Rose Skeeters, a licensed professional counselor in Eau Claire, Michigan, said she’s been in a room full of counselors who scoffed at the mention of treating an often-dreaded diagnosis: borderline personality disorder (BPD).
The contemptuous response among clinicians is one Skeeters is used to. It’s also a common scenario that’s being replicated in private practices and agencies across the country. In a 2022 literature review of mental health workers’ attitude toward people diagnosed with BPD (published in the Journal of Personality Disorders), Karen McKenzie and colleagues found that mental health professionals have largely negative views of BPD — ultimately impeding proper treatment.
“BPD doesn’t just have a stigma in society; it’s in our profession too,” says Skeeters who was diagnosed with BPD in her early 20s before her mental health career fully launched. “Part of why I tell my story and experience with BPD is because it’s a diagnosis that is seriously misunderstood, and the mind of someone with borderline personality isn’t empathized with enough. There are clients out there struggling with this who need our help.”
Skeeters, who hosts the podcast From Borderline to Beautiful, is among a growing wave of clinicians who specialize in the treatment of BPD, which has become one of the most common personality disorders. BPD was first conceptualized as a mental illness by Otto Kernberg in 1975, and then it was officially introduced as a disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980. This disorder is characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self and strong emotional reactions.
The high suicide risk and explosive emotional behavior often associated with BPD are among the many concerns that can prompt eyebrow raises among clinicians and a high referral rate. BPD is also frequently underdiagnosed, largely because it has varying and dynamic symptoms that can initially present as other disorders. Societal stigma doesn’t help either, with BPD being a diagnosis closely tied to hostile behavior in popular culture. During the recent controversial trial between former couple Amber Heard and Johnny Depp, for example, Heard was assessed and diagnosed with BPD by a forensic psychologist and portrayed as angry and impulsive, which was used as a way to discredit her by Depp’s legal team.
Skeeters has the unique perspective of viewing this disorder from an “in recovery” client purview as well as from a clinical lens now as a professional counselor. She notes that despite the distorted perception of the diagnosis, recent research on the effectiveness of psychological treatments for BPD (such as Sophie Rameckers and colleagues’ article published in the Journal of Clinical Medicine in 2021) illustrates BPD to be highly treatable and the most healable among personality disorders.
“The biggest misconception about borderline personality is that it isn’t treatable,” Skeeters says. “It may be difficult to treat because emotions can rev up from 0 to 60 very quickly for someone with BPD, and in those moments, the logic of reality just isn’t there for that person. But this is not a life sentence and it’s not hopeless to get better. With proper treatment, clients can become self-aware and recover.”
A trauma-informed approach
Alisha Teague, a licensed mental health counselor in Jacksonville, Florida, says she’s seen the stigma associated with BPD perpetuate or even exacerbate symptoms for clients because of the damageability to one’s self-esteem. That’s why when working with clients, she makes determined attempts to redefine the disorder’s meaning by zeroing in on its symptomatology.
“Clients with borderline personality are so much more used to being rejected of love than actually healing,” notes Teague, the founder of the private practice Out of the Box Counseling. “When you call it ‘abandonment disorder,’ that helps them grasp a key part of the disorder while empathizing with themselves. I’ve seen clients say, ‘Oh, that’s why I have low self-esteem.’ Then when you tie in attachment theory, a client with BPD can see their behavior is tied to [a] fear of losing the closest person [to them]. That helps us move right into paths to push for secure attachment.”
Lauren Lucas, a licensed clinical social worker for Fox Valley Institute in Naperville, Illinois, says she also treats BPD by first exploring the deepest root of the behavior. And trauma is often an underlying concern. In a 2021 literature review published in Frontiers in Psychiatry, Paola Bozzatello and colleagues found that up to 90% of clients diagnosed with borderline personality have experienced some type of childhood trauma or neglect. Similar studies have determined BPD is more prevalently linked to trauma than genetics.
Lucas recommends counselors take a trauma-informed approach when working with these clients. “Nine times out of 10, a trauma is present for someone with borderline personality,” Lucas says. “Even if it’s ‘little t’ trauma, when clients can understand how their past pain shaped their world, it frees them up for self-acceptance. So often with BPD, there’s this reaction to fear of abandonment that’s driving their behavior.” She finds that being direct about what could be causing some of this plays a crucial role in the client’s movement and growth.
