Psychiatrists and mental health professionals often experience intense negative emotional reactions to patients with borderline personality disorder, according to experts who deal with this population.

"Therapists often feel anxious because borderline patients engage in self-injurious behavior and suicide attempts," said clinical psychologist Neil Bockian, Ph.D. "They also feel frustrated with these patients because they perceive these acts as manipulative and attention seeking. Another common response is anger because of the perception that borderline patients are overly needy or dependent."

Bockian spoke at a conference organized by the Treatments and Research Advancements Association for Personality Disorder last month in Bethesda, Md.

"Ultimately, these negative reactions lead to stigmatizing the patient with BPD," said Bockian, an associate professor of psychology at the Illinois School of Professional Psychology at Argosy University in Chicago. Bockian also is co-author of the The Personality Disorders Treatment Planner, published by Wiley press in 2001.

"Psychiatrists need to be aware of their countertransference to maintain a positive therapeutic alliance with borderline patients," said Eric Hollander, M.D., a professor of psychiatry and clinical director of psychopharmacology at Mount Sinai School of Medicine, in an interview with Psychiatric News.

"The treating psychiatrist and mental health professionals also need to communicate about the patient frequently to prevent splitting. That phenomenon occurs when a patient pits one therapist against another or views one therapist as all good and another as all bad," said Hollander.

Bockian is educating his first-year clinical psychology students to be aware of their emotional reactions to borderline patients. "In addition to teaching them about countertransference, I want them to use their emotional reactions to understand the difficulties borderline patients experience in their interpersonal relationships," said Bockian.

He has the students fill out a lengthy questionnaire after viewing film clips portraying a patient with BPD and a patient with depressive personality disorder (DPD).

"The contrast in their initial impressions is remarkable. The students’ top three reactions to DPD patients were compassion, empathy, and sympathy. Their top three reactions to BPD patients were curious, frustrated, and distancing themselves from patients by leaning away from them in their chairs, rather than toward them," said Bockian.

He recommends that therapists assess their ability to treat this population. "To treat this population effectively requires special training and a supportive treatment environment," said Bockian.

He recommended that therapists seek training in one of the proven psychotherapies for borderline patients such as cognitive therapy or dialectical behavior therapy (DBT). "DBT and other programs specifically designed for people with BPD are far less likely to stigmatize this population," said Bockian.

Hollander said that medication in addition to psychotherapy should be considered when treating patients with borderline personality disorder. Two commonly prescribed classes of drugs in this population are serotonin selective reuptake inhibitors and mood stabilizers (see story on page 20).

Bockian said that therapists can alleviate some of their anxiety associated with treating borderline patients by planning for common contingencies such as hospitalization for self-injuries and suicide attempts. These plans can be developed through written contracts and documentation, said Bockian.

"It is imperative that patients find therapists who are comfortable working with borderline personality disorder and have positive feelings about treating this population," said Bockian. ▪