Counseling borderline personality disorder

Borderline personality disorder (BPD) is a group of personality disorders characterized by self-injurious behavior and difficulties in interpersonal relationships. Some people characterize BPD as "the apocalypse."

I highlight such signs of BPD as: constant anxiety, people with BPD may be anxious because of the crises that accompany their lives, changing events. Often there is an alarming suspiciousness in connection with the state of health. Anxiety leads to psychosomatic illnesses, which reinforces the "vicious circle" - going to the doctors. Anxiety is associated with fear in the lives of people with BPD. A lot of things can scare them, these are new relationships, and intimacy, and parting, and other situations. Numerous spheres of life of people with BPD are “saturated” with fear, as in children aged 3-5 years, who are prone to various fears and anxieties. Especially fear and suspicion can increase in situations of stress. People with BPD have low self-esteem. It is as if a constant critic, distinguished by self-criticism, “sits” inside, and self-doubt and doubts are born from this. nine0005

It is worth noting that it is difficult for people with BPD to answer the question: “who am I?”, “What do I want?”, The so-called diffuse identity manifests itself, where there are no strong goals, values ​​and beliefs. When there is a series of events associated with parting with a loved one, with failures in work or in the sphere of relationships with others, which is typical for people with BPD due to emotional instability, emotional or mental pain arises - it resembles an uncomfortable feeling inside, close to despair. People with BPD may have problems controlling their emotions, which manifests itself in uncontrollable anger and anger, chronic conflicts with others. It is very difficult for them to be in a relationship with one partner for a long time, therefore, changes often occur in relationships, even some chaos, the search for more and more new partners. nine0005

People with BPD tend to change jobs frequently. The work book is literally teeming with notes about various organizations in which I had to work. As a result, they may face certain difficulties in finding employment in the future. The litmus test for BPD in people's behavior is self-harm and suicide. At the same time, self-harm can manifest itself in different ways, from suicidal attempts to masochistic tendencies in behavior, when people with BPD want the other person to scold, offend, hurt. For some people with BPD, various kinds of addictions are characteristic, for example, alcoholism, drug addiction, gambling, Internet addiction. People with BPD are characterized by unreasonable spending of money, risky driving, and promiscuity. Often, after traumatic events, there may be problems with sleep, nightmares, obsessive thoughts about unpleasant situations, memories that disturb and do not allow you to live in peace. In general, the signs of BPD are characterized by polymorphism, and behavioral patterns - by a variety of manifestations. nine0005

You can describe borderline personality disorder with the word: INSTABILITY, where:

N - hate. People with BPD are characterized by a feeling of hatred as a long, intense, negative feeling, reflecting disgust, hostility, rejection of someone.
E - Yeralash. Characterized by disorder, confusion, confusion. Chaotic interpersonal, incl. intimate relationships, lack of structure.
C - Self harm. Among people with BPD, there are suicide attempts, cutting, poisoning, self-harm with the help of other people in interpersonal relationships, self-infliction of pain. nine0017 T - Spending. Unreasonable spending of money on unnecessary purchases, unreasonable expenditure of effort.
A - Ambivalence. Opposite feelings in a short amount of time. For example, love and hate.
B - Pain. Characterized by mental pain with repeated unsuccessful attempts, for example, in building interpersonal relationships, employment, etc.
I - Idealization. The tendency to idealize other people and depreciate them after a short period of time. nine0017 L - Lie. People with BPD are prone to deceit, lies, embellishment of reality.
N - Troubles. People with BPD often find themselves in conflict situations, quarrels, unfriendly relationships.
Oh - emptiness. People with BPD often feel empty inside, lack of interest.
S - Boredom. A feeling of boredom, a decrease in activity, a lack of prolonged interest in any activity, the world around and other people are characteristic.
T - Branding, branding. They often brand themselves. After hospitalization in a hospital, they feel the stigma of the mentally ill, acutely experience such a state, and isolate themselves. nine0017 INSTABILITY characterizes the lives of people with BPD, these are interpersonal relationships, and situations related to employment, and mood, and behavior in general.

