(p. 719) Counseling Clients with Borderline Personality Disorder
We began our joint endeavor after first meeting during our postdoctoral fellowship year. We currently both have full-time fee-for-service private practices in Atlanta, Georgia, and founded a separate group therapy practice, Daily DBT, in 2014. Lauren started her individual practice in 2010 and primarily works with young adults, ranging in age from high school–aged adolescents through adults in their early 30s. Noelle began her practice in 2012 working primarily with adolescents through older adults as well as families.
The Niche Practice Activity
Daily DBT is a practice offering dialectical behavior therapy (DBT) skills groups to high-functioning individuals in the Atlanta area. The defining feature of both of our practices is working with patterns of dysregulation (emotional, behavioral, interpersonal, cognitive, and self) that often group together into the more pervasive problems known to most practitioners as Borderline Personality Disorder (BPD).
Many psychotherapists shudder at the thought of consistently working with BPD and many have horror stories from their token BPD training case. While our practices do include some of those special cases, more often we encounter a range of clients from within the BPD spectrum—for example, an anxiously attached college student struggling to develop healthy friendships and romantic relationships as well as a middle-aged adult, working part time due to interpersonal conflicts, who shows up to sessions one week with gifts and the next with disparaging comments about the psychotherapist and the lack of progress. Despite the clinical picture, a variety of clients (p. 720) do in fact meet full criteria for BPD, not simply those who are difficult to work with from the outset and regularly generate strong feelings in the psychotherapist.
Many of these clients have never had a suicidal thought or engage in self-harm, despite the popular conception of BPD clients. In our individual practices we see approximately 20 individual clients per week with 25% meeting full criteria for BPD and an additional 50% exhibiting strong BPD traits but not meeting full criteria for a BPD diagnosis. Many of our clients are unique in that they are typically of above-average intelligence and high on apparent competence (a DBT term meaning the ability to handle everyday life problems with skill but in an inconsistent and context- or mood-dependent manner).
We also have a variety of tasks involved in running our group business, Daily DBT. We currently offer nine DBT groups that meet weekly (six adult groups and three teen groups). We structure our groups to have two group leaders and a maximum of eight group members per group. Within these groups 50% to 75% of clients meet full criteria for BPD while others have lesser forms of dysregulation. We personally co-lead three of these groups while supervising other leaders, developing materials, and conducting a variety of workshops for parents, professionals, and community members.
One final piece of our niche includes providing supervision for much lower-functioning DBT groups as adjunct faculty for Emory University School of Medicine and providing continuing education training to various professional groups.
Developing an Interest and Training in this Niche Activity
Neither of us set out to hang a shingle on working with BPD (who would!?), but in retrospect we have been on this path from the outset of our careers. Even during our training experiences we both were drawn to complex cases, expressive clients, and intensity. We enjoyed the more concrete therapeutic techniques that involved developing specific skills and at the same time were excited and interested in long-term, attachment-based, and insight-oriented aspects of psychotherapy that required deep relationships with our clients. Lauren then became more specifically interested in working with BPD clients while she was working as the clinical and program coordinator for Emory University’s Garrett Lee Smith Suicide Prevention Grant. Having a longstanding interest in childhood trauma naturally led Noelle to working with BPD individuals within a hospital system.
Joys and Challenges Related to this Niche Activity
We both appreciate the complexity and genuineness that BPD clients bring to sessions. The effectiveness of a two-pronged approach of stabilizing DBT skills and emotion-focused interpersonal psychotherapy is rewarding. Our clients often come into our practices desperate for change and (p. 721) feeling chaotic. We have the opportunity to experience relatively quick and satisfying change and then settle into doing deeper work for a much longer period of time.
Working with BPD clients is also rewarding from a business perspective. We are able to have clients use two services (group and individual therapy), we have a healthy stream of clients coming from colleagues who are anxious or less enthusiastic about working with dysregulation, and we have deep relationships with our clients, who then stay for longer courses of psychotherapy. Many clients benefit from multiple individual sessions a week, therefore reducing the need for many new referrals and allowing us to focus in depth on a smaller caseload. From a financial point of view, these are often clients who are willing to pay outside of managed care for our level of expertise, as they have often seen multiple providers previously who were unable to help. We have never participated in any insurance panels, which has not yet been a challenge.
Then there are the challenges … working with BPD clients means that many of the rewards can often also become challenges. For example, intensity of emotion can feel authentic and connecting when discussing painful traumas but can feel annoying or attacking when discussing rescheduling and other routine office policies. As another example, sensitivity can be engaging and allow for deeper insight when a relationship is off balance but can be excruciating when it’s directed at some detail in the psychotherapist’s physical space (e.g., the color of the sofa, the brightness of the lights, the room temperature). One particular area of difficulty with BPD clients is setting and maintaining boundaries. It’s critical to be prepared to stick to what you believe are important clinical frameworks and then to tolerate the anxiety that comes when a client begins to push those. For example, neither of us is responsive to texts or emails that contain significant clinical information and are clear about the importance of discussing clinical information in session. We recommend that clinicians include their policies about these boundaries in their informed consent materials. This requires both having the conversation about a boundary that can feel overly harsh to a BPD client and then tolerating the anxiety of not responding when an email arrives that you know could leave the client in a painful space until your next appointment (obviously, this is hard when we both value compassion and responsiveness in our therapeutic relationships).
