Treatment Resistance in a Woman With Borderline Personality Disorder

Patients with borderline personality disorder (BPD) or narcissistic personality disorder (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.

Questions to consider when reading the case:

1. In what ways might the therapist help the patient address her problems?

2. If therapeutic efforts fail, how much time should transpire before the therapist advises the patient s/he is unable to help?

CASE VIGNETTE
Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility.

At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very much interested in helping her meet her treatment goals.

The greater difficulty was that Kathy used up quite a bit of time in therapy dwelling on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.

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Discussion
In working with patients with BPD, feelings of entitlement and efforts to avoid criticism are common forms of resistance. Clinicians who respond to a patient’s sense of entitlement with efforts to withhold what is demanded or to interpret the unrealistic nature of the patient’s needs are likely to make such a patient feel misunderstood, criticized, and angry. Providing validation for the patient’s needs without gratifying them offers a compromise that acknowledges the patient’s wishes without reinforcing his or her demands.

The problem of getting a patient focused on talking about difficulties is complicated. One approach involves making attention contingent on it. As a clinician, you can lean back in your chair and look perplexed when the patient dwells on how good he is at things. When the patient shifts to talking about difficulties, you can lean forward and give your undivided attention.

Along with these nonverbal reinforcements of behaviors, it can help to note that you already know that the patient is very good, if not exceptional, at the things he is describing. Then add, “I feel our limited time is valuable and want to make sure you have time to discuss the things you are having difficulty with.” This approach avoids confronting the patient’s efforts to support his own self-esteem while also helping him move onto more relevant material.

[Editor's note: For further reading, please see “Borderline Personality Disorder and Resistance to Treatment,” by Lois W. Choi-Kain, MD and John G. Gunderson, MD, from which this case was adapted.]