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Managing the clinical encounter with patients with borderline personality

disorder in a general psychiatry setting: key contributions from transference-
focused psychotherapy

Article in BJPsych Advances · December 2018

DOI: 10.1192/bja.2018.63

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 BJPsych Advances (2018), page 1 of 8 doi: 10.1192/bja.2018.63

Managing the clinical encounter ARTICLE

with patients with borderline

personality disorder in a general
psychiatry setting: key contributions
from transference-focused
psychotherapy
Tennyson Lee & Richard G. Hersh

There is an evidence base for the treatment of bor- Tennyson Lee, FFCH, FRCPsych, is a
SUMMARY consultant psychiatrist in psycho-
derline personality disorder using specific forms of
This article describes how the core principles and psychotherapy (Stoffers 2012). More important for
therapy and a candidate in training at
techniques of transference-focused psychother- the Institute of Psychoanalysis,
psychiatrists, there is also evidence that structured London. He is clinical lead in
apy (TFP) can be used in general psychiatry to
clinical management of the disorder is effective in Deancross Personality Disorder
help in the management of patients with borderline Service in London and co-director of
personality disorder (or other moderate to severe general psychiatry settings (Bateman 2013). This
the Centre for Study of Personality
personality disorders). It focuses on: knowledge – is encouraging, as 50% of patients in psychiatric Disorder (CUSP), linked to the
appreciating how an understanding of object out-patient settings meet criteria for personality Wolfson Institute of Preventive
relations assists the clinician in assessment and disorders (Beckwith 2014). However, psychiatrists Medicine at Queen Mary University,
treatment; attitude – developing a stance to have negative feelings about working with London, UK. Richard Hersh, MD, is
a special lecturer at Columbia
manage the confusing and negative feelings that patients with a personality disorder (Lewis 1988; University Medical Center, an adjunct
may arise in both clinician and patient; and Chartonas 2017). We believe that knowledge, atti- faculty member at New York
skills – describing how use of TFP techniques tudes and skills derived from the evidence-based University School of Medicine and a
(technical neutrality, analysing the transference psychotherapies will be useful to general psychiatrists faculty member at the Columbia
and countertransference, and judicious use of University Center for Psychoanalytic
working with patients with personality disorders. Training and Research, New York,
interpretation) helps the clinician to continue
USA. Both authors are certified tea-
thinking in the fraught clinical encounter. The
chers and trainers in transference-
structural (including contemporary object rela- focused psychotherapy.
tions) and structured approach in TFP are exempli- Principles of transference-focused Correspondence Dr Tennyson Lee,
fied in clinical vignettes. psychotherapy Deancross Personality Disorder
Transference-focused psychotherapy (TFP) is one of Service, Mile End Hospital, 275
LEARNING OBJECTIVES Bancroft Road, London E1 4DG, UK.
the psychotherapies that has a treatment evidence Email: [email protected]
After reading this article you will be able to: base for patients with borderline personality dis-
• Apply an understanding of object relations the-
order (Clarkin 2007; Doering 2010). Developed by Copyright and usage
ory to interactions with patients with
the American psychoanalyst and psychiatrist Otto © The Royal College of Psychiatrists
Borderline Personality Disorder (BPD) 2018
• Describe the use of the treatment contract and Kernberg, it is a psychodynamic therapy based on
technical neutrality contemporary object relations theory offered for a
• Understand and better manage the counter- minimum of 1 year. Sessions are typically twice a
transference in working with patients with BPD week, although the National Health Service (NHS)
in the UK offers sessions once a week. Applied
DECLARATION OF INTEREST TFP principles can be used in general psychiatry
None. (Zerbo 2013; Hersh 2015, 2017) and this is what
we address in this article.
KEYWORDS
TFP may be considered to provide a structural
Transference-focused psychotherapy; personality
understanding of personality and personality disor-
disorders; general psychiatry; clinical manage-
ders based on object relations theory. It also pro-
ment; countertransference.
vides a structured approach to the management of

1
Lee & Hersh

low-functioning borderline and psychotic level)

