Differentiating Borderline and Histrionic Personalities

I've talked before about the diagnostic role of countertransference - the "feel" in the room when sitting with particular groups of clients. This type of reaction can be quite useful in distinguishing between diagnostic groups with similar symptoms. One population where the countertransference can be particularly strong is with clients with personality disorders.

Now, I have encountered people across the spectrum of personality disorders, but don't have the same level of exposure to this population that I do to, say, mood and eating disorders. As a result the "radar" of my countertransference is not always precise enough for a clear diagnosis. However, my supervisor has extensive experience with Borderline Personality Disorder (BPD), and has a finely tuned radar, at least with Cluster B (the "dramatic, emotional, or erratic" personality disorders).

Therefore, although I suspected a particular client had BPD, she suspected something related but different. It took her some time with the DSM, but she came to an understanding that I though was useful and insightful, so I thought I'd share it with you. Specifically, it concerns the distinction between BPD and Histrionic Personality Disorder (HPD). Both may include a similar intensity of affect, and similarly provocative behavior (of all shapes and sizes). However, the driving force behind these symptoms seems to be the key distinction between the two diagnoses.

Here is what the DSM says about this differential diagnosis: although both can "be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, BPD is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness anad loneliness" (p. 709). Looking further at the diagnostic criteria, HPD is based on a need to be the center of attention, while BPD is based on dysregulation stemming from an unstable sense of self, both independently and in relationship to others.

My supervisor suggests that these different driving forces manifest in the intent behind the client's "dramatic, emotional, or erratic" behavior. Specifically, it is more characteristically erratic in BPD - the emotionality is not typically planned or intended, but the result of the client feeling like s/he is out of control, or even dissolving. In contrast, the behavior seems more instrumental (i.e., goal directed) in HPD - it is in service of gratifying the need for attention, with more calculation as to the effect the behavior will have on others. Thus, clients with BPD may be much more likely to experience unintended effects of their behavior, but still be unable to choose more adaptive behavior. My supervisors suspected that our client had HPD because she seemed more in control and calculating in her behavior than one would expect from BPD.

What do you make of this distinction? How would you think about or describe the differential between these client presentations?

Working with Chronic Populations

Many of my clients have chronic mental health problems. Change happens very slowly, and the risk of relapse is high. As a therapist, it can be hard not to feel worn down sometimes, feeling like our efforts are futile. This is particularly the case (at least for me) when clients who have been making progress suddenly relapse, and seem to be back to square one. Whenever one of my clients gets hospitalized, or returns to an addictive behavior - and even sometimes if they're not making progress for what seems like a long period of time - I start to ask myself what I'm doing wrong, or what I could be doing differently, to be a better therapist so that they can get better. Or, at higher levels of care, I feel like the treatment is ineffectual when people need to come back again and again.

This (as I'm sure you've realized) is largely my own countertransference. While there may be a point at which one should question treatment effectiveness, relapse is fairly normal for chronic mental health and addiction issues - after all, change is hard! Negative countertransference when working with these clients is actually pretty normal, too. What matters is how we as therapists manage our countertransference so that it informs but does not negatively influence the work.

A good starting point is giving my ego a reality check: I am not that powerful that whatever I did or didn't do must have caused my client's relapse. I can't save anybody, nor should I. I am a tool for people to work on saving themselves, but a large part of that process is up to them. There are also a lot of other factors in their lives (more significant than I) that influence symptoms - brain and body chemistry, family issues and other psychosocial stressors, etc. Trying to place blame - on myself, the client, or anything else - is not a valid response. A more fruitful response is nonjudgmental curiosity. I want to see what we can all learn from this slip, without implying that anybody should have done something differently this time.

In order to provide this more fruitful response, I need to actively manage whatever negative feelings I have - disappointment, frustration, anger, guilt, etc. I need to do my own work to process these feelings so that they don't leak into my interactions with the client. Supervision or consultation is useful here, or even personal therapy. If a particular population inspires such negative countertransference that management isn't sufficient to turn responses from negative to productive, it might be time to consider a different population (fortunately, the field is so wide that we often do have the opportunity to change populations or settings when we're feeling burned out, or even just bored).

