Why do many professionals still treat people with BPD as if they can't get better?

Patients with BPD teach their therapists to feel hopeless about them from the very first session. Often even in the first sentence is the message "You can't help me." This is often followed by evidence in the form of multiple previous failed therapies. The message has layers. "Everyone in my past has betrayed me. Why should you be different?" "I will take my revenge out on you for all these betrayals." "I am not worth helping." "I am too defective to ever be repaired."

Sometimes the message comes with threats and ultimatums. "I dare you to try to help me." "I'll give you a month and if I'm not better by then, I'll kill myself." Such deadlines are consistent with the borderline's difficulty seeing beyond the moment. While treatment can make vast differences in the lives of people with BPD, progress is measured in months and often years, not days or weeks.

The verbal messages are often backed up with actions: a history of multiple suicide attempts or signs of previous acts of self-injury. Such messages are daunting even to the most experienced of therapists. The more therapists try to reassure patients that there is hope, the more insistent become the messages that there is none. If messages of hopelessness are not conveyed in the first session, they inevitably come later. Some patients invest their therapists early in treatment with unrealistic powers to help and to heal and respond to disillusionment with redoubled hopelessness and anger.

Many therapists find these messages too overwhelming to allow them to function effectively. The prophesies then become self-fulfilling. Either they refuse to provide treatment or the treatment soon fails. Even therapists who are experienced in treating BPD can only handle a limited number of such patients at one time. Therapists are not immune to anxiety in the face of threat. It is crucial for therapists to appreciate their limits for tolerating anxiety if they are to continue functioning effectively.

A related question is why therapists are so often reluctant to treat patients with BPD. The answer is risk, some real, some perceived. It is hard to hear the messages of hopelessness without at least entertaining the possibility that treatment could end in suicide. Even with the best of treatment, we cannot control outside relationships or external events, which can be unpredictable, sudden, and devastating. Learning to tolerate pain takes time. Early in treatment, the risk of reacting to painful events with impulsive, self-destructive behavior remains high.

The risk that the therapist undertakes in treating high-risk patients is complex. There is the risk of failure and all the second-guessing and soul-searching that follows. There is also the risk of losing someone with whom a relationship has formed that is meaningful to the therapist. Working with patients is not like working on cars. We develop regard. We become involved. There is a special intimacy about being allowed into the private emotional life of another human being. Part of that intimacy is caring about our patients' feelings and their lives.

There is also a concrete risk to the therapist's career. Suicide often results in litigation, even if the therapist has done everything possible to prevent it. There are special circumstances in treating patients with BPD that increase that risk. Such patients are often in conflict with many of the important people in their lives. They are particularly insistent that therapists refrain from contact with their significant others. This is often deeply resented by the other people in their lives, who may project much of their frustration onto the unseen therapist. They are angry about the therapist's unwillingness to talk with them, naive about the responsibility to maintain confidentiality.

When patients do commit suicide, many family members are primed to blame therapists, particularly if they have had little or no previous interaction with them. When people are feeling guilty about their own possible role in bringing about their loved one's death, they are even more likely to project blame onto the therapist. Anger is a common defense against guilt. Such situations are especially prone to result in lawsuits. When patients have been involved in abusive and exploitive relationships and commit suicide, the abuser may take the therapist as the next victim. Unscrupulous individuals may see such situations as an opportunity for profit.

Whether lawsuits are justified or not, the process can be long and blistering. Some have been known to go on for as long as ten years, leaving a cloud over the therapist's practice and life the whole time. They can end careers and destroy marriages. They can shake a young therapist's confidence and leave an older therapist retiring in defeat, even after a long and productive career. This is just some of the destruction suicide can leave in its path.

Both patients and therapists often live with the myth that therapists are supposed to be selfless when they deal with patients. It is true that therapists must not exploit their patients for personal gratification or gain. But it is unreasonable to expect that they would be willing to expose themselves to all manner of personal risk in the interest of treatment. That would be denying the humanity of therapists. And if we did not share the vulnerability of the human condition, we could not empathize with our patients and would indeed be powerless to help them.

Patients do have power to alleviate some of their therapists' concerns. Going into therapy with realistic expectations, and especially an understanding that therapy takes time, can be helpful. Refraining from challenges and ultimatums and being willing to set realistic short-term goals can also help. A willingness to include family members in the process in some way so that they do not feel completely excluded, can avoid the development of conflict around their treatment and make the process easier for everyone involved. This means going into therapy with an appreciation of shared responsibility for the outcome rather than expecting that the therapist is solely responsible for providing hope and relief.

© Dr. Richard Moskovitz


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