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Working with Borderline Personality Disorder

When it comes to helping clients with ‘borderline’ presentations, our capacity to contain and make sense of their underlying state of mind is vital. But it may also be uniquely tested. Ahead of an online training in June, psychoanalytic psychotherapist and former psychiatric nurse Marcus Evans outlines key features of working with BPD, including managing projections, the danger of premature interpretation, and the role of supervision in providing a psychic space where we can process often intense countertransference reactions.

 

Patients with ‘borderline’ features can have a particular effect on therapists and mental health teams. From a psychoanalytic perspective, this is because they have difficulties in dealing with their psychic contents, and tend to evacuate undigested elements of their minds through action. They also form strong transference towards those who care for them, who come to represent parental figures. This blog will look at some key features of working with people with BPD – features that can lead to therapist demoralisation and costly clinical mistakes if practitioners lack specific training, good supervision, and a sympathetic attitude from the surrounding clinical team. 

Strong countertransference reactions

A strong transference produces a strong countertransference reaction. When patients have ‘borderline’ features, certain aspects of their psychopathology will inevitably be re-enacted with mental health professionals. When working in psychiatric teams, we find that different parts of the patient are projected into different parts of the team, and splitting abounds.

These communications often take the form of concrete communications that fill their recipients with feelings – feelings that either provoke concrete reactions in return, or make professionals feel they cannot think clearly about the patient.

These states of mind tend to reduce our capacity to think in a symbolic way about the meaning of the patient’s behaviour. This means that therapists and patients can get into an unhelpful cycle of action and reaction that prevents learning from experience.

The dominance of projections

In many ways it is true to say that these patients draw us into dyadic relationships dominated by projections. These projections affect our capacity to think in an objective or imaginative way. We may feel that we are being driven mad by the patient, that we can’t stand the patient, or that we are trapped in identification with the patient.

In the interests of trying to understand the patient’s underlying state of mind, these fragmented parts need to be gathered together in handover and case discussion. Our capacity to think about, and make sense of, our patients is a dynamic process relying upon numerous factors, including our capacity to verbalise and integrate the different views of the patient.

This is a potentially turbulent process. It requires a constant examination of our contact with the patient, within an atmosphere of curiosity and openness. It also means that therapists and staff teams have to tolerate doubt and uncertainty about their work.

The role of psychoanalytic supervision

Regular psychoanalytic supervision helps us to process our feelings about patients with ‘borderline’ features, as well as examining the transference and countertransference relationship. The supervision group can turn the dyadic relationship between the mental health professional and the patient into a triadic relationship, with the supervisor/group forming the third point of a triangle. This triangle provides space for an objective examination of the clinical picture – which includes our subjective view.

This triadic relationship provides some psychic space, allows us to separate from our feelings towards our patients, and helps to free us from the psychic effects of projections. It also allows room for thinking in an imaginative way about the underlying meaning of the communications, and re-establishing our capacity for symbolic thought.

Supervision can also help us to integrate facts about our patients’ history, presentation and self-destructive patterns of behaviour, together with the current clinical picture. Although knowledge of the patient’s history will not necessarily prevent these re-enactments, forewarned is forearmed. Awareness of the transference and countertransference may prove to be an invaluable aid to management.

The role of containment and danger of premature interpretation

Insights can help with clinical management and the assessment of risk. But we need to carefully consider what it is appropriate to say to patients, in what sort of clinical setting, and when to say it. Premature interpretation of behaviour can lead to the patient feeling assaulted and overwhelmed. The meaning of communications needs first to be digested and verbalised.

Above all, patients with ‘borderline’ features need us to contain their understanding. They need to feel that people listen to them and take their difficulties seriously. In many ways, they are looking for a ‘marsupial’ pouch to offer psychological support and gradually gather the disparate aspects of themselves together. They also need services that can provide a long-term view of their difficulties and appreciate their underlying fragility.

Marcus Evans will be delivering an online workshop for Birkbeck, Working with Borderline Personality Disorder for HE Counsellors, On June 24 2020.

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Marcus Evans

Marcus Evans is a psychoanalyst and was an adult psychotherapist at the Tavistock & Portman NHS Foundation Trust with 40 years’ experience in mental health, originally training as a psychiatric nurse. After qualifying as a psychotherapist at the Tavistock & Portman NHS Trust, he took up a post as head of the nursing discipline. Marcus was Associate Clinical Director of the adult & adolescent departments between 2011 & 2015. Marcus has designed, developed and taught outreach courses for front line staff in various settings for the last 25 years. He was also one of the founding members of the Fitzjohn’s Service for the treatment of patients with severe and enduring mental health conditions and/or personality disorder in the adult department. He has written and taught extensively and is author of Making Room for Madness in Mental Health: the psychoanalytic understanding of psychotic communications, published by Karnac in Tavistock series.

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