Systemic work with clients with a diagnosis of Borderline Personality Disorder, Psychologia, Borderline ...
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The Association for Family Therapy 2007. Published by Blackwell Publishing, 9600 Garsington
Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
Journal of Family Therapy (2007)
29
: 203–221
0163-4445 (print); 1467-6427 (online)
Systemic work with clients with a diagnosis of
Borderline Personality Disorder
Susan A. Lord
a
Clients who are diagnosed with Borderline Personality Disorder are likely
to engage with clinicians in compelling ways. They challenge us with an
urgency that helps us to define ourselves as we work with them. They
confront us with the limitations of our treatment approaches, requiring a
genuineness of interaction and a flexibility that can be both challenging
and uncomfortable. While therapists have made great strides over the
past few decades in their treatment approaches with this population,
there is a gap in the literature on the use of systemic approaches with
these clients. This article examines some of the issues that arise in work
with people with a diagnosis of Borderline Personality Disorder and
offers an application of a larger systems perspective to the development of
viable treatment options for these clients.
Introduction
Clients who carry a diagnosis of Borderline Personality Disorder
(BPD) have historically been viewed as difficult to work with. They
have difficulty engaging in treatment, present with complicated and
thorny problems, and often have limited successes in their interac-
tions with helpers. Recent literature examines the interface between
BPD and Post-Traumatic Stress Disorder (PTSD) (Herman, 1992;
Miller, 1996; Pointon, 2004; Spinazzola et al., 2005; van der Kolk,
2005; van der Kolk et al., 1996, 2005), BPD and Bipolar Illness
(Birnbaum, 2004; Bolton and Gunderson, 1996; MacKinnon and
Pies, 2006), and BPD and substance abuse (Linehan et al., 1999;
Rosenthal, 2006), highlighting some of the enormous complexities
involved in working with these clients.
This article offers a discussion of some of the issues that arise in
treatment with people diagnosed with BPD and presents a systemic
approach that I have found to be useful in my work with these clients.
a
Clinical Assistant Professor, Social Work Department, Pettee Hall, University of New
Hampshire, Durham, New Hampshire 03824 603-862-3150, USA. E-mail: salord@unh.edu
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Susan A. Lord
This approach seeks to engage members of the treatment team as
participants in a reparative therapeutic family system that works with
BPD clients in efforts to offer a level of containment (Bion, 1967) or a
holding environment (Winnicott, 1965) to these clients so that they
can do the work they need to do to grow and to heal.
Background
We have, it appears, come to an inclusive point in our evolution as a
profession, at which we no longer have to work with exclusive models
of practice, but can rather embrace multiple knowledges and practices
in our work (Flaskas, 2005a, 2005b). In the spirit of contextualization,
it is important to articulate and own our personal narratives of where
we have come from as we pull a chair up to the table and locate
ourselves in the discourse. Our work no longer requires that we leave
ourselves at the door as we enter into therapeutic relationships with
our clients and with our colleagues. We are no longer required to be
purely scientists, but can acknowledge that we are also artists whose
instruments include our whole selves in the relational processes of
therapeutic interaction (Larner, 2004; McNamee, 2004).
One of my clients tells the story of a turning point in his training in
art school. He was instructed to draw a still-life from his perspective.
As he was drawing a careful representation of the still-life set out on a
table at some distance from him, his instructor came and stood beside
him, asking that he include his perspective in the drawing and capture
all that he saw before him. He began drawing the edges of his glasses,
the end of his nose, wisps of hair that he could see, and on down his
body, across the room and then the still-life, the table, and what he was
able to see behind it. He did not include what was in his mind, body or
psyche, or the people standing behind him or those who had come
before, though they informed what he saw and ways in which he saw it.
As a clinician who trained during the 1970s in psychodynamic
psychotherapy in a social work programme, during the 1980s in
systemic and narrative family therapy at a family therapy institute,
during the 1990s in Jungian psychotherapy at a Jung Institute, and
who was in therapy for years with a psychoanalyst, I embody a
number of frameworks when working with clients. I agree with
Flaskas that ‘practice grounds theory’ (2005a, p. 127), and seek to
have my practice and the complexity of issues presented by my clients
inform my choices of useful ideas as I work with them and with their
particular situations.
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Through the years, I have worked in a halfway house, a day
treatment programme, on a number of inpatient psychiatric units,
in several outpatient clinics, and I now work in a private practice and
teach practice and family therapy courses in an MSW programme at a
university. Most of the settings in which I have worked have been
multidisciplinary settings in which different views, positionings, the-
oretical backgrounds and ways of working have been welcomed. A
number of the settings were teaching venues where diversity was
encouraged, as were new and creative ideas and practices.
All of this informs my practice. It does not define it. My work
is eclectic; I am not purely a this or a that (as the clients I work with
are not purely thises and thats). I am constantly evolving as a clinician
and I work to position myself in a way that is open to a multiplicity
of voices and perspectives (Anderson, 1997; Anderson and Gehart,
2007). My inner world is peopled by clients I have worked with,
students I have worked with, supervisors and teachers, colleagues,
friends and family members. Over the years I have learned to trust
and to draw more openly upon whatever comes to me as I sit with
clients and work in different ways with what is of use at the moment.
