During a recent consultation, Jay, a young mental health worker at an in-patient facility, asked for advice on how to cope with a borderline personality disorder patient who was struggling with issues of rage and a sense of entitlement. He submitted a long written description, reporting that his work with this patient was "becoming a nightmare." Among other problematic behaviors, Jay reported that his patient cuts herself, threatens suicide, hits her peers, urinates on the floor and screams at top of her lungs when she does not get her way.
She clearly has a strong sense of entitlement, which is characteristic of borderline personality disorder. Jay illustrated this problem with another example: one evening she ordered cereal for her breakfast the following day, then woke up and demanded oatmeal and bananas instead. When no one complied, she overturned a few chairs, threw her tray at the kitchen staff, and then threatened to kill herself and burn the place down. The temper tantrum lasted three hours. As she was completely unreachable, she was eventually placed in restraints and medicated.
Jay complains that "empathy does not work, group therapy, one on one, drawing, meditating, bribery" -- nothing works. He also describes her extreme swings in emotion, especially in her relationship to Jay. "She hates me one day and cannot live without me the next." She has no boundaries and does not respect Jay's. His fellow staff members "are all sick of her." As he is the most junior member on the ward, he is unfortunately "stuck" with her." He feels so angry and demoralized by his work with this patient that is considering a change of career.
Jay's description dramatically illustrates the emotional challenge of working with someone who suffers from borderline personality disorder. His reactions are not unusual; I have felt very similar ways during sessions with my own clients. His account also reminds me of other such stories I've heard, about the way borderline personality disorder patients affect their ward staff. They are highly provocative and evocative; they inspire feelings of hostility and resentment. They make you want to quit the profession.
In order to help someone like this young woman, you first have to get clear on the difference between empathy and sympathy. Jay states that "empathy does not work," but I doubt he or anyone else on the staff is truly empathizing with her... at least they're not aware that they are. She fills them (via projection) with all her own unbearable emotions of rage and anger; the way she treats her caretakers evokes the same feelings within them that she is struggling with. Jay says her behaviors make his "blood boil" -- that's where the empathy comes in. The problem is that, for the most part, we mental health professionals believe it's inappropriate to have such feelings, and when we're forced to admit that we do have them, we want to blame the patient.
What I recommend instead is to use those feelings to connect with her. I suggested to Jay that he say something to his patient like this: "When you can't force me do what you want, it makes you so furious you hate my guts and want to kill me." It's clear from Jay's description that she's struggling with murderous rage and it's important to name it for her, to articulate the emotions and impulses she's feeling. It's easy to assume that she knows what she's feeling; the truth is, her mind is continually blown apart by the violence of her feelings; she doesn't really know what they are in any way you or I would recognize. It's the job of the therapist to help her bear with those feelings and learn to understand them -- very difficult work.
This young woman also finds any kind of frustration unbearable; she's goes into a rage whenever she feels it. In part, this reflects the sense of entitlement you so often find with borderlines; it also betrays the limits of her capacity to bear any kind of pain. She demands to be treated as if she were an infant, really -- ministered to by a perfect mother who would tend to her every need and never let frustration become an issue. It would be important to address this with the patient: "I think you find any kind of frustration unbearably painful; when you feel it, you just want to kill somebody." With my own clients, I've also said things like: "You expect me to understand and gratify your every need without you having to say a single word."
Neither can she bear the experience of separateness; those boundary-crossing behaviors that understandably annoy Jay represent her attempt to take possession of him, to own him, and to deny the separation between them. When the experience of need, separateness and frustration is unbearable, fantasies of merger often come to the rescue. If she "owns" Jay by merging with him, then on some level, she believes she won't have to feel frustration, or become enraged when he doesn't instantly do what she wants him to do. When she feels "at one" with Jay, she "loves" him (it's not really love, of course); when she experiences him as separate and frustrating, she wants to kill him. To me, these are familiar borderline dynamics.
I feel for Jay. His description is overflowing with all the unbearable emotion she inspires in him. Using those feelings as a guide to the patient's emotional experience (countertransference in the broad sense) is the only way to make the work bearable for the therapist, and the only way you can truly help someone this troubled. In my experience, it also helps you feel more compassionate toward their suffering. It is painful and often terrifying to feel murderous rage. If Jay, with his healthier mind and greater mental capacities, finds it so difficult, imagine how hard it must be for his patient to bear with her experience. By using your reactions as a guide to understanding your client (instead of feeling quietly guilty because you hate her), you'll truly empathize with her experience, and probably feel a lot more sympathy as well.
Joseph Burgo PhD is a clinical psychologist who writes extensively about shame, narcissistic rage, bipolar disorder symptoms and working with borderline personality disorder. He also offers online counseling via Skype.
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