Psychodynamic dangers in treating BPD

By Thomas Gutheil
January 15, 2014

Psychodynamic dangers in treating BPDPsychiatrist Thomas Gutheil describes several psychodynamic characteristics of people with BPD that can lead to lawsuits: Rage

Borderline rage is so intense that therapists often feel coerced into acting against their best therapeutic judgment. They may be afraid to set limits or boundaries. Alternatively, their reaction to clients’ rage may be to become too rigid. They may find themselves inappropriately self-disclosing in an attempt to soothe their clients’ anger. All of these reactions are more likely to reinforce clients’ rage rather than soothe it. The ironic outcome is not just a rage-triggered lawsuit, but a lawsuit with actual instances of inappropriate therapists’ actions.

Neediness and/or dependency

These dynamics can easily tap into therapists’ nurturant side, resulting, says Gutheil, in “overinvolvement or overinvestment.” Therapists may find their rescuer fantasies triggered. Clients with BPD either overtly or implicitly plead with therapists not to abandon them as everyone else has. Once therapists participate in rescuer fantasies, they end up participating in the clients’ impossible-to-realize rescue fantasy. The inevitable outcome: disappointment and betrayal.

Boundary confusion

Clients with BPD often lose sight of the boundary between themselves and others, especially important others like therapists. A therapist who offers consistent, clear boundaries provides an important learning structure. When a therapist is drawn into the fuzzy zone of unclear boundaries, writes Gutheil, “reciprocal perceptions of both therapist and patient may be powerfully influenced and distorted by the intense affects, longings and wishes common in patients with borderline personality disorder.”

Manipulativeness and Entitlement

Patients with BPD, writes Gutheil, “are capable of getting even experienced professionals to do what they should know better than to do or – all too commonly – what they do know better than to do.” The manipulativeness can be so ongoing that therapists who successfully avoid the first few attempts may lapse into overconfidence, let their guards down, and succumb to later attempts.

Gutheil likens such therapists to alcoholics who pass by the first three bars and reward themselves by toasting their success at a fourth. Time and again, therapists who transgress boundaries have awareness that they’ve done wrong. Therapists who transgress often preface their actions by saying things like, “While I don’t usually do things like this with my patients,” or “I really don’t think I should be doing this.” Those are vivid warning signs.

In Gutheil’s psychodynamic view, “Some of the most destructive dyadic relationships may begin as a mutual admiration society, not recognized as an idealizing transference and its countertransference complement.” This combination is so powerful that as it gathers therapists in its grip may avoid seeking consultation.

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