Once I have my responses in check, I have to decide how to proceed with the client. What might my responses tell me about what the client may be experiencing (for example, might my feeling of guilt or sense of failure be a reflection of the client's feeling of guilt or failure?). I also have to decide what, if anything, of my response to share with the client. Might it be beneficial for the client to her how her/his actions affect others, with myself as an example? Sometimes yes, sometimes no. When choosing to self-disclose in this way, it's important to have a clear sense of how sharing is expected to benefit the client, and to review with a supervisor or consultant.

Then, it's good to make self-care a regular practice, including more reliable sources of mastery than therapy!

Nuances in Countertransference

In school, we learn a little about countertransference - basically, enough to know that it's normal for therapists to have emotional reactions to clients, which are called countertransference, and that these reactions can provide us with important information about the client's internal experience, and how others may relate to him/her. While that's useful knowledge for beginning therapists, countertransference is actually much more complex.

There are two ways of distinguishing various countertransference reactions that I find helpful. The first is subjective vs. objective. Subjective countertransference comes out of our own issues and histories, rather than the client's. One possible source of subjective countertransference is our past relationships - for example, when a client reminds us of our mother or daughter, a childhood friend or bully, and therefore elicits feelings from these relationships. Another source of subjective countertransference is emotional difficulties, traumas, or other vulnerabilities we've experienced. For example, someone who has had depression may find the experience of treating a client with depression more distressing due to fear of being sucked back into that state, or someone who has experienced rape may have strong reactions to a client describing a rape, let alone a client who has been a perpetrator, or even makes general comments that seem to justify sexual aggression.

While these kinds of subjective countertransference are normal, they do not give us information about the client, and can hinder rather than help therapeutic work. As a result, it's important for us to learn to recognize, manage, and contain our subjective countertransference, to keep it from negatively influencing the work. If we are unable to contain it, the ethical decision would be to transfer the case to someone who might be more objective, and if the reaction is to a certain client population (e.g., perpetrators of sexual abuse) we should seek out a field of practice or practice setting where we won't be working with that population.

Objective countertransference is elicited by the client, out of their own issues and histories. It gives us information about their emotional state, unconscious material, and/or how they may be experienced by others. For example, if we become irritated by a client, they may be experiencing irritation - even if they are not expressing it. If we feel distanced or dismissed by the client, they may also distance or dismiss others, or feel distanced and dismissed by others. Awareness of objective countertransference can be a useful tool in therapy, both by informing our own clinical hypotheses, and through carefully constructed comments sharing our observations, make implicit clinical material explicit.

The other useful distinction between types of countertransference is common vs. idiosyncratic. Common countertransference refers to the reactions that we always or usually have to a particular clinical situation. For example, sitting with someone who is depressed makes me feel like I'm in a black hole, and the feeling is so consistent that I can use it as a diagnostic tool. These reactions can be helpful (e.g., when they are a diagnostic tool), or unhelpful (e.g., if my lethargy when sitting with a depressed client interfered with effective intervention), depending on how we manage and use them.

Idiosyncratic countertransference is the unique reaction we have to a particular client and/or a particular clinical encounter. For example, experiencing a surge of anger toward a client with whom we have not felt angry in the past can point to their own anger, and/or to how they might elicit antagonism from others, while anxiety without a known cause likely reflects the client's level of anxiety. Such idiosyncratic reactions are the most informative kind of countertransference because they provide a window into this client at this moment in time, and may even reveal things that client is not yet consciously aware of. Of course, like all forms of countertransference, the utility of such reactions depends upon our being aware of them and managing them effectively so that we reflect on, rather than enacting, them.

How do you understand, manage, and use countertransference in your work?

Vicarious Trauma

I used to love watching crime dramas; SVU and Criminal Minds were two of my favorites. I don't watch them much anymore, though. It's not that I don't find them interesting - I do. I just don't like how I feel when I watch them. 

This feeling I get - sadness, heaviness, and a hint of disgust - didn't used to happen. I used to feel suspense, nothing more. What changed? I became a therapist.