Expert opinions on borderline personality disorder

Anton Yezhov, PhD in Psychiatry. Institute of Neurology, Psychiatry and Narcology of the Academy of Sciences of Ukraine, Kharkiv, full member of the Russian Psychotherapeutic Association, certified and accredited by the Moscow Gestalt Institute (according to the standards of the European Association of Gestalt Therapists). nine0004

Common requests from border clients might be: “Can I call you at home?” “What if I want to kill myself?” you in the waiting room?", "Could you write to my professor and tell me that I'm too stressed out to take the exam?" Some of these problems are formulated as questions; others arise in the form of action (for example, the therapist finds the client asleep on the floor in the waiting room). The ways to test boundaries when working with borderline patients are endless, and it is critically important for the therapist to know that what is important is not what is important.0003 what conditions to (they may vary depending on the patient's personality, therapist's preferences and situation), and that conditions must be must be constantly monitored and supported by specific sanctions if the patient does not show respect for them. For people with separation-individuation problems, connivance creates more anxiety than containment, much like teenagers whose parents do not insist on responsible behavior. Without clear boundaries, they tend to escalate until they find the boundaries that have remained unspoken all along. nine0005

Borderline clients often react angrily to the therapist's boundaries, but in any case they receive two therapeutic messages: (1) the therapist considers the patient an adult and is confident in their ability to tolerate frustration, and (2) the therapist refuses to be exploited and thus serves self-respect model. Often people on the borderline have a history of receiving a lot of conflicting messages; they found encouragement in moments of regression (and usually ignored in more mature behavior), and they were expected to be able to exploit and allowed to exploit. nine0005

When I first started to practice, I was struck by the amount of deprivation and trauma experienced by borderline clients. I tended to see them as thirsty and needy rather than aggressive and angry, and in the hope of compensating for their difficulties, I tried to jump above my own head. I realized that the more I gave, the more they regressed and the more frustrated I felt. Over time, I learned to stick to the established framework, no matter how cruel it may seem. I did not allow the sessions to go on longer than they were supposed to, even if, for example, the patient had just fallen into a state of intense grief. Instead, I learned to gently but firmly end a session on time and listen to the patient's anger at being kicked out the next time. If borderline patients began to chastise me for my rigid, selfish rules, I noticed that they fared better than when I tried to get them to appreciate my generosity, which is an internally infantilizing attitude. nine0005

Therapists who are new to working with borderline patients often ask when all preparations for therapy will be completed and real therapy will begin. It must be painful to realize that all this work on the conditions of therapy is therapy. The beginner wonders when the borderline patient will "calm down". Tension characterizes all work with borderline patients, and it is critical that the therapist be able to tolerate or "contain" this tension, even when it includes verbal attacks against the therapist (Bion, 1962; Charles, 2004). Once an alliance of the neurotic type is reached, the patient will, by definition, take a giant step in development. Having to spend so much time asking questions of boundaries when working with people who are often bright, talented, and spectacular is quite disconcerting, especially when these questions stimulate overflowing reactivity. Petty fighting from abroad is hardly what we meant by "doing therapy" when we decided to go into this area. Therefore, people working with their first frontier clients may suffer from occasional flare-ups of self-doubt. nine0005

When working with borderline clients, it is usually best to work face to face, even with those who are attracted to psychoanalysis and want to 'dig deeper'. Although they are not subject to the overflowing transferences that characterize psychotic patients, they have more than enough anxiety without the therapist sitting out of their sight. For the recovery of more difficult patients, being able to see the reflection of emotion on the therapist's face can also be critical. Analyzing video recordings of sessions with clients who had previous experiences of therapy failure, Krause and colleagues (e.g., Anstadt, Merten, Ullrich & Krause, 1997) found that regardless of the therapist's orientation, improvements were correlated with the client's ability to see "mismatched" emotions on the therapist's face. For example, when the client's face showed shame, the therapist's face might express anger at someone shaming the client; when fear appeared on the client's face, the therapist's face might express curiosity about that fear. Also, again, since the energy of borderline clients does not need to be rewarded, only unusual circumstances (such as the need for increased support in withdrawal from addiction) may require borderline clients to be treated more than three times a week, as in classical psychoanalysis. nine0005

Voicing contrasting states of feeling

The second thing to pay close attention to with borderline clients is the therapist's speaking style. With neurotic patients, the specialist's comments may be infrequent and intended to have maximum effect ("less is more"). With healthier clients, noting the other side of the conflict, in which the client is aware of only one feeling, can be spoken concisely and emotionally subdued (Colby, 1951; Fenichel, 1941; Hammer, 1968). For example, a woman on the neurotic spectrum may enthusiastically vent about her friend, with whom she is in a somewhat competitive relationship, in such a way that she does not feel any negative emotions. The therapist might say something like, "But you would also like to nail her," along the way. Or a man may rant about how independent and free he is; the therapist might comment, "Yet you worry all the time about what I think of you." nine0005

In these cases, neurotic clients know that the therapist has revealed some of their subjective experiences that they have been keeping out of awareness. Because they can appreciate that the clinician is not trying to belittle them, is not claiming that their unacknowledged attitude is their real feeling and that their conscious ideas are illusory, as a result of this interpretation they may feel that their awareness has increased. They feel understood. , even if slightly hurt. But borderline clients who are spoken to in this way feel they are criticized and belittled, because if the phrase is not reformulated, the main message they receive will be: “You are completely wrong about how you really feel. ” . This response comes from their tendency to be in one or the other ego state, but not in a state of consciousness that can live and endure ambivalence and uncertainty. nine0005