(Caligor 2018).
Fear, suspicion, hate The concept of borderline personality organisa-
Victim Persecutor tion as developed by Kernberg does not equate
Opposites

with the DSM-5 diagnosis of borderline personality

disorder. Instead, borderline personality organ-
isation includes a number of specific personality
Longing, love disorders, including borderline, narcissistic and anti-
Cared-for Perfect
social personality disorder, among others. This con-
child provider ceptualisation is helpful to psychiatrists as it adds a
dimensional aspect to identifying specific personal-
FIG 1 The predominant object relations interactions affecting Nina’s behaviour in vignette 1
ity disorder presentations and also accounts for the
(both aggressive and libidinal dyads are shown). The ‘surface’ negative dyad (victim–
overlap of symptoms in the different disorders (e.g.
persecutor) hides the defended-against, and longed for, positive dyad (cared-for
a psychiatrist may frequently think ‘This patient
child–perfect provider).
has a predominantly borderline personality disorder
presentation – but she also has narcissistic and anti-
personality disorder through its emphasis on the
social features – how do I fit this together?’).
therapeutic frame and treatment contract.
In this article we focus our discussion on border-
line personality disorder, the most comprehensively
A structural understanding studied of the personality disorders, but we consider
Use of the concept of internal objects, object relations it to be a prototype for the moderate to severe per-
dyads and how these contribute to personality organ- sonality disorder presentation that Yeoman et al
isation underlies the structural approach of TFP. (2002) describe as marked by:
• non-specific ego weakness: the ego is unable to
Object relations theory and dyads fulfil its task of managing the demands of the id,
The psychoanalytic use of the term ‘object’ is confus- superego and reality as described by Freud in
ing. In normal discourse we usually expect an object his structural model of the mind (Freud 1923)
to refer to a thing. However, in psychoanalysis • disturbed interpersonal relations
‘object’ usually refers to a person or to an aspect of • difficulty with commitment to love and work
a person. An ‘internal object’ is a mental representa- • some degree of pathology in sexual relations
tion that has acquired the significance of a person in • superego pathology (this results in an excessively
the ‘real’ external world. critical faculty that may be directed both intern-
Object relations theory emphasises that the drives ally and externally; it may manifest in significant
described by Freud – libido and aggression – are superego lacunae marked by dishonesty or anti-
experienced in relation to a specific other (the social traits).
‘object’). An implication of this is that any emotion
Box 1 outlines the key elements in personality
we have is experienced in relation to another – be
organisation and how borderline personality organ-
it a person or a thing.
isation manifests (Yeomans 2015). These elements
Internalised object relations are the building
are most systematically identified using the
blocks of psychological structures and they organise
Structured Interview of Personality Organization
motivation and behaviour. These building blocks
(STIPO-R; Clarkin 2016).
are units composed of a representation of the self
It follows that TFP addresses these specific aspects
and of the other, linked by an affect. These units of
of personality organisation. The objective is to inte-
self, other and the affect linking them are the
grate the patient’s contradictory representations,
‘object relations dyads’ (Fig. 1).
bringing together split-off aspects of personality. The
focus of treatment is the therapy relationship – hence
Personality organisation the name transference-focused psychotherapy. A dif-
Kernberg has developed a psychoanalytic categor- ference with traditional psychoanalysis as it may
isation of personality structure in which he describes have been practised in the past is that in TFP there
different levels of personality organisation at the is more explicit and thorough investigation of what
neurotic, borderline and psychotic levels. The term is happening in the patient’s life outside of treatment.
‘structural’ captures the mixture of subtypes of
defensive functioning, specifically the contribution
of mature, repression-based defences (more at the A structured approach
neurotic and high-functioning borderline level) as The structured approach relates to TFP’s emphasis
opposed to splitting-based defences (more at the on operationalising its treatment (e.g. through its

