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23 - Over the Borderline

In 1992, renowned psychiatrist Dr. George Vaillant wrote an article entitled The Beginning of Wisdom Is Never Calling a Patient a Borderline; or, The Clinical Management of Immature Defenses in the Treatment of Individuals With Personality Disorders. A mouthful of a way of addressing the long-time prejudice against people with BPD. There’s a concept in psychodynamic psychology called object constancy. This is what makes babies like peekaboo. If they can’t see you, you don’t exist. Lack of object constancy is cute in babies, not so cute in adults. So an adult struggling with it might text 30 times in an hour when they don’t get a response. And then respond angrily when they finally do. The sensitivity to real or perceived abandonment and impulsivity for immediate soothing leads to drugs, sex, gambling and other short-term rewarding behaviors. And the overwhelming emotions leads to self-harm or suicidality. Many therapists will avoid taking on clients with a BPD diagnosis.

Marsha Linehan, developer of DBT

Not Portland DBT. Clients with BPD were welcomed. Often we were a court of last resort, clients who had blown out or been thrown out of clinics all over town. Not every client at Portland DBT had a borderline personality disorder diagnosis. Many struggled with trauma, depression, anxiety or substance abuse. And some clients had other personality disorders, most notably narcissistic or antisocial personality disorder. This would be some of the most difficult clients, who were not responsive to treatment. Like the client I had who had stabbed his wife and was verbally aggressive with me. His narcissistic personality disorder was worsened by the steroids he was taking. One session with him was one of the few times in my career when I was visualizing how I would knock a client down if he came at me.

One of the rules at a full fidelity DBT clinic is being available by phone 24/7. You can see how this addresses the object constancy dynamic. But it’s hard on clinicians. To survive as a DBT clinician you had to train clients as to when it was a genuine emergency, and when it was just seeking reassurance. The latter was not an acceptable option and would lead to frying the clinician and ruining the relationship.

Although there was high turnover of therapists, the camaraderie was strong. It was a great place to learn and have clinical skills tested. And clients with BPD usually had significant trauma histories. If a clinician could access compassion for that trauma, they could help clients to genuinely get better.

The psychiatric powers that be, who author the Diagnostic and Statistical Manual of Mental Disorders (DSM), reportedly debated renaming BPD as complex relational trauma. But due to politics and personalities, it didn’t happen. Thanks to DBT, borderline personality disorder is more treatable than any other personality disorder.

I obviously cannot go into any details about clients. But I can say that I could connect with all but a handful of them. I found I could relate to clients with BPD, appreciating their pain. They just had difficult ways of seeking connection, like cutting themselves or threatening suicide. I stayed at Portland DBT eight years, which was five years longer than most.

My frustrations over tough administrative policies and lack of reward for seniority grew. And working with clients with BPD, you had to bring your best game with no hidden resentments. I remember one time, when I had had a personal problem, and I went out to greet one of my more severely impaired clients in the waiting room.

I said, “Hi,” and she said, “What’s the matter? Did I do something wrong?”

When you come from a traumatic background, you get very good at reading other people. Better than most clinicians.

I recognized I was burning out. And my daughter mentioned that her former college roommate was now the office manager for a psychiatrist who wanted to build his practice with more therapists.

So I went to meet Dr. Paul Conti.


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