Why do many professionals still treat people with BPD as
if they can't get better?
Patients with BPD teach their therapists to feel hopeless about them
from the very first session. Often even in the first sentence is the
message "You can't help me." This is often followed by evidence in the
form of multiple previous failed therapies. The message has layers.
"Everyone in my past has betrayed me. Why should you be different?"
"I will take my revenge out on you for all these betrayals." "I am not
worth helping." "I am too defective to ever be repaired."
Sometimes the message comes with threats and ultimatums. "I dare you
to try to help me." "I'll give you a month and if I'm not better by
then, I'll kill myself." Such deadlines are consistent with the
borderline's difficulty seeing beyond the moment. While treatment can
make vast differences in the lives of people with BPD, progress is
measured in months and often years, not days or weeks.
The verbal messages are often backed up with actions: a history of
multiple suicide attempts or signs of previous acts of self-injury.
Such messages are daunting even to the most experienced of therapists.
The more therapists try to reassure patients that there is hope, the
more insistent become the messages that there is none. If messages of
hopelessness are not conveyed in the first session, they inevitably
come later. Some patients invest their therapists early in treatment
with unrealistic powers to help and to heal and respond to
disillusionment with redoubled hopelessness and anger.
Many therapists find these messages too overwhelming to allow them
to function effectively. The prophesies then become self-fulfilling.
Either they refuse to provide treatment or the treatment soon fails.
Even therapists who are experienced in treating BPD can only handle a
limited number of such patients at one time. Therapists are not immune
to anxiety in the face of threat. It is crucial for therapists to
appreciate their limits for tolerating anxiety if they are to continue
A related question is why therapists are so often reluctant to
treat patients with BPD. The answer is risk, some real, some perceived.
It is hard to hear the messages of hopelessness without at least
entertaining the possibility that treatment could end in suicide.
Even with the best of treatment, we cannot control outside
relationships or external events, which can be unpredictable, sudden,
and devastating. Learning to tolerate pain takes time. Early in
treatment, the risk of reacting to painful events with impulsive,
self-destructive behavior remains high.
The risk that the therapist undertakes in treating high-risk
patients is complex. There is the risk of failure and all the
second-guessing and soul-searching that follows. There is also the
risk of losing someone with whom a relationship has formed that is
meaningful to the therapist. Working with patients is not like working
on cars. We develop regard. We become involved. There is a special
intimacy about being allowed into the private emotional life of
another human being. Part of that intimacy is caring about our
patients' feelings and their lives.
There is also a concrete risk to the therapist's career. Suicide
often results in litigation, even if the therapist has done everything
possible to prevent it. There are special circumstances in treating
patients with BPD that increase that risk. Such patients are often in
conflict with many of the important people in their lives. They are
particularly insistent that therapists refrain from contact with their
significant others. This is often deeply resented by the other people
in their lives, who may project much of their frustration onto the
unseen therapist. They are angry about the therapist's unwillingness
to talk with them, naive about the responsibility to maintain
When patients do commit suicide, many family members are primed to
blame therapists, particularly if they have had little or no previous
interaction with them. When people are feeling guilty about their own
possible role in bringing about their loved one's death, they are even
more likely to project blame onto the therapist. Anger is a common
defense against guilt. Such situations are especially prone to result
in lawsuits. When patients have been involved in abusive and exploitive
relationships and commit suicide, the abuser may take the therapist as
the next victim. Unscrupulous individuals may see such situations as
an opportunity for profit.
Whether lawsuits are justified or not, the process can be long and
blistering. Some have been known to go on for as long as ten years,
leaving a cloud over the therapist's practice and life the whole time.
They can end careers and destroy marriages. They can shake a young
therapist's confidence and leave an older therapist retiring in defeat,
even after a long and productive career. This is just some of the
destruction suicide can leave in its path.
Both patients and therapists often live with the myth that
therapists are supposed to be selfless when they deal with patients.
It is true that therapists must not exploit their patients for personal
gratification or gain. But it is unreasonable to expect that they
would be willing to expose themselves to all manner of personal risk
in the interest of treatment. That would be denying the humanity of
therapists. And if we did not share the vulnerability of the human
condition, we could not empathize with our patients and would indeed
be powerless to help them.
Patients do have power to alleviate some of their therapists'
concerns. Going into therapy with realistic expectations, and
especially an understanding that therapy takes time, can be helpful.
Refraining from challenges and ultimatums and being willing to set
realistic short-term goals can also help. A willingness to include
family members in the process in some way so that they do not feel
completely excluded, can avoid the development of conflict around
their treatment and make the process easier for everyone involved.
This means going into therapy with an appreciation of shared
responsibility for the outcome rather than expecting that the
therapist is solely responsible for providing hope and relief.
© Dr. Richard Moskovitz
The Role of Shame in BPD