I think it is the result of what they call secondary or vicarious trauma - the emotional side effect of listening to, and being empathically attuned with people who are suffering. It's most often associated with trauma treatment, with good reason: listening to horrific things that have happened to people, particularly at the hands of other people, shatters our illusions and forces us to confront the cruelty people are capable of. 

However, I don't think vicarious trauma is limited to only explicitly trauma-focused therapy. After all, most people have encountered some form of hardship in their lives, and people who present for mental health treatment are likely to have encountered mistreatment, stigma, and/or oppression in various shapes and sizes. Then there is the trauma of what is happening in their own minds. Most obviously in delusions and hallucinations, but also in problems as mundane as depression and anxiety, psychiatric conditions involve distorted thinking. It can be hard to keep your footing in reality while also experiencing genuine empathy. 

We sometimes speak of the effects of empathic connection with someone who is suffering as a form of countertransference. It's not the traditional, psychoanalytic definition, but it is certainly an emotional response elicited by clients. When I sit with someone who is depressed, I feel like I am under water. When I sit with someone who is manic, I feel like I'm coming out of my skin. I used to feel like my brain might short-circuit when I sat with someone psychotic (before I learned not to follow them too far into the abyss). 

These feelings I get are not problematic, but rather an invaluable source of information. They also stop when the client leaves the office. When I was a student, I wasn't as good at letting go of the feelings, and often felt overwhelmed by the onslaught of my responses at the end of the day. I have learned to let them go, and to compartmentalize, and to protect the core of myself from the wash of other people's emotions, to stay anchored while I step into someone else's experience. I am intentional about self-care to maintain my stability. I almost wouldn't even notice emotional side effects of doing this work...if it wasn't for the crime dramas.

The best explanation I can come up with is that I see and hear enough real-life drama - crime and otherwise - to take all the entertainment value out of those TV shows. It doesn't help me slough off whatever feelings might be left from the day's work, but magnifies them. I just can't enjoy them anymore. (But, of course, it's worth giving up those shows to do meaningful work that I do enjoy).

Have you noticed any ways that your work affects what you do or enjoy in your outside life?

Another Take on Termination

A few months ago, as I was leaving a job, I wrote about the termination process in individual therapy. Now, as I prepare to transition from the program where I've been filling in to my permanent program (set to open in a few weeks!), I'm reflecting on how termination seems different at a different level of care.

The therapeutic relationship is (obviously) different in individual therapy than it is in a setting where treatment is provided by a multidisciplinary team in groups on a milieu (as it is in all higher levels of care). Specifically, the relationship is more intimate and therefore more intense in individual therapy, making termination feel more like a loss. In contrast, relationships are more diffuse in a group setting, so termination is less significant (at least termination between client and clinician; I think clients feel more sadness about terminating with "the program," because the whole is more than the sum of its parts).

At the last partial program where I worked, staff held mini "graduation" ceremonies for clients as they left the program - diplomas and all. At the program where I work now, staff help clients lead their own ritual of saying goodbye with each of their peers sharing something positive about who they are and/or how they've changed/grown. While we introduce the process, this ritual happens without staff present. In both programs, clients have tended to feel more sad at saying goodbye to peers, and anxious about leaving the safety the program symbolizes, than anything they may feel terminating with staff.

Perhaps as a result, my own feelings about terminating from the program are almost opposite to the feelings I had leaving my last job (which involved all individual therapy). At my last job, I was sad to say goodbye to clients, but didn't have a lot of feelings about leaving colleagues or the clinic. This time, I don't have a lot of feelings about leaving clients, but am sad to leave the team.

My theory is that my feelings about terminating with clients are countertransferential (reflective of the client's degree of attachment to me), while feelings toward colleagues perhaps reflect the degree to which the team, versus individual clinicians, is the central therapeutic relationship. Of course, my feelings could simply reflect the amount of time I've spent with a client, and how collegial my relationships with colleagues are.

How do you feel about termination? Have you noticed different feelings in different settings? If so, what do you make of it?

What We Learn From Our Own Feelings

At an orientation for new MSW students this week, a more advanced student shared one of her first-ever process recordings. In it, she had misinterpreted a client's standoffishness as resulting from (rather than causing) her discomfort. The advanced student explained that, at the time, she hadn't understood what was going on with the client well enough to understand her reaction.

