Long Term Psychotherapy and BPD, Part 1: A Dialogue on Hope

• Hope as a Double-Edged Sword
• Long-Term Therapy as Holding
• Conclusion

“Isn’t hope the most bewildering of emotions?” (Sedgwick, 1999, p. 133)

Hope as a Double-Edged Sword

In this, the first of a two-part essay, we (Anne, the client, and Trish, the therapist) seek to share multiple perspectives of our therapeutic relationship, particularly regarding Anne’s diagnosis of borderline personality disorder (BPD). This format recognises the interconnections between multiple stakeholders, and also honours the risks and investments of all parties involved in the treatment of those with BPD. For us, the form of an epistolary dialogue means that we can speak directly to each other, as we do in our therapeutic relationship.

The critical theorist Eve Kosofsky Sedgwick recounts her sessions with psychotherapist “Shannon” in A Dialogue on Love (1), in which her own personal narrative is interwoven with her poetry and Shannon’s clinical notes about their sessions. It is a powerful account of the relationship between client and therapist. While the book does not offer Shannon space for a more active voice than his clinical notes about Eve, the book is striking (but not unique) in its ability to represent multiple perspectives in an account of a therapeutic relationship. This dialogic approach to presenting the clinical work between therapist and client is also reminiscent of the work of Irvin Yalom in his Every Day Gets a Little Closer: Twice-Told Therapy (2).

Italicized content throughout this essay represents Trish’s reflections on the unfolding process between herself and Anne.

Trish (she/her): You have been through so much; you have many stories of suffering. I know you don’t like thinking of yourself like that, as if you were broken. You aren’t. You are so full of life and possibility. You radiate energy and have boundless enthusiasm for what you and others can do together. I recall the times, many times, I have sat with you as you poured out your hurt in front of me. Pain that started long ago and has woven its way through the years. Often you have asked me how much more therapy you have to do before things get better. You told me how hard you have worked over the years and yet you still were in hell.

I remember the day you came in and told me of events that unfolded, which sounded like your life was unravelling in a way I hadn’t heard before. This just couldn’t go on, and I knew that some kind of intervention was needed. I had been thinking about BPD for a while as something that could explain the way in which you inhabited your world. But how do you say to someone who already feels bad about themselves, “Oh, by the way, just on top of everything else, I suspect you have this disorder called Borderline”? I remember the anxiety in the pit of my stomach as I confronted taking this risk and voicing my hunch to you. If you received this information well, it could mean some more specific pathways to things getting better, such as group therapy, Dialectical Behavior Therapy and, perhaps most importantly, a chance to separate your symptoms from the core of you. So I spoke the words, and you listened.

Anne (they/them): I remember sitting across from you struggling so hard one session, and feeling so shit about myself, and you saying you felt so badly for me that the things I ended up doing just took me further away from getting what I needed. You said you just wanted me to be able to get the love I wanted and needed. I wanted that too, but I would get impatient with you for not giving me something more conclusive to try. For not solving my problems. I remember you asking me if I knew what BPD was. I didn’t. I thought it was multiple personality disorder and saying something like “I have a lot of problems, but I don’t think I have multiple personalities!” but you told me to go home and read about it and see what I thought. It wasn’t the kind of experience a lot of people I now know with BPD have: it wasn’t a hierarchical pronouncement, a label pasted on me in a clinical setting by someone in a white lab coat, a punitive ‘othering.’ I experienced that moment like I was with a trusted friend, a friend who happens to have considerable professional expertise in these things, who gently suggested that they were 99% sure I might have this condition, and that understanding it might help me feel better. It was the gentlest and kindest of experiences, maybe, that I’ve ever had. And it saved my life.

Hope can be elusive for some with BPD. My loss of hope was one of the things that increased over time and that, