What Brings You Here? - Advice for the couch

Personality diagnoses are often made out to be the Mt. Rushmore of all disorder categories out there. The existing discourse around personality disorders can come with its own set of assumptions. So in today’s newsletter, our therapist Osheen Shrivastava takes us through the misconceptions surrounding borderline personality diagnosis and how we can help our clients navigate it.

As a clinical psychologist, there’s a lot you’ll learn about personality in your training. In your practice, there will be a lot that you’ll also unlearn. My journey with working with clients with a diagnosis of borderline personality disorder, has been quite revealing. I’ve realised that there’s a lot more to it than just the diagnosis. So today take a walk with me around much of the hum-drum that exists out there and my learnings with them.?

Listening to Feelings

As a therapist, anyone would tell you that being in touch with feelings is paramount. This became even more necessary for me while working with clients experiencing immense emotional dysregulation. A lot of literature talks about the ‘difficulty’ of working with clients presenting with extreme emotionality, impulsivity or feelings of emptiness. In my earlier days, I too would notice a sense of exhaustion and overwhelm in response to this presentation. However, over time, I have come to understand that it is important to simply acknowledge these emotions for myself. I’ve realized that the more I’m able to process my own feelings in response to my client’s emotions, the more it allows me to use this experience to help clients who are struggling to regulate emotions themselves. In a sense, difficulty with emotional regulation doesn’t make the person difficult to work with, it is how we’re able to make sense of those feelings together in the session that helps to navigate emotional turmoil in different areas of their life.

Dealing with Self-harm and Other At-Risk Behaviours

Dealing with clients experiencing self-harm is a part of any therapist’s journey, and there are times when it can bring up overwhelming dread or fear. I’ve gone through feelings of paralysing fear to helplessness, to an excessive sense of responsibility about trying to “rescue”. But as I’ve met more clients with such experiences, I’ve learnt to delve into the context that brought them to this feeling. Rather than viewing it as a symptom, looking at self-harm as a coping response to immense pain and helplessness has changed my perception of the concerns presented. I had to learn to walk the tightrope of validating their feelings while at the same time, exposing them to alternate perspectives for those moments of trigger. Distress tolerance skills have come in quite handy here as well.?

Navigating your own Fears?

The diagnosis “borderline personality disorder” and the associations it carries can mean that a lot of fear is invited into the room– sometimes, real and sometimes, perceived. “What if this conversation leads to a rupture?” “How will we handle another crisis?” It was difficult for me as a therapist to be driven by these fears. I found myself drawing compassion from my supervisor, my fellow therapists and refocusing some of that empathy towards myself that I often hold for my clients. Even through several instances of reschedules, crisis calls, the push and pull in the therapeutic relationship, what persisted to help was a curiosity about what was happening in the therapeutic relationship. Rather than running away from ruptures, inviting the patterns to be explored together actually helped my clients break down their own relational patterns in a safe space and gave us the foundation to re-work them through therapy.?

Unpacking the Label

The field of psychiatry has gone to lengths to understand and collate diverse signs of distress into neatly divided disorder categories but my experience has shown that most times, client’s lived experience takes priority. The name might be “borderline personality” but what becomes more important to explore is the story behind that label. Helping clients unpack this diagnosis, and the stigma that surrounds it has served an important function in my work with my clients. A lot of research has pointed out that most people with a diagnosis of BPD have experienced a history of trauma or neglect, and in the end, it is these experiences that we have to help our clients steer through.?

Celebrate the wins, big and small, round or tall

As a starting therapist, it is not uncommon to hear clients with personality disorder also being discussed with a sense of chronicity. It can often instill a feeling of hopelessness, giving a reflection that change is slow or even, unsustainable.? It requires active effort to not give into the discourse around the diagnosis, and meet each client as an individual with their own unique story and experiences. As a therapist, I found it was important to spend time with my clients discussing their strengths and unique skills, as well as to reflect the progress being made, irrespective of the shape or size of this progress.

All in all, this journey remains as intriguing as it is challenging. But I’d like to believe there is more experiential learning and insights over the years. My experience with clients with borderline personality disorder has actually ignited in me a resolve to break away from what is believed about the diagnosis, and actually get into the mud to see together how it came to be the way it did. This journey is far from over and you know what– I’m all up for this ride.

Tell us what has your experience been like in the comments below :)