2 BJPsych Advances (2018), page 1 of 8 doi: 10.1192/bja.2018.63

 Managing the clinical encounter in borderline personality disorder

clinical guidelines manuals) and anchoring it within

a clear treatment frame (Yeomans 2015; Caligor BOX 1 Elements of borderline personality organisation
2018). Much as a surgeon needs to establish a
Identity Object relations
clear and clean field for operating, so a clinician
working with a patient with a personality disorder In borderline personality organisation the Lack of integration results in rapid alternation
diagnosis needs to establish a procedure that individual lacks identity consolidation, i.e. between loving and depriving objects. This
lacks a coherent sense of self and/or of confuses both the individual and those around
allows maximum chance of a therapeutic effect.
others. This results in non-reflective, contra- them – others are perceived as alternately
The treatment frame is established via the treat-
dictory or chaotic experiences of the self and idealised or devalued. Relationships can be
ment contract (Yeomans 1992, 2017), which sets others. highly unstable.
out the patient’s and service’s respective responsibil-
Defences Aggression
ities. For example, the service may expect of patients
that they attend their treatment sessions regularly These are at a primitive level. There is pre- There is a moderate to high level of aggres-
dominant use of splitting – with a radical sion directed at the self and others. This can
and on time, and that they attempt to reduce their
separation of good and bad feelings, of good manifest in irritability, anger, rage, envy and
risk-taking behaviour. In turn, patients may expect
and bad objects. (This is opposed to the use of hatred.
of their service that the clinician provides a safe, repression by individuals with a higher level Morality
containing environment. Once agreed on, any chal- of personality organisation.) This excessive
lenge to the frame (which is anticipated, given that The lower the level of personality organisa-
use of splitting leads to the lack of integration
the clinician is working with a patient with a person- tion, marked by antisocial traits with more
and sense of identity of the individual.
extreme ego-syntonic aggression, the more
ality disorder) is then an area for exploration. The Reality guarded the prognosis.
treatment contract is a clinical document, not a
Reality testing is usually intact but is subject
legal one. This means that the clinician is keen to to fluctuation: particularly under stress,
establish that the patient really understands the thinking becomes paranoid and confused.
implications of what they are agreeing to (e.g. under-
taking to reduce and stop a self-harming behaviour
that has been a coping mechanism for many years is
Some practical examples
no light matter). The clinician will not feel pressed
into offering a treatment if the treatment contract is The terms introduced thus far are rather abstract,
not agreed to. and in the following fictitious clinical vignettes,
TFP has been operationalised in a manual which are based on our clinical experience, we give
(Yeomans 2015) that emphasises strategies, tactics examples of what we mean. The vignettes also
and techniques: show how key clinical contributions from TFP –
the clinician’s knowledge, attitude and skills – help
• strategies support the overall objective of therapy, in the management of patients with borderline per-
namely integration of ‘split-off’ negative and posi- sonality disorder (or other moderate to severe per-
tive experiences of self and others sonality disorders):
• tactics refers to the setting of secure conditions of
therapy, by establishing a clear treatment frame • knowledge – appreciating how an understanding
in the treatment contract of object relations assists the clinician in assess-
• techniques are the minute-by-minute interven- ment and treatment
tions and include the clinician’s ‘technical neu- • attitude – developing a stance to manage the con-
trality’. (‘technical neutrality’ does not mean fusing and negative feelings that may arise in both
that the clinician is distant and passive; instead, clinician and patient
the clinician refrains from taking any particular • skills – describing how use of the techniques in
side in the patient’s internal conflict; this distin- TFP (technical neutrality, analysing the transfer-
guishes the TFP approach generally from a ence and countertransference, and judicious use
more supportive or case-management approach). of interpretation) helps the clinician to continue
Other core elements of the therapist’s techniques thinking in the fraught clinical encounter.
include use of the transference, the countertrans-
ference and interpretation. Importantly, in its
Vignette 1: risk management
technical application, TFP encourages the clin- Nina is a 34-year-old unemployed White British
woman. She has a partner, Eddy, with whom she
ician to monitor all three channels of possible has an intense, unstable relationship – alternately
communication – verbal, nonverbal and the coun- seeing him as the best and then the worst of partners.
tertransference. This is important as patients with She has recently moved into the area and is being
borderline personality disorder may communi- seen for the first time in out-patients by a psych-
iatrist. She has a queried diagnosis of borderline per-
cate particularly in nonverbal ways and through sonality disorder, and has in the past attracted
the countertransference. Indeed, what is not ver- numerous diagnoses, including depression, post-
balised may be more important clinically. traumatic stress disorder, complex post-traumatic

