MHM Magazine

24 | MENTAL HEALTH MATTERS | 2024 | Issue 3 MHM mechanism used by people who suffer from personality disorders. Splitting can cause great conflict between individuals and within multi-disciplinary teams, resulting in team members taking sides for or against the patient and other professionals. How do personality disorders arise? Recent advances have led to a change in the way these disorders are classified. A combination of various factors lead to the development of BPD: • Heritable and biologically based • Early trauma • Attachment pathology • Emotional dysregulation • Invalidating environment • Genetic vulnerability • Temperament Neurobiological, metabolic, and brain structural differences exist in individuals with these disorders. Case study G a case of emerging BPD. She came to therapy from 14 years until 18 years old. She had been admitted to Tara Child unit for 9 months at 12 years of age. She presented with depression, anxiety, mood swings, intense conflict within the family, self-harm and repeated suicide threats, inappropriate communica- tions and messaging with strangers (inviting them to her home). G’s mother died suddenly when she was 13 months old, a traumatic loss, her maternal family tried to take over custody of her and her older sister which resulted in intense conflict over financial and childcare matters within the extended family. Father remarried a woman with three older children, difficulties and conflict arose in the blended family. G felt abandoned by her mother and her father (due to his remarriage). Her relationship with her stepmother was conflictual as she pushed against the boundaries that were imposed by her. The stepmother was far firmer and stricter than her father but could be harsh and explosive at times. Maternal grandmother would intervene and undermine boundaries and limits imposed by her stepmother. This was highly devisive and facilitated splitting within the family. Social services had been called in several times due to the degree of conflict in the blended family. G’s mood would fluctuate dramatically in therapy sessions, depending on if she felt heard and understood by the therapist or felt abandoned, angry or defensive based on the interactions in the session. Her experience of therapy was coloured not only by her actual experiences in the room but also how safe, contained or connected she was feeling in her life. G would often project her fears and anxieties onto me and interpret my behaviour through this distorted lens. When confronted on her self-destructive or manipulative behaviour she would rage and threaten to kill herself or run away from home. Once to control the therapist she cut a chunk of her hair as she felt this would force the therapist to comply with her needs. In this moment I reflected her anger and need to control me. I had to manage my own anger and frustration at her attempts to manipulate me. To do this I reminded myself that this was an angry, wounded young woman, who didn’t know how else to feel heard or understood. Her angry actions were aimed at me but were not personally intended. At times G would idealise me, saying I was the only person who cared about her and could save her from her family; other times she would attack me, saying I didn’t care about her, and she may as well kill herself. This was highly evocative and would fill me with anxious and angry feelings. It’s not about you (Don’t take it personally) Attacks on healthcare providers by clients with BPD are not intended personally. They are emotionally dysregulated, struggling to manage intense overwhelming feelings, and often operating from fight, flight, freeze or fawn mode. It’s vital to remain grounded and remember that the person with BPD is in great emotional pain and suffers from early wounding that impacts on their ability to attach and form stable con- sistent relationships. They have not chosen to cope in the way they do but have often experienced severe trauma and loss, resulting in them developing dysfunctional coping mechanisms. Self-harm is an attempt for them to regulate their emotions to prevent them from engaging in suicidal behaviour. Self- harm has multiple motivations but is primarily aimed at emotional regulation, including communication (a cry for help) or control/ punishment of others. When triggered by a client’s manipulation remember that this is an indirect way of getting a need met, this does not mean the need is not valid. Alexithymia (inability to put words to feelings), is common in BPD, they can’t find the words for their feelings. Assisting them to label and express their emotions is an essential part of therapy. When working with clients who have BPD it’s important to stay grounded and notice when you’re feeling emotionally triggered in response to them. Self-awareness and being able to emotionally regulate your feelings and manage your responses is vital to maintaining a therapeutic relationship and modelling ways of managing conflict and sustaining relationships. References available on request. MHM | 2024 | Volume 11 | Issue 3 | Navigating the Therapeutic Relationship in Borderline Personality Disorder H