Lucas adds that a client experiencing BPD is often plagued with self-hatred or self-loathing emotions, making a psychodynamic approach a direct pathway for clients to have empathy for themselves. “Sometimes the biggest hurdle can be a client’s self-shaming,” she says.
Shame is also a core feature of BPD, as noted by Tzipi Buchman-Wildbaum and colleagues’ 2021 meta-analysis published in the Journal of Personality Disorders. Christine Hammond, a licensed mental health counselor in Winter Park, Florida, says that for clients with BPD, feeling “seen and heard” with their root trauma (and in general) can help to offset those lurking shame emotions and accelerate their empathy for others.
One way for clients to feel seen is by using a family systems approach — whether it be exploring upbringings or reconciling with family members directly and indirectly in session. “My approach for most personality disorders is to not necessarily treat the individual but the family as a unit itself,” Hammond says. Roles and dynamics within the households, she explains, often provide a blueprint for what’s happening in present day.
“A lot of times, in a family dynamic, clients are used to matching volume for volume or verbal assault with verbal assault. It’s the only way to survive or be heard,” Hammond says. “Seeing that some of this isn’t their fault can lead to more empathy for themselves. The goal isn’t to hang out in the past or stay in trauma-land for too long, though. It’s to find paths forward.”
An alliance based on patience and transparency
As with any client, a therapeutic alliance is necessary for one’s emotional safety and well-being. Because people with BPD often struggle with mistrust, Hammond acknowledges that counselors may need to build trust gradually.
“Part of the challenge as a therapist is accepting clients constantly pushing back and sometimes trying to sabotage because that can happen when they’re attempting to undo the deepest wounds of mistrust,” Hammond says. “No matter how safe therapy can be in their mind, trusting someone … takes building that stability over time because they’ve maybe never had it in their entire life.”
Because a lot of counselors are afraid to work with someone diagnosed with BPD, clients are used to constantly changing clinicians, Hammons notes, which only adds to the feeling that nobody understands or relates to them. But counselors can work against that pattern by simply being there, she adds.
Sara Weand, a licensed professional counselor in Philadelphia, says that offering clients a safe haven through an alliance can be essential when they may be consumed with emotional turbulence.
“The biggest thing you can do to build trust is honoring that their feelings are real,” Weand advises. “So many times, therapists can get lost in the facts, but that merely perpetuates invalidation. It takes a special skill to be able to meet the person where they’re at and accept them there before launching into work.”
Weand views the therapeutic alliance as a partnership where she and the client are working together toward a goal. This partnership, she says, relies on two things: the counselor understanding that they do not know everything and the client realizing that what they’ve been doing isn’t working.
She often explains this concept to clients by comparing this alliance to being in a rowboat together with the goal of reaching the other side of the lake. “It’s not my job to row a certain way if it [the responsibility of rowing] is theirs. And it’s also not me rowing back if there’s a hole in the boat,” she says. “It’s important to have mutual responsibility. That may be fostering a healthy relationship of push-pull for the first time in their life because they can see I’m not going to ditch them or abandon them like maybe they have been in other parts of their life. But I’m also going to push them regularly.”
Lucas echoes Weand’s point about client accountability, noting that she’ll often be transparent from the start so clients know what they’re in for.
“The need for a sense of safety and security is paramount, and as a clinician, you’re not going to make any progress without that,” Lucas explains. “I personally find that being direct can be really refreshing for clients with BPD when forming the alliance. We talk about how coming to therapy is not always going to be comfortable and pleasant. I can still provide unconditional positive regard while also not always agreeing or saying yes. Finding a way to articulate that with care and security can help work against the fear of abandonment or black-and-white thinking.”
A proper barometer for diagnosis
Transparency is also important when it comes to diagnosing BPD. Yet another casualty of the stigma tied to BPD is a reluctance among some clinicians to properly assess and diagnosis this disorder. In particular, practitioners who work with an eclectic mix of clients often have trouble determining if and when to diagnose a client with BPD, especially if another diagnosis such as posttraumatic stress or major depressive disorder exists, Skeeters says.
Skeeters strongly believes a diagnosis, if accurate, is necessary to convey to a client for their well-being and stresses that clinicians shouldn’t sway away from delivering one.
“It’s always important to give clients [the] truth. If a clinician is afraid of how a client may act, then that is their own stuff coming up,” she says. “You wouldn’t tell someone who has diabetes they have something else or that ‘you maybe or could have diabetes.’ If you’re walking on eggshells because you don’t want to hurt the person, it will likely make it worse in the long run because one thing someone with BPD is craving more than anything is trust. Telling them the truth, even if it’s hard, will help toward that.”
In fact, Skeeters admits that one of her biggest complaints is that her BPD wasn’t diagnosed earlier. “In some ways I feel like I lost out on years of my life because therapists misdiagnosed me or were too scared of delivering the diagnosis. I was told that I had bipolar II and was treated for an eating disorder when the underlying issue was tied to borderline personality,” she says.
Hammond, however, cautions clinicians to consider the client’s age and development before giving them a diagnosis. She says timing is everything and resists assigning a BPD diagnosis to her teen clients because, as she points out, a client’s maladaptive behavior can more thoroughly be inspected in adulthood. “I hate adolescent diagnoses,” she stresses. “I go to Erik Erikson’s eight stages of personality development, and a client needs to be developed enough before diagnosing in my opinion.”
Lucas also pays close attention to the delivery of the diagnosis, and she trusts her intuition on when the right time may be to discuss this with clients.
“The approach I take is first having a discussion on what a diagnosis means to them,” Lucas explains. “Then I’m acknowledging their trauma and how it affects their behavior in the here and now. If they experienced neglect growing up and are struggling with their partners in relationships today, then I might say, ‘Here’s what we may call that.’ It’s never an easy conversation. But to my surprise, there’s a tremendous amount of relief that can come when a client is able to name why they’re acting the way they are. The language in the delivery matters just as much as the diagnosis.”
Skeeters takes time to explain the diagnosis to her clients. She begins by saying, “This is what I’m theorizing with a diagnosis,” and then she describes why and how it applies to treatment. A diagnosis, when delivered from a collaborative sense, can bolster self-awareness and, as a result, improve a client’s work ethic in therapy, Skeeters notes.
DBT as the ‘gold standard’ treatment method
The method of choice for BPD is undoubtedly dialectical behavior therapy (DBT), which combines standard cognitive-behavioral techniques for emotion regulation and reality testing with concepts of distress tolerance, acceptance and mindful awareness that largely spawns from meditation practices. Marsha Linehan, the psychologist who developed DBT in the late 1970s as a result of her own mental illness, defined the dialectical component of DBT as “a meditation-focus,” which is accepting things the way they are while simultaneously pushing for change to achieve happiness. Allowing clients to engage in both of these experiences at once paves the way for an increased emotional and cognitive regulation by helping them learn the triggers that lead to undesired explosive and reactive states.
Weand, a DBT instructor in Philadelphia, describes DBT as a balance between meeting a client where they’re at while also pushing for change. DBT is all about building a client’s skill set to face their inner conflict in a way that projects outward in a healthy manner, she explains.
“DBT is the gold standard of treatment for BPD for a reason, and that’s because it works,” Weand says. “It allows the therapist the opportunity to validate the client and really connect on a human level. The skills are all practical, but the meditation-focus creates room for slowing it down and honoring feelings as real. CBT [cognitive behavior therapy] can work as a standard therapy, but for people with BPD who feel so deeply, sometimes, painful shit is just painful shit and you can’t necessarily reframe that.”
“DBT can be effective with suicidal ideation,” Weand adds, “but it’s important to have proper boundaries as a therapist and refer to advanced care because DBT is not suicide prevention.”
One treatment that is often complementary to DBT is eye movement desensitization and reprocessing (EMDR), which, as Lucas points out, can help with the dissociation a client with BPD may experience when they are unable to regulate intense emotion.
“One of the biggest things EMDR can help with is the acceptance piece of regulation,” she says. “We cannot change what happens to us, but we can change how we react” to it.
Hammond says that DBT’s focus on mindfulness can help to bolster a client’s self-awareness and therefore improve their ability to control or manage explosive and eruptive behavior. The overall gain from DBT isn’t necessarily removing a behavior; it’s slowing things down so that triggers can be managed and dysregulation can be altered, she explains.
“We usually don’t see the behavior completely go away,” Hammond adds. But it provides clients “with a higher level of awareness and really knowing themselves.”