BJPsych Advances (2018), page 1 of 8 doi: 10.1192/bja.2018.63 3

Lee & Hersh

stress disorder and bipolar affective disorder. She is countertransference enactments. By tolerating
presently being treated with high doses of two anti- these feelings, the therapist will have a strong
depressants, an antipsychotic and a mood stabiliser.
She starts the interview very tearful and eager to
sense of what a patient like Nina might be experien-
please. However, in the course of the appointment cing (Maltsberger 1974).
she becomes increasingly angry and demanding
and then suddenly says ‘You don’t know anything
and you’re a waste of time. I’m leaving now and Naming the actors or identifying the dyads: use of the
I’ve got lots of tablets at home and I’ll just take object relations model and exploration of the
them and save everyone’s time’. She makes ready transference
to leave.
The psychiatrist in general practice can use the TFP
technique of ‘naming the actors’ in situations
Managing the encounter marked by heightened affect or confusion.
Tolerate the confusion and affect ‘Naming the actors’ is the therapist’s first bid at
When the patient says ‘You don’t know anything and putting into words what they are observing. The
you’re a waste of time’, the clinician may well be think- therapist aims to describe the dominant observed
ing ‘She’s right – I don’t have a clue what to do. And affect, how the patient might be experiencing him-
whatever I do will just make things worse’. or herself and an important other, including the ther-
The use of TFP principles in general psychiatry apist. The goals of ‘naming the actors’ include a
would suggest that a clinician should be open to con- general containment of affects, an attempt to give
sidering the contribution of possible personality dis- the patient an experience of feeling understood,
order pathology, even with limited information, as is and the opening of a dialogue between the patient
suggested in this vignette about Nina. The clini- and therapist about the dominant object relations
cian’s initial goal in a situation like this would be dyad in play. The therapist does not aim to get it
to tolerate the expectable confusion and not feel 100% correct, but rather invites the patient to
moved to organise the patient’s often contradictory correct any aspect of ‘naming the actors’ that feels
or inchoate material. The clinician who can tolerate inaccurate. This process is the opening gambit in a
the expectable confusion seen with patients with series of interventions that can include identifying
moderate to severe personality disorder pathology the dominant object relations dyad in evidence and
will therefore have a chance to think clearly first, its reversal, and eventually speculation about what
rather than act reflexively. dyad may be defended against.
In Nina’s case, there is a perceptible change: at the
beginning of the appointment she is anxious and
What am I thinking and feeling? Use of the
countertransference sees herself as needy and vulnerable, possibly
fearful of an uncaring other. There is a rapid reversal
As noted above, the clinician who has considered the
with the threat of self-harm; the clinician becomes
possibility of an element of moderate to severe per-
the anxious one, with the patient in the more power-
sonality disorder pathology will be attuned to a
ful role. Over time the therapist might begin to
patient’s use of splitting-based defences such as pro-
speculate that this reversal of the dyad of victim/vic-
jection, projective identification, splitting, idealisa-
timiser might serve to obscure Nina’s covert longing
tion, devaluation and omnipotent control. In such
to be properly treated and cared for by a benevolent
a case, the patient may have ‘projected’ feelings
parental figure. (See the response by the clinician
that are intolerable, such as aggression or hateful-
below, where there is identification of the defensive
ness, and then identified those feelings in the therap-
dyad, for an amplification of possible reasons for
ist. At the same time, the therapist may be aware of
this reversal.)
countertransference feelings of uncharacteristic
aggression. The clinician who is alert to the possibil-
ity of emerging countertransference patterns in the De-escalation with understanding
treatment of a patient like Nina will be less likely An example of a clinician’s acting out response might
to act out (‘Don’t talk to me that way!’ or ‘I’ll find be: ‘I have been trying to help, but it seems you are just
you another doctor’) and may be better able to getting very frustrated and raising your voice at me.
explore those intolerable feelings with the patient. Maybe you need to see another doctor’. Such a
The aggression a patient projects into the clinician response is likely to indicate that the clinician is
can be of such intensity that the term ‘countertrans- failing to identify, explore or manage their own
ference hate’ is appropriate (Winnicott 1949). It is (understandable) negative feelings, but is instead
critical that a therapist working with severely dis- letting these feelings direct their behaviour.
turbed patients such as Nina learn to tolerate these A more helpful response might be: ‘I think having
challenging feelings, rather than discharge these doctor after doctor who doesn’t really seem to want
feelings through actions that might be described as to help, who doesn’t seem interested, who may think

