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Section 13
Mentalizing as Treatment in Borderline Personality Disorder

Question 13 | Test | Table of Contents | Borderline CEU Courses
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

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On the last track we discussed self-esteem.  Two aspects of self-esteem that we looked at are low self-esteem and setting boundaries.  We also reviewed the self-esteem assessment and the ‘LEMON’ Enforcement technique.

As you know, to effectively deal with a difficult BPD client, we may need to accept the fact that quick improvement may not be a reasonable goal. Therefore, on this track we will discuss the difficulty of treating BPD clients. We will examine the reputation of BPD and how to maintain optimism and patience. We will also cover dealing with abusive BPD clients and Steps for Relating to BPD Clients. As you listen to this track, you might consider how to apply the ideas to your client.  Also, if a colleague could benefit from this information, feel free to share it with her or him.

#1  Reputation of BPD
As you know, in spite of the lack of consistency in your client’s behavior and our knowledge of BPD, we are still called upon to treat this disorder. Somehow, BPD clients have developed a reputation for being almost untreatable. In fact, I once heard a therapist comment that no one likes these people. I have found, however, that this is far from the case. Think about your experience treating BPD clients. You may be able to report one miraculous result or a fair number of good outcomes. 

Even with these successes, feeling discouraged when it seems like your client may never improve is common in treating borderline clients. Would you agree? Take Francis, a BPD client, an example. Francis had had numerous jobs, all of which she quit because she was convinced she could not succeed. Francis, age 38, vacillated between hating me one day and refusing to leave my office the next. Francis could clearly be described as hostile and impulsive. On more than one occasion, Francis threw objects at walls, my receptionist, and myself. 

Francis often devalued me, constantly telling me that I was insignificant. Sound like your BPD client? If so, you might consider these five suggestions for dealing with your difficult or abusive BPD clients. 

  1. Respond silently with a reinforcing phrase.
  2. Use silent humor.  In your mind, can you picture Francis getting a pie in the face, or slipping on a banana peel?  Could this help you avoid feelings of frustration or anger with your client?
  3. Speak firmly and let the client know in advance that certain behaviors are not acceptable, as in the case of throwing objects mentioned above.
  4. Identify mistreatment immediately.  For example, when Francis told me I was insignificant, I responded by stating, "That felt like an insult.  Is that what you intended?"
  5. Be careful that you are not pulled into a useless argument or shouting match.  As you probably know, BPD clients are skilled at using tactical arguments to avoid their problem.

In addition to dealing with difficult or even abusive BPD clients, you may find it helpful to reconsider your basic therapeutic relationship with the client.

Technique: 6 Steps for Relating to BPD Clients
With the help of other therapists and colleagues, I have begun to implement the following Six Steps for Ways to Relate or Connect with my BPD Clients in my practice. I have found that by focusing on relating to my clients, I can alleviate a lot of the frustration that often accompanies treating borderline personalities. As you listen to these Six Steps for Relating to BPD Clients, consider a BPD client you are currently treating.

Some of theses are pretty basic therapy practices, but I felt a review of some basics might help to act as a checklist for you during your next BPD session; to make sure in the "heat of the moment" so to speak, you aren’t forgetting them.

  1. Ask yourself, in my last session did I approach my paranoid BPD client with a supportive, relaxed and self-reliant manner during the entire session?  Or is relaxation something I need to work on in our next session?  For my frantic or out of control BPD client, did I use self-control and acceptance, as well as I could have?  If not how can I mentally prepare myself for our next session?
  2. How did I handle my BPD clients negative or suspicious views?  In a gentle, non-threatening way, did I consider raising doubts and questions about his or her negative or suspicious views?  For example, Francis yelled, "I don’t know if you’re helping me or trying to make it worse!!"  To consider raising doubts or questions about her negative or suspicious views I asked Francis  if she thought that I would jeopardize my own practice in an effort to hurt her.  As you can see, without questioning Francis’ perceptions of reality, I allowed her to doubt her own suspicions.
  3. Consider asking your client if he or she feels if acting on suspicions might turn them into self-fulfilling prophecies. We then discussed suspicions she had that check-out clerks were out to "get" her and make her angry by working slowly.
  4. When your BPD client feels social pressure to behave a certain way, consider if it is appropriate to expose his or her projection by asking, "Who says you have to?" 
  5. Consider finding ways to get the client to agree that his or her perceptions are distorted , but still thoroughly color his or her view of the situation at hand.  For example, Francis often told me that I was insignificant and as she put it "didn’t provide her with anything worth while."  She sometimes did so as an argument to extend our session.  She would use my insignificance to reason that my time did not matter.  At the time it seemed appropriate to state to Francis, "At least you make me feel significant, since you want to spend more time talking to me.  But can you help me understand why someone like you would want the advice of someone as insignificant as me?"
  6. As you know the level of self-respect or self-esteem is usually very low for the BPD client.  Would it be appropriate for you to consider teaching your client to earn self-respect or raise their self-esteem through making a few solid commitments and sticking to them? 
  7. Think of the BPD client you are currently treating.  Could using the Six Steps for Relating to BPD Clients help you maintain a perspective of borderline as a diagnostic label instead of an anathema? 

#2  Maintaining Optimism and Patience
Second, I find to help me maintain a balance in working with my BPD clients, it helps to maintain a certain level of optimism and patience and recall some client accomplishments.  I had worked with Francis for five years, during which time she married, had a child, and divorced.  Francis quit therapy for some time after her divorce, but returned one year later.  Now 44, Francis lived alone in an apartment by herself. 

Francis slowly began to become less socially active, keeping her relationships at a superficial level. Francis finally began to experience only slight degrees of anxiety and depression.  She was starting to control her impulses and avoid hostile behavior. After a trying and lengthy therapy, Francis began to show signs of improvement. 

Think of your Francis.  Have you seen the same client for years before results finally began to materialize?  Can you think of other clients you have treated who provide you with good reasons for maintaining optimism and patience? When treating clients, I keep in mind that BPD is not stagnant, but rather dynamic, fluid, and capable of being treated.  Would you agree that such reminders can be motivating as a therapist and possibly lifesaving to the client?

On this track... we have discussed the difficulty of treating BPD clients.  We examined the reputation of BPD and maintaining optimism and patience.  We also covered dealing with abusive BPD clients and Steps for Relating to BPD Clients. 

On the next track we will discuss borderline parents.  We will explore learned BPD behavior, how BPD affects children, and "take aways."

Peer-Reviewed Journal Article References:
De Meulemeester, C., Vansteelandt, K., Luyten, P., & Lowyck, B. (2018). Mentalizing as a mechanism of change in the treatment of patients with borderline personality disorder: A parallel process growth modeling approach. Personality Disorders: Theory, Research, and Treatment, 9(1), 22–29. 

Fonagy, P., Luyten, P., & Bateman, A. (2015). Translation: Mentalizing as treatment target in borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 6(4), 380–392.

Harpøth, T. S. D., Kongerslev, M. T., Moeyaert, M., Bo, S., Bateman, A. W., & Simonsen, E. (2019). Evaluating “mentalizing positive affect” as an intervention for enhancing positive affectivity in borderline personality disorder using a single-case multiple-baseline design. Psychotherapy. Advance online publication.

What are two topics we discussed regarding the difficulty of treating BPD clients? To select and enter your answer go to Test.

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