For clinicians who lack experience in treating patients with BPD, scenarios like this one are common. Some believe that treatment of a comorbid Axis II pathology can be deferred until after a patient has been discharged, despite the clear relationship between acute symptoms and interpersonal conflicts or other social stressors. In this vignette, Sara’s treatment team diligently attended to her depressive symptoms, but the approach they used encouraged an undue hope that somatic treatments would resolve her depression. It also encouraged a passive role on Sara’s part; she was not held responsible for any part of getting better. Her failure to stop cutting herself could be interpreted as her resistance against treatment, but it was almost certainly related to the misinformed strategies taken by the treatment team. Sara’s treatments reinforced her belief that her problems were outside herself and that she could rely on someone else to fix them.
Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms, but comorbid BPD decreases the likely response to medications. Psychotherapeutic interventions that require activity and responsibility on the patient’s part are most effective. When there are ongoing borderline issues (such as recurrent self-harm and extreme reactivity to interpersonal issues), these issues need to be a central focus in the ongoing treatment from the start.11 By giving such patients tools to manage their anxiety, their affects, and their impulses in lieu of self-harm, we give them the opportunity to manage their own safety. This helps them begin to focus inwardly rather than depend on rescue by others.
Entitlement as a form of resistance
Patients with BPD or narcissistic personality disorder (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.
Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility. At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very interested in helping her meet her treatment goals.
The greater difficulty was that in therapy, Kathy dwelled on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.
In working with patients with BPD, feelings of entitlement and efforts to avoid criticism are common forms of resistance. Clinicians who respond to a patient’s sense of entitlement with efforts to withhold what is demanded or to interpret the unrealistic nature of the patient’s needs are likely to make such a patient feel misunderstood, criticized, and angry. Providing validation for the patient’s needs without gratifying them offers a compromise that acknowledges the patient’s wishes without reinforcing his demands.
The problem of getting a patient focused on talking about difficulties is complicated. One approach involves making attention contingent on it. As a clinician, you can lean back in your chair and look perplexed when the patient dwells on how good he is at things. When the patient shifts to talking about difficulties, you can lean forward and give your undivided attention. Along with these nonverbal reinforcements of behaviors, it can help to note that you already know that the patient is very good, if not exceptional, at the things he is describing. Then add, “I feel our limited time is valuable and want to make sure you have time to discuss the things you are having difficulty with.” This approach avoids confronting the patient’s efforts to support his own self-esteem while also helping him move onto more relevant material.