4 BJPsych Advances (2018), page 1 of 8 doi: 10.1192/bja.2018.63

 Managing the clinical encounter in borderline personality disorder

things are your fault, would be frustrating – maybe highly aroused, an object relations dyad of a typ-
even enraging’. This response conveys to the ically persecutory nature, and level of aggression.
patient an appreciation of how they may be ex- Nina does, however, have a genuine caring for her
periencing the psychiatrist and is an example of a daughter and partner – her level of morality indi-
therapist-centred interpretation (Steiner 1993: cates that she is not at the most severe end of low-
pp. 131–46). functioning borderline personality organisation.
The use of clarification, confrontation, judicious This is a positive factor in her prognosis.
interpretation and identification of the dominant
object relations dyad and role reversals are illu- 2 It may not always be possible to name the
strated in the following potential response by defended-against dyad. It is not infrequently – as
Nina’s clinician: in this case – a longed-for scenario of ideal care.
In the heat of a clinical interaction, it may easily
‘You started this meeting saying you were feeling
anxious and nervous and that I wouldn’t listen to be missed. It also may not be appropriate timing
you. Now you are saying that you think this is all a to raise this subject if there is a risk of humiliating
waste of time and you want to end this all and kill the patient. Nevertheless, it can be helpful for the
yourself. Is that correct? [clarification] By threatening clinician in managing a negative countertransfer-
to self-harm and saying you don’t care what you do,
things seem reversed – so that I’m now the anxious
ence to keep in mind the defended-against dyad
one and you’re in control of taking your life [identify- (e.g. the wish for a ‘perfect’ carer) when exploring
ing the reversal of the dyad]. with the patient the negative dyad on the surface.
This sudden switch in how you feel about yourself Note that technical neutrality does not mean a
and those around you is in fact a problem you have
disengaged impassive approach. Instead, the clin-
described that also affects your relationship with
your husband. [Fig. 1 – there has been a reversal, ician is active and shows empathy for the internal
with the patient switching from being the victim to conflicts the patient is experiencing.
being the persecutor in the negative dyad.]
You started off the meeting telling me how long you 3 A therapist-centred interpretation can offer a
had waited for this appointment – that after years, you
hoped I would be able to help you – because the most greater chance for the patient to feel that they
important thing for you is to be a good mother [clari- are understood. It is less challenging for the
fication]. You may now be so scared that such an patient than a patient-centred interpretation
important thing will not happen that it seems safer such as ‘You are feeling lost and frustrated, as
to walk out on this [interpretation, identification of
defensive dyad]. [Fig. 1 – this is the positive dyad
though you are in a situation you have no
which has been defended against by the more control over’.
surface negative dyad.]
Rather than ending this meeting, I think what has Vignette 2: TFP-informed prescribing
just happened here is what you describe happening
Mr B is a 25-year-old unemployed man. He has
with your loved ones, and this worries you. I think
recently moved back home to live with his parents
your meeting with me is an opportunity for us to
after failing his final year of university. Mr B has
understand what leads to these switches in you and
been recently evaluated and given diagnoses of
what you can do about it. There is something very
major depression and social anxiety disorders. He is
important that we need to work out.’
being treated with venlafaxine (having failed to
An illustration of the importance of picking up all respond to a number of other antidepressant medica-
tions) and olanzapine (used by his previous psych-
three of the channels of communication is that a iatrist as an adjunct to antidepressant treatment).
few minutes before her outburst, when she said When he first meets with his new psychiatrist (Dr
‘You don’t know anything and you’re a waste of C), Mr B insists he needs a higher dose of olanzapine
time,’ Nina had become less engaged and had (even though he complains at times of excessive sed-
ation) as well as a second antidepressant medication.
started looking out of the window and at her
He describes marked and persistent affective instabil-
watch. If the clinician had picked up on this non- ity and mood reactivity, almost all interpersonally
verbal behaviour earlier, he may have been able to mediated, often in the context of routine requests for
identify Nina’s frustration before it crescendoed to accountability by teachers and family members.
an unmanageable level, and intervened earlier. Dr C uses an applied TFP approach in his work,
even when he is not planning to act as a patient’s
psychotherapist. This approach has a number of
Notes on the above scenario
deliberate steps, as shown in Box 2.

