Borderline personality disorder is a hot topic recently, and Personality Couch has explored its history and presence in the media, criteria and symptoms, and suicidality/self-harm. It’s a disorder characterized by deep emotional pain…but what about treatment? Is there hope? YES!!! There are actually many treatments for borderline personality disorder, which you can Google and likely find Dialectical Behavior Therapy (DBT) as the evidence-based, gold-star treatment. Instead of telling you about all the information that’s already out there everywhere, I’m going to talk about what isn’t talked about - the unspoken dynamics happening in treatment with borderline personality disorder.

Treating borderline personality disorders is one of my specialties. I enjoy it for many reasons, including the need for an individualized approach to treatment because no two persons with borderline personality disorder are alike. The growth made in treatment is hugely influenced by tricky, unspoken dynamics that are invisible. So what are they?

Boundaries

While boundaries can be spoken and visible, they are often unspoken and invisible. Boundaries are involved in all the therapeutic processes throughout the entirety of therapy. Boundaries are important for personality disorders in general, but especially for borderline personality disorder. This is due to the safety and validation that boundaries provide in the chaotic pain of this disorder. We can think of boundaries as the frame of the therapy puzzle.

Boundaries Outside Sessions

Some examples of important boundaries outside of sessions include following rules and policies with paperwork (i.e. must be complete), payment (i.e. must be made the day of session), and communication (i.e. goes through the administration team). The policies are needed to set a professional therapeutic environment, not just an informal conversation with an acquaintance. It’s essentially the groundwork for treatment.

Boundaries Inside Sessions

There are also boundaries that are involved inside of session work, such as attendance, communication during session, and work put into sessions. I always emphasize that the days someone does not want to attend therapy are likely the most important days that they should, since that might be when they’re depressed, angry, avoidant, etc. Not to mention there can be policy-related consequences to not attending. I also highlight that anything can be discussed in therapy (even anger, attraction, fears, aggression desires), but we can’t necessarily behave on it. For example, you can be angry and scream at me, but you can’t knock over the lamp (Please be aware that every therapist sets their own boundaries. It may not be okay to scream at your therapist). Additionally, therapy is the client’s space, and therefore, I cannot do the work for the client.

Therapeutic Relationship

(Super important factor!)

Attachment

The relational connection or lack thereof (attachment) between client and therapist is important for treatment. For those with borderline personality disorder, there is often a quick attachment to the therapist because of their high pain, need for help(er), and need for relationship (due to fear of abandonment). The client might view the therapist as a hero, rescuer, or the best thing ever (idealization). Uncommonly, and sometimes fleetingly, the client might view the therapist as a villain, persecutor, or the worst thing ever (devaluation). When either of these happen, providers need to be careful and accept it without reinforcing it.

Because of the pushes and pulls involved in treating personality disorders, boundaries and attachment often overlap and can be quite problematic. My biggest pet peeve is when providers take up the client’s therapeutic space with clinically irrelevant self-disclosure. It’s highly unlikely that the client needs to know about their therapist’s love life, diet, or own struggles with mental health. Therapists can become too involved in their clients’ needs, especially when their client wants them to constantly meet all their needs and tell them what to do. I’ve seen some providers portray a controlling or possessive resistance when a client wants to end therapy, which means something is wrong there. Other big, bad boundary crossings include unsolicited advice regarding nonclinical matters, socialization outside of sessions, physical contact, and romantic intimacy that is acted upon. Honestly, these are all red flags! 🚩🚩🚩

Transference/Countertransference

The attachment in the therapeutic relationship inevitably leads to transference and countertransference. Because the client does not have a full picture of who the therapist is as a human being, the client unconsciously perceives the therapist to be similar to a different attachment they have a map for, usually from childhood, like their mother (transference). The client then unconsciously behaves in similar ways that they acted with their mother, which leads to countertransference. This is when the therapist has their own perceptions, emotions, and reactions to the client that often mirrors what the transferred person (like mother) felt, which is often frustration or pulls to rescue. It’s common for the Drama Triangle (podcast/blog) to show up in these dynamics!

Corrective Experiences

Corrective experiences are difficult to explain because they are extremely individualized. It’s an experience that occurs in the therapeutic relationship that “corrects” or “heals” a traumatic or bad experience that occurred with a different attachment (usually in childhood). While I may celebrate the admission or expression of anger for someone who turns their anger inward, I might celebrate the self-containment or accountability for someone who is outwardly destructive in their anger. A more complex example would be for someone who has been parentified, I can set boundaries to facilitate corrective experiences by making sure I am the “parent” in the therapeutic relationship. I handle tracking the time, making sure we’re scheduled, etc. In contrast, if someone is regressed, I can set boundaries to not play into any dependency or “tantrums.” I might make it the client’s responsibility to make sure we are scheduled or have the boundary that I will not call them if they are late or missing a session, with the purpose of increasing their tolerance of taking responsibility for themselves.

Repairing Ruptures

Corrective experiences can also include repairing attachment ruptures in the therapeutic relationship. A rupture can happen when there is any conflict or potential for conflict between the therapist and client. This is SUPER important in the treatment of borderline personality disorder because of the fear of abandonment. I have to validate the conflict or concern without judgment, allowing the client to be upset in a way where it is also emphasized that I will not abandon the client. Sometimes, this includes me being incongruently excited and celebratory that the client has brought up their concern. Then, the repairing of the rupture includes sitting in the distress, exploring what is happening, taking accountability, and resolving the conflict interpersonally.

Connections & Insight

Making connections and facilitating insight is also an important part of the invisible dynamics of therapy. Making connections involves putting separate pieces of a client’s story together. It’s the middle part of the puzzle, and it is similar to finding all the pieces that make up a certain design, color, or shape, and putting them together. While therapists (should) do this in their own head, it’s important for the client to make and verbalize the connections with guidance (Not rescuing. Not advice. Not answers) from the therapist. Client-led connections are much more powerful and helpful. Facilitating insight includes self-reflection, self-awareness, and looking deep into the self, and then being able to verbalize it. Therapists can call out what’s happening in the room in the moment (immediacy) to help clients with this. For example, a therapist might ask the client what is leading to the clenched fists when discussing their mother or the picking at the couch when discussing their father.

In sum, treatment for borderline personality disorder is extremely individual with a ton of invisible dynamics. This can actually be pretty frustrating for clients because there’s not necessarily tangible evidence of growth or boxes being checked off like in some manualized treatments. So because the growth is also “invisible,” it can feel like progress isn’t being made, or maybe even feeling “stuck.” However, the healing often occurs over time without realization (ya know, since all these things are frustratingly invisible!). But then, when prompted to explore their progress, clients can usually verbalize their growth, and it can be super powerful!