Behavioral Outpatient Progress: Fill & Download for Free

Thanks for the A2A!I was once told by a psychotherapy supervisor to only have one or two borderline** patients at a time. I understood it could be tiring, exhausting, but I did not heed the advice. One very important reason for that was there were way way too many borderline patients out there needing help. To try and adequately serve your patient population you may be seeing dozens of borderlines.I like the work with borderline PD patients, so perhaps the “burden” of that (if that is a fair word), is diminished. In the inpatient unit, there can be a lot of games (informal, psychological, games by manipulative patients) and dealing with acting out. But it can be enjoyable too. Some borderlines who have many narcissistic traits can be extremely frustrating, as they progress very slowly if at all, and tend to be incredibly entitled.In outpatient treatment with those with borderline PD, it’s an up and down road. A lot of acting out, provocative behavior, threats (suicide, parasuicide), drama, paranoia, that “walking on eggshells feeling “ (which I later need to describe further, as I think we use the phrase too quickly without listening to the other side enough).I would work with most of my borderline patients once, preferably twice a week therapy and medication management. The intention would be that the therapy would take years to complete, but that each therapist builds upon the work upon the prior therapists, and so progress keeps being made.People with borderline personality disorder tend to be intelligent, passionate, with an intense and nuanced emotional language, many interests, real fire in their bellies, special unique and wonderful ways of looking at the world (that many can learn from if they just listen). They can be very insightful, with scathing humor, and wicked insight. There’s a breadth to their emotion that can sweep up people, and inspire and create and be real standouts in the communities that we need so much today. From political activism to protecting the environment, to love for animals; from the most passionate wellsprings of the fine arts, literary arts, performance arts, etc. they tend to have a special extra passion that others may not show. They tend to love hard and be very creative - and those are some of the most essential qualities needed for artists.Such a huge portion of people with borderline personality disorder have a history of being victims of abuse, that to try to avoid treating as many BPD patients as one feels one can, probably is leaving a vibrant and suffering population of people behind, sidelining them or even stigmatizing them.Some of my very very favorite patients have been my borderlines, seen in twice a week therapy. They were sometimes some of the hardest to take care of - crises and family meetings always coming up, off-hour calls for help. Some I would have to limit to only one call every 24 hours.They do also tend to get better with time. With age, life experience and maturity, a lot of the real primitive conflicting emotions are tempered, and they can step back and do make some reasonable assessments and decisions without running to initial knee-jerk fears. They often deep down know the “right answers” to their questions, even as they are upset by them, as they can be quite perceptive and intelligent, and it’s a matter of guiding them to the answer or helping to keep them there. That’s gratifying to do.I was pleased that by the time I closed my practice, all my long-time severe cutters, whom I had been seeing for years, had stopped cutting. I can’t take all the credit for that - they had prior therapists, and of course the patients did most of the work - and I don’t know how they did after my practice closed. But it can be very rewarding to see a truly passionate, potentially such a free and creative spirit, be able to survive and enrich the lives of others.I don’t see Borderline Personality Disorder as a strict limitation to a person’s life. It can be hard to see when in the throes of the disorder, but there is a part of it all that is beautiful and that with therapy, other activities, and experience as springboards for a beautiful impactful life.**At the notice of a previous commentator, I am trying to deal more with the use of “the borderline” as a noun. I apologize for my use “of borderlines” as a noun. It is off-putting if one is not used to the lingo what medical communication may require. I do not intend be demeaning, patronizing or to define a person by their illness. I do feel “person with borderline PD” is more accurate, but is extremely clumsy to use. It also follows the pattern within the lay and medical communities to use these adjectives turned into nouns. From “narcissists” to “asthmatics, “diabetics,” to “the disturbed,” “progressives” to (like me) “the Chinese” to “ the disabled” we have all been doing this for a long time, extensively. It is strangely exceptional to apply “pwBPD” while not using the “pw” with other disorders. No insult is meant at all. I’m fine being called a depressive because I am depressive.

They say knowing is half the battle, but in this case it is a very, very long and and exhausting war to fight in.It is really hard to say. BPD is one of those disorders where you really have to examine each person on a case by case basis. As well, sometimes awareness doesn’t stop behaviors.I can only really speak for myself on this, and believe I provide a fairly good example. I have been out of an intensive outpatient program focused on DBT for six years now, unmedicated and without counseling, and appeared to be doing well. At the very least, I was functioning in society, controlling the most destructive behaviors, and using my skills as best I could. However, due to some hard life events, I overdosed earlier this month and found myself back in the hospital for a week. Every doctor who spoke with me at one point said, “You’re very insightful.” Those exact words. They were impressed with my knowledge of the disorder, the awareness I had of the behaviors I exhibited, by own self-insight and analysis. That did nothing to stop my overdose, however. Even as I did it, I knew the symptoms I was exhibiting, the impulsive behavior, the suicidal ideation, manipulation, and emotional dysregulation. Knowing didn’t stop me. It just made me feel frustrated with myself after.A person can be functional and informed for years, but with a disorder like BPD, I recommend at least some outside help, if only to refresh and practice skills with, to make sure suicidal ideation is kept in check, and to encourage positive progress.If absolutely set on going it alone, there are a lot resources online that supply mindfulness and other DBT activities and reading. I enthusiastically encourage that therapy model, and it was designed with Borderlines specifically in mind. Find apps and online tools and USE them.And of course, have a doctor on standby or speed dial, just in case. In the event of a crisis, you will save yourself a lot of money and time by having a resource in the community to reach out to.