1 Nina’s story and presentation illustrate the nature

of borderline personality organisation in terms of Step 1
her lack of a sense of identity, primitive defence Dr C begins by ‘tolerating the confusion’ associated
mechanisms (of a splitting nature, e.g. projective with the urgency conveyed by Mr B in their initial
identification), tenuous grip on reality when appointment. Dr C is aware of his countertransference

BJPsych Advances (2018), page 1 of 8 doi: 10.1192/bja.2018.63 5

Lee & Hersh

Mr B does not accept Dr C’s suggestion that recur-

BOX 2 A transference-focused psychotherapy approach to the clinical rent major depressive disorder alone is not the
encounter problem; again, consistent with TFP training, Dr C
does not ‘insist’ that Mr B accept his diagnosis,
The following steps structure and manage the 3 A deliberate discussion of the patient’s
but plans to revisit the topic at some point in the
first clinical encounter with a patient with personal goals, treatment goals and target
future. (TFP stresses that, although the clinician
borderline personality disorder in a general symptoms for medication.
psychiatry setting. should be clear and forthcoming about their diag-
4 Contact with the patient’s prior treater(s).
nostic impressions, including those of personality
1 An extended evaluation process that 5 A family meeting, if the clinician thinks that
traits or disorders, the patient’s agreement about
includes a focus on both diagnostic criteria the patient is dependent on the family in
the diagnosis is not required to move forward with
(using ICD-10 or DSM-5) and a series of some fundamental way (living with family,
financially supported by family) and if a the treatment.)
questions informed by the Structured
Interview of Personality Organization family meeting is required so that the
(STIPO-R; Clarkin 2016). The aim of the clinician can feel he or she can safely treat Steps 3 and 4
evaluation is to clarify the patient’s relative the patient. Dr C also reviews at length Mr B’s goals for treat-
functioning or impairment in multiple 6 A treatment contract outlining the ment and obtains permission to speak to Mr B’s
spheres (work, relationships, self-care). respective responsibilities of both parties. prior treaters. Mr B is initially uncooperative with
2 A straightforward sharing with the patient This process automatically addresses a the process of determining treatment goals, respond-
of the clinician’s tentative diagnostic patient’s unconscious wish or expectation
ing ‘My goal is to feel better! Isn’t that enough!’. Dr C
impression. This might include a discussion that medication alone will resolve their
nevertheless goes into detail about the realistic goals
of clinical disorders such as depression and problems (a common feature in borderline
personality disorder). for antidepressant medication and recommends that
anxiety, as well as either a technical or
layman’s discussion of personality disorder Mr B stop the atypical antipsychotic. (Dr C’s recom-
pathology, if it is in evidence. mendation to stop the antipsychotic would be con-
sistent with National Institute for Health and Care
Excellence (NICE) guidelines as well (NICE 2009).)
of annoyance and some fear related to Mr B’s history
of having ‘emergencies’ because of non-adherence Step 5
to medications as prescribed. Dr C proceeds with Dr C insists on a family meeting, as he feels he needs
the steps outlined in Box 2; he goes forward with his to review with the family the risks that Mr B’s
own evaluation, even though Mr B protests, saying current medication regimen and periods of non-
‘I have depression! Why do you have to ask me adherence and impulsive drinking present to his
all these questions?’. Dr C completes his evaluation, safety. Mr B is initially adamant that he would not
which combines questions related to standard agree to a family meeting. Dr C is also aware of his
ICD-10 or DSM-5 criteria and also explores at own need to feel comfortable proceeding with the
length other aspects of Mr B’s behaviour and treatment: he feels that a family meeting is essential
functioning. if he is going to be able to think clearly in his treat-
Dr C learns in his interview with Mr B about the ment of Mr B and not feel overwhelmed by anxiety
patient’s relative lack of identity consolidation (i.e., about the family’s disapproval of his decision-
a limited and inconsistent sense of his interests, making. Dr C is polite but firm: if Mr B would like
values, friends), use of more primitive lower-level him to take over responsibility for prescribing,
splitting-based defences (particularly splitting then they will have to arrange a time to meet together
between prior treaters and omnipotent control of with Mr B’s family.
his parents through his vague threats of suicide)
and relatively impoverished object relations (few Step 6
friends, no meaningful romantic experiences). Dr C When Dr C describes to Mr B his expectation that
is comfortable describing his diagnostic impression the two formulate a contract that sets out their
to Mr B, including layman’s language of borderline respective responsibilities, Mr B is taken aback
personality disorder (Box 3). and shares his confusion, as he had always consid-
ered his prescriber as someone whose job it was to
Step 2 make him better. Dr C describes his goal of a collab-
Dr C explains that there is an overlap of feelings of orative process that would include, for example, Mr
distress in both borderline personality disorder and B avoiding binge alcohol use, which had previously
what psychiatrists diagnose as recurrent major complicated his response to treatment. Mr B is dis-
depressive disorder. Dr C explains that his missive of Dr C’s suggestions, countering: ‘Don’t
assessment indicates that Mr B’s experience of low you think I would avoid alcohol if I could? Don’t
mood is more suggestive of borderline personality you understand how depression can lead to drink
disorder than a recurrent depressive disorder. sometimes?’. Dr C acknowledges that Mr B is