Untangling black-and-white emotional thinking
A common symptom of BPD is black-and-white emotional thinking (i.e., splitting), which involves seeing people or situations as all good or all bad. Skeeters says that type of intense relational trauma is a byproduct of an “emotional playground” that clients with BPD can find themselves trapped in and reactionary to when reenacting old wounds with partners. For that reason, if clinicians are working with a couple and one of them has BPD, then that individual’s treatment must come before couples therapy can begin.
“Growing up, I viewed the world through a hyperbolic lens,” Skeeters recalls. “I was very sensitive and assumed that others viewed it that same way too. In my effort not to become abandoned, I ended up becoming this tyrant with dysfunctional beliefs. It can feel like other people are making you out to be a monster and that just makes it worse. I didn’t know that other people weren’t hyperbolic or lacked empathy the way I did. When it came to my relationships, to even start the path to recovery, I had to be brutally honest with myself and know how my behavior affects others around me when I’m on that emotional playground.”
Lucas says that the best way to address black-and-white emotional thinking and encourage accountability is through preventive measures and psychoeducation.
“Because folks with BPD have more extreme experiences with emotions, it’s important to provide tools of regulating and grounding for moments of being triggered,” she notes. “When it’s showing up in a relational aspect, it’s [about] helping clients understand the way their brain may be operating in those moments [and] why they might fixate on how things should be or need to be. When someone is splitting or seeing in black and white, it can be difficult to see the gray area or the nuance of an argument or situation in a relationship. When we look at those patterns, not naming them as good or bad per se, but honor where they’re coming from and why they’ve served someone, then they can be adjusted better.”
Weand says she’s noticed that most of her client’s black-and-white thinking comes after a big fight or a relationship failure. “I’ll have a client come in and their biggest pain is that ‘people think I’m crazy’ and [they] just want to feel like they’re not a monster,” she said. “They truly fear they’ll be doomed to be [perceived] this way their entire lives. The reality is they may be doing [and saying] things that look crazy [and that affect or hurt others]. … But once you show them where it comes from and that it can be regulated, there’s hope.”
Transference and countertransference can be ongoing issues when treating clients who have BPD, so counselors need to do their own work by becoming more self-aware and going to therapy themselves.
Teague acknowledges that her own personal experiences with a family member who has BPD once challenged her ability to work with clients who are diagnosed with the same disorder. It took personal tragedy to push her to do her own self-work to develop the self-awareness and emotional availability that she now uses in helping clients with BPD.
“In 2020, I was smacked in the face by so many terrible things: a tragedy with a client happened, a friend from high school died [and] then everything with George Floyd came about,” Teague recalls. “I didn’t realize it right away but all of my own personal trauma was coming up. If I didn’t go back to therapy to do my own work and forgive myself to become self-aware, then I wouldn’t be able to work with this type of population. You need to have that awareness because countertransference is bound to come up for some types of cases. You need to have the tools within yourself first.”
Weand acknowledges that she needs to keep her caseload low and have only 10 clients so that she has full emotional availability for clients with BPD. “We have to be honest with our own limitations,” she said. “Mood-dependent behavior is tiring, so by setting those limits and having those boundaries, we’re giving our clients the best fit in a therapist.”
Hammond said she’s seen therapists fret when working with clients experiencing BPD, and she can often trace it to their own inner struggles that may need to be worked out elsewhere.
“Obviously, if you have countertransference that makes it unhealthy for the client, then a referral is necessary,” she says. “But I see too often therapists might have their own issues or misconceptions with BPD or don’t have the right education on it so they’re very quick to toss them [the client] to somebody else.” She acknowledges that this tendency is not helpful, and she hopes clinicians will develop healthier attitudes toward clients with BPD moving forward.
“When you look closer, you can see that BPD clients are some of the most creative, imaginative and passionate people we have in the world,” Hammond says. “That’s why it’s so sad they’re misconstrued because I greatly enjoy working with them — seeing them fight to improve and then [eventually] get there is one of the most healing and powerful things you can do as a therapist.”
Scott Gleeson is a licensed clinical professional counselor in the Chicago suburbs, specializing in trauma and relational dynamics. He spent over a decade writing for USA Today, where he won national writing awards from the Associated Press and NLGJA: The Association of LGBTQ Journalists. His debut contemporary novel, The Walls of Color, and its sequel, Spectrum, will hit bookshelves in 2024 and 2025, respectively.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.