One of the things that surprised me when I first started studying Borderline Personality Disorder was how much disagreement there was about who was Borderline, what it meant to be Borderline, what were the relevant subcategories, and how best to treat people with Borderline Personality Disorder.There are a number of ways to think about what might be a useful way to divide BPD into subcategories. Here again, there is no single universally accepted theory about this. Here are some of my favorite ways to think about sub-categories of Borderline PD.James F. Masterson: RORU vs. WORUAll people with Borderline Personality Disorder use “Splitting” as a defense and, by definition, lack “whole object relationships”—the capacity to integrate their liked and disliked qualities into one coherent, realistic, and integrated self-image. Instead they tend to alternate between seeing themselves (and others) as either all-good or all-bad.The object relations theorist James F. Masterson (1926–2010) named the two parts of Borderline clients’ split self image the “Rewarding Object Relations unit” (RORU) and the “Withdrawing Object Relations Unit” (WORU). Each contains a view of the self and a view of the other person and a feeling that the person associates with that split, self-unit.RORU—All-Good PartView of Self: The good compliant lovable childView of Other: The good motherEmotion: Mutual good feelingsWORU—All-Bad PartView of Self: The bad, unlovable childView of Other: The bad, abandoning motherEmotion: Mutual bad feelingsThese two subcategories describe the two basic ways that the Borderline client is likely to present in therapy and how they are likely to view the therapist. Each presents the therapist with a different set of therapeutic problems.Problem with the RORU: With the RORU no significant progress will be made by the client if the therapist mistakes the shared good feelings for progress or a real therapeutic working alliance. It is simply a recreation in therapy of the dysfunctional childhood deal with the parent: I will get your love by never growing up and leaving you. I will be your compliant child forever and you will be my loving mommy.Instead of accepting the mutual good feelings of the RORU, the psychotherapist needs to view the client as an adult who needs to restart their maturation and learn to cope with the challenges they face now as an adult.Problem with the WORU: This is just as unrealistic as the RORU, but less pleasant for both client and therapist. The therapist needs to help the client see their situation more realistically and start taking charge of their life. The client may still feel like the bad, rejected child and be ennacting that with authority figures (such as now with the therapist), but that is part of an old operating system which was itself a legitimate reaction to their childhood experiences. Now it is preventing them from suceeding in their adult life and poisoning many of their relationships. They need an image update.If you would like more information on these subcategories of BPD, see Masterson’s book: Psychotherapy of the Borderline Adult. NY: Brunner/Mazel, 1976.Level of FunctioningOne of the best predictors of therapeutic success is how well the Borderline client is able to function out in the world on a daily basis. This can be another useful way to divide the Borderlne diagnosis into subcategories.High Functioning: These people meet their daily responsibilities successfully with minimal disruption. They go to work, have relationships, and pursue hobbies. They rarely disrupt other people’s lives with their problems. They can identify goals for their therapy, show up for their sessions, and steadily work on their issues.These clients internally struggle with the same issues as other Borderline clients—abandonment and engulfment fears, feeling like an inadequate child in an adult body, impulsive romantic relationships, trouble managing their healthcare and longterm planning, longing for love and reparenting—but they handle their issues more privately.As a result, if you are not their therapist, family member, or close friend you might never suspect that they have these problems. In fact, they may never get correctly diagnosed as being on the Borderline spectrum because most clinicians only recognize the lowest functioning Borderline clients as meriting the diagnosis.Moderate Functioning: These clients start projects appropriately, but run out of self-support and have trouble completing things. Their negative feelings and poor adult planning create difficulties for them in their everyday life.Their problems are more obvious than the high functioning Borderline client. They may stay up at night binge watching television and drinking, then call in sick the next day (or days) at work. They may suddenly cancel their therapy session because they are not in the mood to come or because they made some other plan that conflicts with their session time. They make lots of excuses. They are used to “this” being what life is like for them.Low Functioning: These clients are either unemployed or underemployed and working at a non-challenging job (not a career) that is below their intellectual capacity and their educational level. They have a great deal of trouble meeting any of their adult responsibilities. They may have applied for “disability” payments, have been briefly hospitalized for either substance abuse or some form of mental breakdown.It is very hard to do outpatient therapy with these Borderline clients because they miss half of their sessions (often without letting the therapist know ahead of time that they are not coming), are hard to engage in meaningful therapy work, and impulsively quit therapy whenever they get tired of trying.When they do stay in therapy, unless the therapist is very firm and well-trained, they will often waste their sessions by complaining about their life without being willing to do the necessary therapy work to change anything. In between sessions, when they feel desperate and lonely, they are likely to send long rambling text messages late at night and be offended if they do not get an answer.These clients are suffering, but their problems and style of coping make it hard for the average clinician to treat them. They usually do best with a very structured Dialetical Behavior Therapy (DBT), which was invented specifically to address the issues of lower functioning Borderline clients.Categorization by Primary DefenseIf you happen to look through the DSM 5, you will find many problems that are given their own diagnosis, and some which are listed as their own form of Personality Disorder—like Dependent or Avoidant Personality Disorder. In my opinion, many of these are just descriptions of a Borderline maladaptive coping mechanism that is being over relied on.I think of these as subcategories of the basic Borderline diagnosis. Almost all of my Borderline clients could be described as avoidant. Many of them are over dependent on others as well. And, often clients with eating disorders or substance abuse problems are trying to distract themselves from the pain of tyical Borderline issues.Punchline: There are many possible ways to subdivide the Borderline diagnosis into subcategories and very little theoretical agreement among clinicians on the best way to do this.A2AElinor Greenberg, PhD, CGPIn private practice in NYC and the author of the book: Borderline, Narcissistic, and Schizoid Adaptations: The Pursuit of Love, Admiration, and Safety.www.elinorgreenberg.com