For these reasons, beginning therapists often find themselves in a situation where they think they are expressing caring understanding, but notice that the borderline patient reacts as if he is being attacked. One way to get around this problem is to recognize that the BORD lacks the reflective capacity to perceive an interpretation as additional information about itself, and therefore needs to give this function to the interpretation itself. Therefore, the patient is more likely to hear empathy in the words: “I can see how much Mary means to you. However, is it possible that there is also another part of you - a part that you certainly will not be guided by - that you would like to get rid of it, since it is in some way competing with you? Or: “You definitely say that you are characterized by independence and self-confidence. Interestingly, it seems to co-exist with some opposing tendencies, such as being sensitive to my opinion of you." Such interventions lack the punch and beauty of laconic expressions, but given the peculiarities of the psychological problems of borderline people, they are the ones who are more likely to achieve the goal. nine0005

Interpretation of primitive defenses

The third feature of effective psychoanalytic therapy with borderline patients is the interpretation of primitive defenses as they arise. This work does not fundamentally differ from ego-psychological work with neurotic patients: we analyze defense processes as they arise in the transference. But because the borderline's defenses are so primitive, and also because they can manifest in quite different ways in different ego states, the analysis of these defenses requires a special approach. nine0005

With borderline clients, "genetic" (historical) interpretations, in which transference reactions are associated with feelings belonging to a figure from the client's past, are rarely helpful. With clients at the neurotic level, one can greatly benefit from a comment such as: "Perhaps you are so angry with me because you perceive me as your mother." The patient may agree, notice differences between therapist and mother, and be interested in other cases in which this association might be relevant. With borderline patients, reactions can range from "So what?" (which can mean "You look so much like my mother, why should I react differently?") to "So how can this help me?" (which could mean "You're just spouting your psychiatric rubbish. When will you finally start helping me?") or "Sure!" (which can mean “Well, finally you understand everything. The problem is my mother, I want to change her!”). Such reactions can be confusing, disarming, and discouraging for young therapists, especially if genetic interpretations have been a useful aspect of the therapist's personal psychotherapeutic experience. nine0005

With borderline patients, one can safely interpret the emotional situation here and now. For example, when anger spreads in the therapeutic dyad, it is likely that the patient's defense is not a substitution or a direct projection, as was the case in the previous example of the neurotic patient with the mother transference; instead, the patient appears to be using projective identification. The patient tries to get rid of the feeling of "bad self" (Sullivan, 1953) and the associated emotion of rage by transferring them to the therapist, but the transference of image and emotion does not occur "purely"; the client retains a sense of "worthlessness" and anger despite the projection. This is a painful price for an inferior psychological separation—a price that the borderline person pays and that the psychotherapist inevitably shares. nine0005

Consider how borderline clients differ critically from both neurotic and psychotic clients. The psychotic client is detached enough from reality not to care whether the projection "fits" the person. A neurotic person has an observing ego that is able to notice that he is currently projecting something. Borderline patients cannot successfully get rid of the sensation of projection. They cannot remain indifferent to how realistic the material being projected is because, unlike psychotics, they have retained the skill of testing reality. And they cannot put it on the unconscious part of the ego, because, unlike neurotics, instead of using repression, they switch between states. Therefore, they continue to feel what they are projecting along with the need make it fit the person so they don't feel crazy. The therapist accepts the client's anger (or other strong emotion) and, while the client tries to "fit" the projection by insisting that he is angry because of the therapist's hostility, the therapist begins to feel angry because he is not understood. Because of these transactions, borderline clients get a bad rap among many mental health professionals, even though they are not always unpleasant people and can usually be treated appropriately. nine0005

An interpretation that might affect a borderline person in this situation would probably be: “You seem to be convinced that you are a bad person. You get angry about it and link the anger to the fact that I'm really bad, and that my anger causes your anger. Try to imagine that both of us have both good and bad, and that all this is not so scary. This is an example of a primitive defense confrontation here and now. It represents the therapist's attempt, which will have to be repeated in various forms over several months at most, to help the patient move from a psychology in which everything is black and white, "all or nothing", to one in which the various aspects of the self, good and bad, and a range of emotions are consolidated within a single concept of "I". This type of intervention is not easy for most people, but fortunately the practice pays off. nine0005

Obtaining supervision from the patient

The fourth dimension of working with borderline clients is that I have found it helpful to ask the patient to help resolve the "either/or" dilemmas that often confront the therapist. This technique, where the specialist asks the patient to be their supervisor, is directly related to the all-or-nothing approach inherent in the borderline patient's picture of the world.

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