A Clinician's Perspective
Although borderline personality disorder is usually identified by impulsive behaviors and highly emotional outbursts, current thinking suggests that the condition primarily reflects a profound sensitivity to relationships. Individuals with BPD have an unstable sense of self and others, and this instability is played out in how they experience the people in their lives. Problem behaviors can be dangerous and must be addressed before underlying issues can be worked on meaningfully, yet it is easy to get caught up with putting out brush fires and overlook the fear of rejection or abandonment which are at the heart of the illness.
Examining the individual's interaction with others can provide a vehicle for understanding this core issue, and I believe that a relationship-oriented approach is the key to successful treatment. Mentalization based therapy, interpersonal groups, and aspects of dialectical behavior therapy encourage individuals to reflect on their internal experience in the context of relationships and to identify ways that they are attributing emotions to others which may be inaccurate. Group psychotherapy is a particularly effective modality and provides a forum for observing oneself with others, finding support and validation, and drawing strength from shared experiences.
Relationships require mutuality, and it is critical for therapists to examine their part in interactions with clients. Unlike treatments where the clinician is identified as the expert with knowledge to impart, I believe that therapy with BPD requires therapists who are willing to join into mutual relationships with clients in which they are open about their own emotional experience of the work. Effective therapies will inevitably include times in which the client directly challenges the clinician in ways that might feel like personal attacks. It is essential that the therapist try to be open and not defensive in considering the validity of the client's perspective, as well as offering reasonable transparency about his or her own subjective response.
Not all clinicians are willing to interact in this manner, and not all therapists are comfortable working with clients with BPD. Given the sensitivity to relationships that is at the core of having BPD, I believe successful treatment requires having therapists who are willing to establish open and reasonably mutual relationships with their clients. If the clinician is willing and able to do this, working with clients with BPD can be personally gratifying, incredibly interesting, and effective beyond expectations.
~George Smith, LICSW
Program Director, Borderline Center Outpatient Program at McLean Hospital