Borderline Personality Disorder has an absolutely awful reputation. Many therapists refuse to see them. It’s considered absolutely immune to treatment. They make up a disproportionate number of visitors to crisis chat, and an even more disproportionate number of high frequency callers (we don’t diagnose, but often people share their existing diagnoses). A fair chunk of our training is about how to handle them, even though the way to handle them is “exactly the same as everyone else, be sure not get lazy enforcing boundaries.”
I’m not a counselor or psychiatrist (yet), but here’s a model I’ve found really useful for BPDs: they’re stuck with the coping skills of a teenager, forever. At age 14, right before I got my third or fourth period, I was terribly upset over something. Whatever it was, I knew even as I raged that I was not actually upset over that thing, I was upset because Hormones, and eventually they would subside. And that made me even angrier, because here I was so upset over something I knew didn’t matter. Or maybe just because my Hormones had a new target. Either way, it was super unpleasant, which made me unpleasant to other people, and I was incredibly grateful when that part of puberty subsided.*
BPDs never get over that. I talk to some extremely self aware borderlines- people who’ve done years of regular therapy and a full course dialectical behavior therapy and many hospitalizations and drugs. You don’t hear much about this group because they work very hard to keep the symptoms of their BPD hidden. But for all that, they are- at 30 or 50 or 70- in the emotional place I was when I was 14. Subject to violent emotional storms they can’t control. And it’s not their fault. If it could be changed through effort, it would be changed by now. You could dump those emotions on “normal” people and they would react approximately the same way, because lashing out and withdrawing are perfectly sane reactions when your body is telling you you’re about to be kicked out of the tribe and eaten by lions.
Not everyone does all that treatment, of course, and even these gold star BPDers are probably very difficult to have a serious relationship with. But this framing and the clear boundaries of a crisis chat I find it very easy to fulfill the promise of the service, which is to give them a space to be heard without being judged. I can empathize with the pain they’re in even if it is something internal that inflicts it on them. And I hope that one day we find a more successful treatment than insurance-billable Buddhism.
*I also enjoyed when my mental image of my body caught up with my near instantaneous physical development and I stopped hitting myself on all of my parents’ beautiful antique furniture with dangerously pointy corners at hip height. 14 was a rough year.