I integrate theories and frames to work with inner and outer systems
(Jenkins, 2006; McNamee, 2004; Pocock, 2006) as I move my lens
in and out, working psychodynamically and systemically with indivi-
duals, couples and families as seems appropriate to what is needed.
I think, communicate and act in the multiple languages I have learned,
and work in a way that may appear to be chaotic, but is experienced
by me as an ordered and clear approach. I cultivate in myself
and in my work a level of organization at which disorganization is
possible, as I believe this promotes a richness and creativity that
would not otherwise be accessible to me or to the work in which
I participate with clients. The language of this article is thus a mixture
of psychodynamic and systemic constructs that I have found to be
of use.
Terms and labels
Systemic ideas are about contextualizing issues and examining
relationship patterns in human systems (Jenkins and Asen, 1992).
While systemic ideas are those that focus on interpersonal processes
and interpersonal contexts of individual experience, psycho-
dynamic ideas focus on intrapersonal and intrapsychic processes
(Flaskas, 2005a, p. 126).
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Susan A. Lord
I am not a clinician who believes in labelling clients. However,
I practise in a context in which insurance plans require that I assign
diagnoses in order to be reimbursed for services rendered. I also
practise in a context in which diagnoses are a part of the language
through which therapists communicate with one another about clients
(Allen, 2004). I make it a practice to offer my clients choices about how
they are to be labelled: ‘We have to decide on a diagnosis to use for
insurance purposes. Would you rather be called a this or a that?’ We
go over the categories in the DSM IV (American Psychiatric Associa-
tion, 2000) and together decide which more closely captures what is
going on for the client. While diagnostic categories can be useful in
locating a client on a spectrum of possibilities, I find it more useful
in my interactions with other clinicians and with clients to describe
behaviours, situations and dynamics that clients find difficult to
negotiate in their lived experience.
Borderline Personality Disorder and trauma
The DSM IV (American Psychiatric Association, 2000) defines people
with BPD as manifesting difficulty in a number of areas: relationship
instability, problems dealing with anger, suicidality and/or self-
destructive behaviours, identity disturbance, chronic emptiness or
boredom, and abandonment issues.
People who carry a diagnosis of BPD tend to come from families in
which there has been some kind of trauma. Often a texture of trauma
exists that has repeated for generations. They grow up in families in
which there are alcohol and/or drug abuse, incest, physical abuse,
major mental illness and other situations that have rendered people
unable to cope well with their lives. I think of people with a diagnosis
of BPD as having developed in an inconsistent, unpredictable, and
therefore unsafe environment (Byng-Hall, 1995; Dallos, 2004; Hill
et al., 2003; Main, 1991; Stern, 1998). They are walking wounded:
people who have been unable to integrate their experiences and
whose adaptations to their lives have required certain patterns of
acting out, projecting, raging ‘against the dying of the light’ (Thomas,
1952, pp. 207–208). They are survivors.
Individual treatment considerations
Individual theorists (Adler, 1985; Bateman, 2004; Bateman and Tyrer,
2004; Gunderson, 2002, 2004; Hellerstein et al., 2004; Herman, 1992;
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Leibovich, 1981; Linehan, 1993; Livesley, 2005a, 2005b; Miller, 1996;
Paris, 2005; Russell, 1975; Teicholz and Kriegman, 1998; Winnicott,
1947, 1965) locate the developmental failure in people with a
diagnosis of BPD as occurring in the area of relationships. They
identify inconsistent parenting that vacillates between smothering and
abandonment and offers little in the way of object constancy. Winni-
cott coined the term ‘holding environment’ (1965) to describe
an optimal environment in which, what he called ‘good-enough
mothering’ (I would add fathering) offered the developing child the
opportunity to identify with and internalize the mother. He spoke of
the importance of being able to ‘destroy the object’ and have it survive
in order to be able to progress and move on (Winnicott, 1947).
Because of an inconsistent availability of good-enough parenting
for people with BPD, they become caught in a web of identification,
idealization, and attempts to destroy relationships with significant
people in their worlds, including treatment team members, hoping
that these significant others will be able to survive these painful
interactions and remain constant enough to offer them a chance to
grow and to heal.
Crises and containment
Crises occur quite regularly in work with people with BPD. I think of
these crises as failures in containment (Bion, 1967). This is a useful
psychodynamic construct in that it implies an interactive component.
Russell (1975) spoke of a ‘crunch’ (p. 2) in therapy with the client with
BPD, in which the client renders into the treatment his or her
repetition compulsion in a way that requires the therapist to offer
an experience of containment that is a very real risk for both the
therapist and the client. He says:
It is as if the patient chooses the treatment crisis, the potential rupture of
the therapy relationship, to try to convey that which is most important to
him. And worse yet, he does so not in words, but by recreating the
anguish for which he came into treatment to begin with. Crises represent
the resistance of the borderline. And so, there is a paradox. A situation
arises where the need for some kind of understanding and containment
is at its greatest, and yet the situation is such that it is least likely to occur.
(Russell, 1975, p. 3)
It seems it is for this reason that clinicians have such strong responses
to these clients. They are either attracted to or repelled by them in
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2007 The Author. Journal compilation
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2007 The Association for Family Therapy and Systemic Practice
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