6 BJPsych Advances (2018), page 1 of 8 doi: 10.1192/bja.2018.63

 Managing the clinical encounter in borderline personality disorder

BOX 3 Disclosure of diagnosis and discussion of medication: a typical dialogue MCQ answers
1d 2d 3b 4c 5c
Dr C We’ve had a chance to review your history and the Dr C Some of what you’ve described does make me think of
current difficulties you are seeking help for. Do you think I’ve borderline personality symptoms, like your impulsivity and your
asked you most of the important questions related to your threats of suicide. Would you agree that those fit a pattern of
history and goals for treatment? poor coping strategies?
Mr B Yes, I suppose so. Mr B Maybe. But isn’t borderline untreatable? That’s what
Dr C I wanted to talk with you about my impression, which I’ve heard.
would include discussion of your diagnosis. Is that something Dr C Actually, borderline personality disorder is a condition
you’d like to hear? with a favourable prognosis. Unfortunately, medications don’t
Mr B Well sure, but isn’t it clear that I have depression? I’ve work very well for most of the symptoms.
been told that many times. Mr B Is that why I’ve had so many different medications with
Dr C Well, I think you may have elements of a mood disorder, so little response?
but I am also wondering if you have a pattern of personality Dr C That could be. One goal for our work together could be to
rigidity that is marked by reflexive feelings about yourself and look together at the fluctuations in mood you often experience
about other people. and review whether medications are at all helpful with this.
Mr B Are you talking about a personality disorder? I’ve been But to do so productively we would need to have an agree-
told that in the past but I think it’s wrong. Like borderline ment, what we call a treatment frame that outlines our
personality disorder? responsibilities.

