over and over I helped her set a goal, work to reach it, then set a new goal.
She moved to an apartment near the clinic. She gained visitation and then custody of her children. She regained her drivers’ license. She stopped drinking.
It sounds miraculous and in some ways it was. But the take home messages are clear: she extended trust and let me support her. She didn’t decide she needed an older or more experienced therapist. She was brave enough to keep coming back, despite feeling terrible and having me fail to take that terrible feeling away. I taught her coping skills—concrete things she could do when she felt anxious or full of rage. I taught her skills for managing in her own apartment. I held the vision of her as a competent parent when no one else believed she was capable of parenting. And I was brutally honest with her, telling her every time she had a bad idea or made an unwise choice.
Finally she was ready to stop coming to therapy. I’ve never been happier to see anyone complete treatment before or since—but not because I was relieved to finally be getting rid of her. I was glad to see her complete treatment because of the living proof she had become that not every person struggling with BPD was a dire and hopeless case. Sherry taught me that regardless of diagnosis and predictions about treatment, people can get better. Her willingness to set goals and work toward them, and my ability to tolerate the bumps in the road along the way, added up to a successful treatment episode.