Business Aspects of this Niche Activity
Referrals are generated mainly through our community of providers and former clients. This primarily includes referrals from other psychotherapists and psychiatrists. Many psychotherapists encounter clients in whom they recognize a personality disorder early on and believe that does not work with their expertise and therefore are looking to refer out. Other psychotherapists find themselves working with a client with BPD and recognize the need for an adjunctive service such as a DBT skills group or a short course of one-on-one skills training. This collaboration with other individual providers in particular expands our referral networks dramatically. It has afforded us the opportunity to have our therapeutic skills and personalities well known with the psychotherapists and psychiatrists of the 50+ individual clients currently enrolled in group services. Frequently, group members themselves recommend our services to others. In addition, the combination of (p. 722) doing individual therapy from various theoretical orientations, as well as offering the structured DBT component, allows us to converse fluently and form relationships with a broader network of community providers than we would have access to if we focused solely on one treatment modality to target BPD. Referrals are also generated through various other business activities, including providing supervision, offering continuing education workshops, and parent and community speaking engagements.
Given the boundary issues that arise with BPD clients, the billing and payment arrangements have to be clear from the outset. Specifically, when discussing services, potential individual clients are made aware of the base fee for individual sessions as well as crisis or coaching calls. This policy is also included in the information shared during the informed consent process. For clients who intend to use these latter services we require a credit card to be placed on file so that payment can still be taken at time of service. When discussing DBT skills group polices with potential clients, we make clear that group members pay for all group sessions within each module regardless of attendance. Therefore, for group services, cancellations, no shows, and so forth are still billed regardless of notification prior to the absence. For individual services a 24-hour cancellation policy is consistently enforced. From a business perspective we have learned that this policy dramatically reduces absences and allows for a consistent income. Unfortunately we did not come to this more streamlined billing process early in the growth of our practice. We adjusted our payment policy to prevent clients’ emotional reactions from interfering with consistently obtaining funds (i.e., desire to overpay or underpay, refusal to pay for late cancellations, early terminations with an outstanding balance).
Developing this Niche Activity into a Practice Strategy
For mental health providers who are interested in working with BPD clients, we have a variety of recommendations. First of all, we would encourage psychotherapists to seek training experiences that include longer-term insight- and emotion-focused therapies (e.g., attachment, interpersonal, psychodynamic), cognitive-behavioral therapies such as DBT, and process group experience that allow a psychotherapist to see interpersonal dynamics at work. We also recommend that psychotherapists develop a solid consultation and mentoring network that would allow for authentic discussion of transference and countertransference processes. This network should include other professionals who are committed to being available for consultation if and when risk issues or boundary issues arise outside of scheduled business hours. Being able to reach out to close colleagues at times that feel random and imposing can be critical to managing the emotions and practical problems that can arise when working with BPD clients.
A variety of group experiences can be useful for psychotherapists who are also interested in adding a DBT group component to their practice. Experiences with specific behavioral or DBT groups is an obvious requirement. Skills learned by observing or co-leading interpersonally oriented process groups can also be critical for recognition of the processes that are occurring in (p. 723) and impacting the group, regardless of whether or not it is an explicit component of the group. This in turn can lead to DBT groups that form well and work on multiple levels.
Positive self-care strategies are essential when working with BPD clients. Engaging in consistent and ongoing personal psychotherapy and/or supervision can be extremely helpful, especially in situations where a client triggers significant person-of-the-therapist issues. Our experience is that process-oriented supervision has been particularly supportive. To work in a personality disorder niche, psychotherapists need to develop the ability to be transparent, to consider criticism as it comes to you, to be mindful of personal reactions and where they are coming from, and to tolerate the anxiety of behaviors typically associated with BPD pathology (e.g., criticism, suicidal risk, triangulation, splitting, manipulation, pushing boundaries, refusing limits). Additional personal self-care strategies outside of the workplace also help sustain psychotherapists in this line of work. These can range from cooking, to meditating, exercising, vacationing, or simply eating and sleeping well on a regular basis.
While working with BPD surely is not for everyone, we have found this to be a stimulating, rewarding, and business-savvy niche. We would encourage psychotherapists to challenge themselves by working with increasingly dysregulated clients and start building a skillset that can sustain a rewarding life-long practice.
For More Information
The following associations have useful websites:
Linehan Institute: Behavioral Tech (www.behavioraltech.org)
Linehan Institute (www.linehaninstitute.org)
American Association of Suicidology (www.suicidology.org)
Your local state psychological association can also be a good resource; see http://www.apa.org/about/apa/organizations/associations.aspx>.
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