likely to struggle with this, but reaffirms the need for which may not happen frequently in an acute
them to have some basic agreement about their psychiatric setting)
responsibilities from the start. • a set of guidelines that provides an overall struc-
Mr B grudgingly agrees to both the family meeting ture (a map) with appropriate specificity (e.g.
and the details of their treatment contract. Dr C feels how to track the speed of change of the patient’s
more confident that he can safely proceed with the mental state by recognising dyads and their rever-
treatment, while continuing to refine the goals of sal); these guidelines are sufficiently practical to
their work together. allow application to other settings, not just
psychotherapy.
Summary Most important, TFP principles can help clini-
TFP provides a structural understanding and a cians manage challenging patients in real time.
structured approach for clinicians faced with the The goal is to help the clinician to think before
chaotic world of patients with personality disorders. acting, and to use countertransference cues to
It does this by providing: better manage difficult situations rather than act
on them.
• a coherent package of knowledge, attitudes and
skills:
• knowledge: a working application of contem-
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MCQs
Select the single best option for each question stem c assessment of superego pathology or moral b if the patient breaks the treatment frame, the
values can help clinicians avoid situations com- clinician will always be willing to renegotiate,
1 As regards using principles of transference- plicated by a patient’s pattern of lying, cheating given an understanding of how difficult it is for
focused psychotherapy (TFP) in prescribing or stealing patients with borderline personality disorder to
for patients with personality disorders: d psychodynamic concepts have no place in con- keep within the frame
a evaluating a patient’s defences is not likely to be temporary treatment of psychiatric disorders c the treatment contract sets out the treatment
important, as all patients taking medications will e the use of a treatment contract underscoring the frame, i.e. the agreement on how patient and
use predominantly mature defences respective responsibilities of the patient and clinician will proceed in treatment
b prescribers should not use psychodynamic con- clinician can address, from the outset, a border- d the treatment contract sets out responsibilities
cepts in decision-making, as strategies for line personality disorder patient’s expectation for the patient but not necessarily for the clinician
managing medications require research data that the treater and/or prescribed medications e the treatment contract ensures that the patient
only alone will address their difficulties. complies with the treatment plan.
c patients with borderline personality disorder will
do best with pharmacological treatment for their 3 As regards the application of technical 5 In general psychiatry, in the acute encoun-
symptoms, as there are no evidence-based psy- neutrality in general psychiatry: ter with a patient with borderline personality
chotherapeutic treatments for the disorder a in applying technical neutrality it is important that disorder, which of the following TFP princi-
d TFP principles can help clinicians avoid the the clinician is able to remain unmoved ples is not correct:
polypharmacy often associated with treating b technical neutrality means keeping equidistant a use of a structural approach, as in an under-
patients with borderline personality disorder from the patient’s conflicting forces standing of which internal representations may
e a patient with borderline personality disorder and c an example of technical neutrality in the be dominant at any particular time
a pattern of rapid shifts between idealisation and encounter with an angry patient is to encourage b use of a structured approach, for example being
devaluation will always have a positive response the patient to collect and calm himself able to fall back on what has been agreed in the
to psychiatric medications. d an example of technical neutrality is saying to the treatment contract
patient ‘You are feeling very persecuted by me at c the clinician can respond immediately because
2 TFP principles should be of use to clinicians the moment and I need to see what I can do to TFP is an operationalised approach
in general psychiatry for all of the following improve this’ d identifying what dyads may be operating at the
reasons except: e technical neutrality needs to be put ‘on pause’ time
a structured treatments of borderline personality when the patient is in a high state of arousal. e considering what defensive function the negative
disorder have been shown to be more effective dyad may serve.
than unstructured ones 4 As regards the use of the TFP concept of a
b patients with borderline personality disorder are treatment contract in general psychiatry:
likely to present particular challenges in clinical a if the patient breaks the treatment frame, the
practice marked by their use of splitting-based clinician discharges them immediately, using the
defences principle ‘one strike and you’re out’

8 BJPsych Advances (2018), page 1 of 8 doi: 10.1192/bja.2018.63

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