I Hate You, Don't Leave Me

Inside the mind of a borderline.

Therapist Personality and Borderline Personality

The Patient-Therapist "Fit"

Although much has been written about the syndrome of Borderline Personality, less has been observed about the personality of the treating clinician. What are the characteristics of a therapist best suited to treat these patients?

Most important, the therapist must recognize and understand that his patient is struggling with BPD, and the accompanying cluster of symptoms. A clinician must be able to tolerate complex paradoxes in the therapy similar to those with which the borderline patient struggles. Just as the borderline tries to navigate between extreme emotional swings, such as happy to sad and love to hate, the practitioner must balance flexibility and innovation with consistency and maintenance of boundaries. The therapist must adapt to the changing demands of the patient, yet also present dependable, consistent acceptance. Support and empathy must be balanced with confrontation of truthful, practical realities.

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A therapist should possess enough confidence to withstand potential challenges of competence and caring, yet not be so arrogant as to thoughtlessly dismiss the patient’s complaints. Maintaining a sense of humor may help retain a sense of proportion in dealing with “crisis” situations.

The treater must be more sensitive to her own reactions to the patient (countertransference). A recent study (American Journal of Psychiatry, January, 2014) explored therapist responses to their borderline patients. Patients with BPD, more than any other personality profile, aroused stronger reactions from clinicians. Feelings of helplessness, inadequacy, guilt, anxiety, and disorganization were endorsed by these practitioners. Some also experienced concerns of becoming overinvolved and making special allowances that violated boundaries, while others reacted against such feelings of responsibility by clinging to more rigid limits. The study also demonstrated that therapists’ erratic reactions often reflected the fluctuations in patient behavior. When the patient was angry, the clinician was more likely to either back away from confrontation, for fear of enraging the patient even more, or to become more aggressive with interpretations. More favorable feelings were experienced toward borderlines who functioned at a higher level.

The optimal patient-therapist “fit” occurs when both parties work toward the same goals and develop mutual trust. Just as the borderline strives to achieve understanding of his emotional fluctuations, the therapist, likewise, must recognize the responses that she experiences. In this way, the optimal partnership in therapy is established.

 

Jerold Kreisman, M.D., is a psychiatrist and best-selling author of numerous books.

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