What do I do in the first session with a client who has a borderline personality diagnosis? Well obviously I start by making sure they’re diagnosed correctly, and then develop a treatment plan, like a therapist should do for anyone. But to help you understand the process of diagnosis and what a plan for treatment looks like, I’ll need to give you the broader picture — which is also what I do in a first session, present the broad picture. In this case it means assessment, engaging in some education, and making a plan.

Borderline personality is one of my favorite disorders. Now you may ask, “What exactly makes a therapist have a ‘favorite disorder’ anyway?” I’m glad you asked. Typically it’s one that particular counselor feels unusually effective treating. I’ll admit, some therapists can find individuals with a BPD diagnosis frustrating, and I was somewhat in that camp for several years. I felt like I was helpful but rather clumsy up until about 2014 when I decided I was going to figure this one out. I read two books, and realized I was already seeing contradictions in approaches that just made me more confused. So something like 15 books and probably more than 75 articles later, I finally got a sense of how to be effective. (Shout out to Dr. Russell Meares’ A Dissociation Model of Borderline Personality as the best of the bunch.) 

So let’s start with diagnosis. Now I’m extremely-online enough to know it would be a bad idea to give too much diagnostic information in one place and have all my readers self-diagnose from a blog article. If you’re looking for that, you’ll just have to go blame a wiki or something if you get it wrong. That said, if you’re worried enough to self-diagnose, maybe go see a therapist and get an actual diagnosis? I mean, just a suggestion. (hint hint)

That said, when I start off considering a BPD diagnosis, even before I start gathering detailed information, I ask 2 general questions. I created these questions to represent four of the more significant diagnostic criteria (but that’s still not enough to qualify for the diagnosis even if you have them all). The first is: Tell me what you think of when you hear these words: “abandoned, angry, and empty.” They could also be made into a phrase, “struggling with persistent anger over the emptiness caused by feeling abandoned.” However I say it, I’ll then ask the person whether or not they feel like they relate to the prompt, and if so, how? If their response sounds like it might meet BPD criteria, I then ask, “Do you feel like you have a strong sense of who you are?” While not having a strong sense of self can be indicative of several personality disorders, it can also be trauma, just being a normal teenager or having your average mid-life crisis.

There are no answers to these questions that put you in the immediate “yep you’re borderline” category, obviously, but it’s more about the pattern that begins to emerge. After gathering information on other diagnostic questions, maybe even giving a survey, I’ll work on developing a treatment plan. While this disorder used to be considered lifelong and untreatable, I tend to expect that I can take someone from the hospital to step-down in 9-12 months. (The only hang-up for that timeline is if they’re currently in an abusive relationship they can’t get out of. That throws a significant wrench into the process.)

Now let’s talk a a bit about treatment approaches. Although I’m certified in DBT (Dialectical Behavior Therapy) which was the first intervention process shown to be effective with BPD clients, I rarely engage in the whole DBT process. I mention DBT because many clients with BPD will often come to me from a psychiatric hospital stay with a series of previous therapists and either some experience with DBT or a recommendation to find a DBT therapist. Don’t get me wrong, I’m glad to have the tools to use DBT, and I certainly think it can be necessary in situations where there’s a significant danger to self or others; in fact, I think it can be a useful safety net for many disorders. That said, I think there are still some things missing that BPD clients need, and I’ve often thought of repackaging DBT and presenting my own version of something like “Gestalt-informed DBT.” 

Trust me when I tell you I’m using my best coping strategies not to nerd-out on the details of a bunch of really interesting (to me at least) studies on BPD. But please forgive me if I take just one paragraph and throw some in. The creator of DBT released a study in the late 90s that showed DBT clients reduced self-destructive behaviors, and those behaviors remained reduced even after therapy ended. However, clients didn’t report actually feeling better. (That’s why I think it needs a little something.) make the client feel better. By the mid 00s several other approaches including Mentalization Based Therapy and what came to be called Psychodynamic Interpersonal Therapy published studies also demonstrating improvements on BPD individuals surveyed a year after therapy ended. However, in these cases, not only were there reductions in destructive behavior, but these clients also reported internal improvements in their emotional state. 

Obviously, my goal is first to keep everyone safe, so that’s where DBT might come in. However, beyond that, I’d rather focus on helping someone feel better so they don’t become unsafe in the first place, and this is typically a two-pronged approach.

Part one is very close to DBT with a few adjustments and additions. Particularly in those first few sessions I engage in some education and begin working on skill development. This involves getting to understand yourself and your thoughts about others from what we’ve traditionally called “a non-judgemental stance.” If you’ve heard that before and either think it’s too hard or possibly nonsense, there’s a good reason for that reaction. Behaviorism will tell you it’s hard to just stop doing something, including judgement, unless you replace it with something else. If you don’t have a replacement, you’ll just keep doing the same thing and then feeling worse for failing to stop yourself. So here is where we work to understand what your thoughts and feelings are doing. We begin to recognize the value of these emotions in different contexts, and then, rather than trying to make bad emotions go away, we try to learn to make our emotions more accurate so they serve their proper function. This is where the Gestalt idea of “figure and ground” comes in. I want to help you clarify your sense of who you are as a distinct person (figure) apart from the background confusion and noise of the rest of your life. I want to start giving you an anchor, a foundation, a sense of stability you can return to and begin to build on.

Part two goes in tandem and is very similar to my approach to treating trauma. In fact, the presence of significant trauma in the lives of most of my borderline clients is the reason that I began focusing on trauma treatment and specifically began focusing on sexual trauma. The similarity is this: even though a trauma may have happened 30 years ago, it still feels like it’s happening right now. That feeling forms a lot of that confusing background “noise” I just mentioned and makes us respond to things that are happening now, as if they’re threats from the past.

For instance, just like anyone else, when a person has complex trauma or borderline personality they draw from past experiences to solve current problems. How did I deal with this before? What should I do? Or should I avoid doing anything? Now, imagine facing a seriously dangerous event and thinking “Oh, this reminds me of that other time … oh wait! That turned out horrible and I have no idea why.” You start searching for another memory that might be helpful, but then it turns out that one was worse, traumatic, and even more confusing. What does a person do when you try to think back on what you learned, but never really learned anything good? What happens when every important decision brings up the memory of a tragedy? Or sometimes it’s even more confusing, and the exact same action in one situation worked well, but in another was very painful. Again, trauma feels like it’s happening now, even if the event is long over. So after considering a problem like this for very long, the person stops responding to what’s going on now, and their brain starts working to find solutions to events that are long over. Projecting past confusing and painful failures onto the here and now is rarely helpful… but actually, it can be.

I plan to write a blog on “closure” at some point (I’ll link it here), till then lets just say that it isn’t merely putting something in the past so we don’t have to think about it anymore. That’s actually a trauma response that’s trying to avoid the event, rather than understand it. Closure is finding answers to whatever questions your brain has about what happened, deciding what the event means, and learning what it means about your future. This is central to anchoring that “sense of self” mentioned earlier.

In this sense, acting out past trauma in the present becomes an opportunity to address that event. We want to use the skills we’re developing to decide what ways information from past events can help us here and now, and what things don’t apply to the present. By clearly separating these different events and addressing trauma responses as they arise, we can establish points of certainty to rely on in the future. Thus, the treatment process involves applying new skills to overwhelming events both in the present and in the past, and really that’s the definition of growth.