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3 Reasons Many Therapists Don’t Like to Treat Borderline Personality Disorder

Specialized training is necessary for effective treatment.

Key points

  • Finding good treatment for symptoms of BPD can be challenging.
  • Many therapists either avoid or refuse to treat BPD. Treating BPD requires specialized training or experience for optimal results.
  • Often, insurance companies do not pay for the treatment of BPD.
Finding the right therapist.
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Many individuals seeking treatment for symptoms of borderline personality disorder (BPD) find that many therapists are reluctant to treat this condition.

This only adds to the suffering of those seeking help and increases their sense of hopelessness and futility.

Understanding why some therapists avoid treating this disorder will help you find therapists who are willing and skillful in treating the nuances of this disorder.

1. Insurance Reimbursement

Most insurance companies in the United States do not reimburse for personality disorder treatment. This can be a major obstacle to individuals seeking help for this serious disorder. Some therapists work around this by diagnosing comorbid conditions, such as anxiety or depression, that are often present with BPD symptoms. Other therapists are uncomfortable with this practice and, for this reason, avoid treating BPD.

2. Fear of Patients Lashing Out

Individuals with symptoms of BPD are particularly sensitive to perceived criticism. This increases the likelihood that they will feel attacked when a therapist attempts to offer suggestions or insights. This often leads to lashing out.

Inexperienced and undertrained therapists sometimes react defensively to the patient’s lashing out. This is ineffective therapeutically and often leaves the therapist afraid of the patient.

In the following example, Dr. Shrink experiences Jalen lashing out in response to a question.

Jalen: Last night, my partner told me to shut up and walked out.

Dr. S.: Did that just come out of nowhere?

Jalen: What are you asking?

Dr. S.: I am trying to understand the context.

Jalen: You think I brought this on.

Dr. S.: I didn’t say that.

Jalen: Your question was an accusation.

Dr. S.: I was just trying to understand what got your partner upset.

Jalen: You are more interested in how my partner feels than my feelings.

Dr. S.: That is not true.

Jalen: I don’t know why I am wasting my time and money here with you.

Dr. S.: Perhaps you would be more comfortable with another therapist?

Jalen: At least I might find someone who cares.

Dr. S.: I can help you find someone.

As soon as Jalen lashed out at him, Dr. Shrink became defensive and then encouraged Jalen to see another therapist. A more experienced therapist who is not intimidated by lashing out could have turned this exchange into a therapeutic intervention.

Here is how Dr. Masters, who had specialized training and experience working with BPD, might have handled it:

Jalen: Last night, my partner told me to shut up and walked out.

Dr. M.: That must have been very upsetting to you.

Jalen: Of course, it was.

Dr. M.: Has something like this happened before with your partner?

Jalen: Yes. I don’t feel safe.

Dr. M: Yet you stay in this relationship anyway?

Jalen: Are you saying that I should leave?

Dr. M.: I am wondering what you think?

Dr. Masters knew to respond to Jalen’s initial statement with validation. When Jalen confronted him, he was not defensive. He just stated his motives, and Jalen accepted it.

3. Concern About Patients Sabotaging Treatment

Sometimes individuals with symptoms of BPD lash out so intensely that it sabotages the treatment in such a way that even the most skilled therapist cannot stop this process. A common example is a patient cutting off all contact, or ghosting the therapist. The patient stops coming to sessions and refuses to take calls or emails from the therapist.

Another form of sabotage involves the patient attacking the therapist through a third party. Examples include making an ethics complaint against the therapist’s license or disparaging the therapist on websites or other platforms. This is a form of triangulation and puts the therapist in a position to defend herself. She must discredit the patient. This presents a conflict of interest that almost always defeats the treatment.

Moving Forward

The effect of these three aspects of treating patients with symptoms of BPD, as well as other challenges, discourages many psychotherapists from treating individuals suffering from this disorder. This is most unfortunate for those who suffer. Individuals with symptoms of BPD should seek out therapists with specific training in working with this disorder. Psychotherapists who endeavor to treat this disorder should obtain specialized training and experience with the most effective techniques in treating this group.

The exclusion of personality disorders from reimbursement by most medical insurers is a significant obstacle for almost everyone seeking treatment for BPD and any provider offering services to this population. Specialized treatment for personality disorders is generally only available through private pay. The cost is generally very high and not affordable for most people. Addressing this inequity will require advocacy and lobbying, forcing the insurance industry to treat personality disorders on parity with other mental disorders. Making politicians and mental health advocates aware of this problem will increase the chances that this obstacle will be addressed, thus giving access to specialized care to more individuals who suffer from symptoms of BPD.

To find a therapist, visit the Psychology Today Therapy Directory.

More from Daniel S. Lobel Ph.D.
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