A 22-year-old African-American male named Morris was referred to me by Dr. Henri. Morris was diagnosed with borderline personality disorder (BPD) after a nonlethal overdose had led to an ER visit. This event occurred after several years in which his “treatment-resistant” depression had persisted despite many medication trials. Neatly dressed in black jeans and shirt, he seemed wary and perhaps, I thought, a bit frightened when he arrived. While we were in the waiting room, his worried overweight mother introduced herself and began to describe Morris’s “deep-seated pain.” Morris angrily interrupted her and quickly preceded me into my office. Slouching down in his chair, he said, “Dr. Henri gave up on me. I trusted him—that’s not easy for me—but he insisted I needed to see you.”
I asked whether he was OK with the new diagnosis of borderline personality disorder. “BPD you mean?,” he replied. Yes, he met the criteria, he said, but “I’m still depressed, and that’s still what I want help with. It’s my priority.” “That’s a reasonable goal,” I replied, “but what I will want….” He irritably interrupted, “I just need to know right off whether you can help me with my depression.”
Morris illustrates a common clinical problem. Many patients really have major depressive disorder (by DSM definition) and seek help, but if medications fail, they become fearful about whether to expect a recovery. Often they have not been introduced to the important role of psychosocial factors in creating or perpetuating their depressed mood. Moreover, as with Dr. Henri, many psychiatrists prefer by training, if not by orientation, to adhere to prescribing medications, and most psychiatrists avoid treating patients with BPD (Shanks et al. 2011). These facts are particularly relevant to cases like Morris, insofar as BPD represents the major source of chronic “treatment-resistant” depression (Skodol et al. 2011).
I told Morris that I thought I could help him with his depression, but that to do so I would need him to work with me to help him improve his life. I explained, “Most people with BPD are depressed, but for them having rather miserable relationships and vocational histories contributes a lot to why they feel so bad. Undesirable living situations and/or failures to achieve what you expect of yourself exacerbate and prolong depression. These are reasons that medications usually won’t help much.”
In this sequence I was trying to reorient Morris to look at his psychosocial adaptations as both the cause of his depression and as the way to relieve it. I was careful not to discredit his previous psychiatrist (to whom he remained loyal) or his previous diagnosis.
I went on to tell Morris, “Even though patients with MDD who have BPD are usually unresponsive to medications, improvement in BPD usually results in the remission of depression [Gunderson et al., 2004]. If we can successfully improve your relationships and vocational life, medications will become less significant, and the remission of your depression will be more enduring.”
When Morris replied, “I don’t think you know how bad my life is—it seems impossible to change it,” I welcomed the shift. He was developing an alliance with me. With prompting, he continued, “It starts with my mother. She’s always around, and I think she really hates me.” From this and my observation in the waiting room, I immediately recognized the pattern of a hostile-dependent family relationship and a dramatically hyperbolic mode of attribution that pose familiar issues for BPD patients. I said, “That’s very important. I can help you, and if your mood and relationships don’t improve, we should consider why.” Alarmed, Morris replied, “Does that mean you will be looking to have a way out— like Dr. Henri? I don’t want to go through that again.” I had unwittingly triggered his rejection fears. “No, no,” I reassured him. “I want to emphasize only that you should expect improvement, and I will want you to help evaluate whether progress is being made.”
In this exchange, I was working to establish an alliance with Morris about the importance of attending to interpersonal problems, the expectation of improvement, and the necessity of his collaborating with me in evaluating progress. In such cases, these messages need repetition and reinforcement.
To establish a therapeutic alliance in these early appointments with BPD patients, therapists need to help patients understand why the diagnosis of BPD offers realistic hope for a lasting remission—of their depression and more general well-being—and that to achieve remission, they need to become active collaborators in their treatment and give up the passive hope that they can improve ONLY WITH medications. To form such an alliance, therapists need to know the facts about BPD’s genetics and course; they also need to know that good sense, reliability, and warmth are sufficient help for the majority of patients to achieve lasting remissions (Gunderson & Links, in press). ■
Gunderson JG, Morey LC, Stout RL, Skodol AE, Shea MT, McGlashan TH, Zanarini MC, Grilo CM, Sanislow CA, Yen S, Daversa MT, Bender DS. Major depressive disorder and borderline personality disorder revisited: longitudinal interactions. J Clin Psychiatry, 65(8): 1049-1056, 2004.
Gunderson JG, Links PL. Handbook of Good Psychiatric Management (GPM) for Borderline Patients, American Psychiatric Press, in press.
Shanks C, Pfohl B, Blum N, Black DW. Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workship. J Pers Disord 25(6):806-812, 2011
Skodol AE, Grilo CM, Keyes KM, Geier T, Grant BF, Hasin DS. Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample. Am J Psychiatry 168(3):257-264, 2011