The Untreatable Borderline Personality Disorder Client: A Therapeutic Nightmare

Borderline Personality Disorder (BPD)is one of the hardest disorders of all to treat. It can be improved with some therapies, but the road is long and hard. Many seem to go on for years or decades with little or no improvement. There are reports of cures, and I am familiar with a woman whose BPD cleared up at age 55 after having come on in childhood. That’s probably a typical cure. Decades of nasty illness followed by a lifting of the illness in middle age.
Many mental disorders improve in middle age, and even many personality disorders improve during this age period.
Schizophrenia often ‘burns out” in middle age, and florid positive symptoms are replaced by more negative symptoms.
Many anxiety disorders attentuate in middle age.
Even psychopaths often get better or at least less destructive in middle age, as many of them also burn out in a similar fashion as schizophrenics. A number of highly antisocial psychopathic men get better in middle age as the antisocial behavior attentuates. It is often replaced by depression, heavy drinking and a pessimistic, cynical, imbittered and misanthropic person who nonetheless does little damage to society anymore.
It should be noted the clients with BPD vary widely in their symptom pathology.  Some are much more functional than others. Quite a few can even function well at their jobs all day, but when they come home from work, they fall apart and shift into full BPD pathology.
However, some people with BPD are so ill that they seem nearly untreatable. It is these people who will be the subject of this post, not BPD’s in general. These people seem so far gone and broken that one wonders how anyone could ever even begin to put them back together again. I suppose some progress could be made, but the damage is so severe that I have a hard time seeing how even the best therapist could possibly fix these people in any significant way.
A typical case might be a young woman who, only in her late 20’s to early 30’s, already has 8 -13 suicide attempts and many hospitalizations behind her. She goes into the hospital on a regular basis. Therapy seems to do nothing but feed her pathology as she manipulates gullible new therapists to believe her lies, nonsense, and projections as the new therapist confuses symptom pathology with the truth. Drugs do almost nothing.
Diagnosis itself is often difficult because the BPD is so severe that the person often appears psychotic/delusional. One wonders what are delusions and what are not. Even the delusions do not seem to last for long, as they are dropped, changed around, added to or substituted in a wildly chaotic fashion.
Usually there is a lot of combativeness and involvement with the court system, as the extreme rage leads a litigious person.
Splitting is severe and textbook.
Self-image is so unstable that the person almost literally adopts the full personality and even persona of whomever is on their radar at the moment. The clinician needs to be prepared that this person will so identify with the clinician that they will adopt the therapist’s image and persona as their own. Boundaries nearly do not exist for these people, and they often fall in love with their therapists, try to seduce them, or on the other hand become furious at them to where sessions became rage attacks at the therapist, and the therapists is at odds of how to respond without violating ethics.
The client can become overtly suicidal even during sessions, and infatuation with the therapist can quickly split to where the therapist is the source of all evil. Homicidal threats and homicidal-suicidal threats against the therapist may now appear. The client then hospitalizes themselves due the “horrible trauma from the evil,  incompetent therapist” and soon finds sympathetic new therapist, typically a feminist woman, to unload her story on. The new female therapist forms an alliance with the client against the “evil male” former therapist and accuses him of damaging the client.
Commonly, the therapist gets angry and tells off the client. This leads to abandonment and a vengeance agenda against the therapist, who has now “irreparably damaged” the BPD and “caused them to spiral out of control.” Be prepared to get accused of abandonment, causing severe trauma in the client and making them dramatically worse. The client may become hospitalized due to allegations of damage from an incompetent therapist.
These people are so difficult and chaotic that many clinicians refuse to see Borderline patients. Some are on the record as saying that when they say a Borderline client coming their way, they hide under their desk until they go away. For a lot of therapists, these clients are nothing but trouble, and endless parade of drama and chaos. Therapy itself is chaotic, mercurial, and wild with severe splitting and often extreme idealization of the therapist for good or ill or both, interrupted by fairly regular hospitalizations. The therapist begins to wonder what’s in it for them and thinks you could not pay them enough to suffer through such clients. These clients make an excellent argument that therapeutic abandonment is the proper choice with some clients.

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7 thoughts on “The Untreatable Borderline Personality Disorder Client: A Therapeutic Nightmare”

  1. People with BPD need compassion and understanding, not stigma. Fear of abandonment is the number one criteria for BPD. The worst thing you can do is leave them. To learn what Borderline Personality Disorder is really about, check out my blog: I have been in recovery for ten years now. Dialectical Behaviour therapy helped me. It can help many others too. It needs to be more accessible and affordable.

    1. Hello Joyce,
      Congratulations on your ongoing recovery. I grew up with a severely borderline mother and can only describe it as 45 years of an extremely hurtful, chaotic hell. I was terrified of her and cut complete contact for a total of about 15 years. However at the age of 69 after finally addressing her guilt and shame as a result of being the victim of sexual abuse at age 12, she appears to have gone into remission and to be a changed person. I’m still cautious but the difference is quite dramatic. Good luck with your ongoing recovery.

    2. Is there any hope for a borderline person? Robert, you said that even therapists say you “can not pay them enough to suffer through such clients”?
      But as far as suffering goes, the person with BPD is suffering too. I promise you. It’s nightmare and 100% real for this person. There is no medication and absolutely no hope. That’s how it feels and that’s the stigma as well! The rollercoaster ride and intensity of all emotions, all the time is not fun. It’s not a show or an act for someone suffering with this, it’s literally exhausting and excruciating.
      This documentary does an excellent job of describing BPD in my opinion, from both sides? Especially what they said about manipulation, and about a BPD’s sensitivity. Please watch it

  2. The so called Artists are naturally inclined to get carried away with the diversity and the beauty, most of the times, in my humble opinion.

  3. Hello everyone,
    I actually have been a psychiatric nurse for 15 yrs… this post is excellent and brings up many great discussion points. Through the years I have experienced a wide range of reactions to individuals with BPD. Dread is what I used to feel early on … now I find meeting clients somewhere in the middle has worked. Letting them feel in control of some of their decisions and care and above all making them responsible/accountable for their decisions and consequences. After all, the behaviors and emotional outbursts are a coping skill masking horrific emotional pain. P.s. Congrats Joyce & DBT is truly amazing … we were trained years ago on the principles

    1. Thank you for acknowledging that a person with BPD is in horrific emotional pain. Sometimes it’s so helpful just hearing someone acknowledge that.

  4. Also, having seen pts with BPD and knowing some over the course of 15 years, many of them have much more mild symptoms as they age… or coping skills have improved or with age comes wisdom!! 😉

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