One of the new students expressed skepticism: "Didn't you have referral information? And access to a Diagnostic Manual?"

The experienced clinicians in the room smiled and shook our heads - likely the new student won't understand why a manual isn't enough information until she starts her own work with clients. 

The truth is, no book can adequately capture the information we, as clinicians, learn from our own feelings. (Students - this is why your professors, supervisors, and advisors all keep pressing you to reflect on your feelings!) Provided that we've done enough of our own work to separate our "stuff" from the client's, the feelings we experience while sitting with someone provide invaluable data on that client's experience. 

I think there are at least three ways that our feelings can be a source of clinical information:

1. Perhaps most obviously, our reactions to a client may be similar to the reactions he or she receives from others. For example, someone whose dependency makes me feel claustrophobic may be having relationship issues because their significant other feels similarly. 
2. Our feelings while sitting with a client may also mirror what the client is feeling. For example, when I sit with someone who is severely depressed, I always feel like I've entered a black hole - bleak, and slow.
3. Lastly, with enough experience encountering various diagnoses (and reflecting on our reactions), I think we each develop a knack for determining a client's most likely diagnosis based on the feeling they elicit. This may not be true of every diagnosis in the DSM, but I have definitely found it to be true of many. For example, psychosis is tricky to sort out using DSM criteria, but schizophrenia, schizoaffective disorder, and mood disorders with psychotic features all have a different "feel."

How do you use your feelings as a source of information while sitting with a client? Are there times when your reactions seem more or less helpful?

Difficult Clients

We all have them: clients who push our buttons. We can't hold it against them...after all, they wouldn't need us if they didn't have problems! But it can be a challenge to sit with them session after session, maintaining empathy and keeping our own negative reactions from interfering in the work.

Therapists sometimes call our reactions to clients "countertransference." Originally, it referred narrowly to the therapist's reaction to the client's transference. While countertransference of this sort definitely does occur, it seems unfair not to acknowledge our own contribution to the reactions we have. Thus, countertransference often refers to the therapist's reactions more broadly, both those naturally arising from the client's presentation, and those arising from our own history, personality, and unresolved issues.

It follows, then, that therapists all tend to have negative reactions to certain "types" of clients, while reactions to other client types is more idiosyncratic. Several of the personality disorders seem to trigger an almost visceral reaction in the therapist - and not just the much-maligned "borderlines," who often trigger negative reactions by virtue of the intensity of their own distress, and their episodic complete rejection/devaluation of the therapist (none of us like to feel despair, or incompetence). Clients with narcissistic personality disorder may also devalue the therapist, and may  be hard to empathize with if they aren't empathic toward others. Those with antisocial personality disorder may "feel" dangerous, like predators, while those with dependent and histrionic personality disorders may feel suffocating, demanding, or flooding with the intensity of their distress.

Another category of "difficult client" is the "help-seeking help-rejector" - the one who expresses a desperate wish for symptom relief, but then shoots down any treatment recommendations that are offered. The therapist may be left feeling inadequate or helpless, and may start to feel exasperated.

Our own make-up can also shape our vulnerability to certain client "types." It may get under our skin that a client is confrontational, or passive. Perhaps he or she reminds you of your mother/father/boss/ex, or has presenting problems are too close to something you've struggled with in the past. Hopefully you know what triggers a negative reaction in you, so that you can be vigilant against allowing these feelings to "leak out." I know that I struggle to be accepting of narcissism, so I am extra-careful to not act on my impulse to burst a narcissistic client's bubble.

Supervision or consultation is the best bet when a client brings out a negative reaction in you. Especially in agencies where it's not possible to refer out the clients who might not be a good therapeutic match, a good supervisor can help you sort out your own "stuff" from what the client is bringing, perhaps think differently about him/her, and respond in the best possible way. Other forms of self-care are also important: reducing vulnerability by getting enough sleep, a healthy diet, exercise, recreation, and social support, and recognizing when seeing a therapist yourself might be helpful.

What clients do you find most challenging? What do you do to maintain equilibrium?