The “Unstable” Client- Borderline Personality Disorder
I vividly remember when I met my first client in Toronto as a caseworker. A young person who came with a whole list of complex mental health diagnoses and a referral form filled out by their therapist laden with remarks such as “unstable mood”, “engages in risky behaviour”, “unable to break patterns of toxic relationships”, “difficulty managing school work” and “persistent self-harm”.
The primary diagnosis was underlined- Borderline Personality Disorder.
So I went ahead and met this client in their university library. My first impression was that this person was feisty, confident and rightfully skeptical of me as their new worker. This client was so much more than the underlined diagnosis and yes, their symptoms were crippling at times and had very real consequences for their daily life. But that was also the first time I got a little snippet of what folks with BPD go through- both internally and externally- as therapists and healthcare professionals often dismiss them for being “too much” and “too unstable.”
If you google BPD you are sure to get a long list of symptoms and traits such as intense and overwhelming, often unstable emotions and relationships, high stress and anger levels, engaging in risky, often self-harming behaviour, unsure about identity and a general lack of self-awareness. The term “black and white thinking” is used to describe BPD clients’ thought patterns because they often view situations, people and the world in general existing on the extreme ends of the spectrum. Things are either really really good- so awesome! Or they are extremely bad- even catastrophic. You are either the best person they have met or the absolute worst of humankind. And this happens partly due to how their brain perceives information around them.
Causes of BPD
Borderline Personality Disorder is not a result of one or two single causes. It is often due to a combination of genetic, environmental and brain chemistry factors. In fact, research suggests that you are five times more likely to develop BPD if a close family member like parent or sibling has BPD (source).
Environmental factors that may lead to BPD are childhood abuse and/or neglect and disruption in core attachment relationships and unmet attachment needs.
In some cases, the brain chemicals that are responsible to regulate mood do not function adequately leading to changes in some areas of the brain. This has been linked to explain some of BPD behaviour such as inability to regulate emotions, strong impulsive urges and depression.
BPD also does not exist in isolation. It is often accompanied by depression, anxiety, complex-PTSD and/or self-harm. These conditions can be extremely scary for the person experiencing them and seeking help can be intimidating. A person’s sense of self is shaken when they are navigating the world with BPD symptoms. Symptoms can feel emerging way too fast and way too intense. Clients can get stuck in the cycle of intense emotions- inability to self-regulate - dissociation - indulging in impulsive behaviour - emotional crash - isolation and repeat.
Relationships to Self and to Others
We all begin to form a relationship to ourselves early on in childhood. Our identity begins to form and our environment impacts the way our identity continues to form. A person who is aware of their identity and has a basic understanding of their sense of self is able to meet their basic emotional needs. They are able to form relationships and maintain them. This ability is also closely connected to the ability to regulate our emotions.
People who have BPD have difficulty to build and maintain this relationship with themselves and with others. They often struggle with figuring out who they are and what they believe in. And while these questions can come up for you even if you do not have BPD, for those who do, these questions occur more often and are more intense in feeling. BPD clients also struggle with figuring out what their values are leading to a perpetual feeling of emptiness.
For example, my client I mentioned above struggled with answering my question “So do you value completing schoolwork on time or being a friend in need to someone who’s struggling?” And while both these values can co-exist, my client had difficulty prioritizing one over the other. They found it confusing to choose what they wanted at the moment and what consequences each choice would lead to.
In another instance, my client shared that they find themselves going on social media to find out what their friends are upto instead of sending a text because they wanted to “see if they were having fun without me”. This exercise left them feeling hurt, invisible and convinced that their friends did not need them…that they were a burden to their friends. My client felt extremely lonely and isolated which led them to confront their friends about this occurrence leading to a conflict and my client engaging in uncontrollable shopping. They spent their entire month’s allowance, racked up a big credit card bill, felt awful afterwards and then did not show up for our meetings due to the shame they felt. This is what that cycle I mentioned above looks like.
This constant battle inside a BPD client’s mind of trying to figure out where and how they fit in can be exhausting. Their intense emotions can keep them from being their authentic self and building meaningful connections.
Due to the perceived volatility of a BPD client’s reactions, friends, families, even clinicians shy away from engaging with them. Insecure attachment is at play when a BPD client tries to make friends or have an intimate relationship or go to therapy. There is a strong correlation between a person having BPD and having insecure attachment due to their early childhood experiences (source)
The Light at the End of the Tunnel
If you’ve read so far, it can seem like a pretty bleak picture. However, I am here to emphasize that there is light at the end of the tunnel (and its not another train!). In my experience, folks with BPD respond well to a combination of consistent support. Dialectical Behaviour Therapy (DBT) focuses on mastering skills that help clients with emotional regulation and interpersonal effectiveness. Working on the childhood attachment piece can unlock that ambivalence that is so common in BPD clients. Harm-reduction becomes an integral approach when working with BPD clients because so much of it is figuring out how to engage in an impulsive behaviour safely.
For some, medication can be a good option to help with the changes in the brain chemistry.
I worked with this client for well over three years. We met every single week except for a couple of missed meetings here and there. Below are some of the strategies that really helped:
Worked on their childhood attachment piece to identify their triggers
Adapted their immediate environment at home and school to support them for skills practice
Co-created a safety plan for when they were in emotional distress and engaged in self-harm
Gradually built their skills to cope ahead and identified their strengths
Collaborated on developing their values and practiced identifying when certain situations, relationships, people and actions to did not align to those values
Coordinated with their primary health team to adjust medication dosage
Held family sessions to address some of the cultural barriers to their recovery and also the cultural practices that would help them.
My client worked very hard and I’m sure they continue to work hard because BPD is a complex diagnosis.
If you received a new BPD diagnosis, it can be scary at first but with the right support, you can manage your symptoms. I am here to support you figure out what it means and how to move forward.
You can book a free consultation to discuss how we can do that.
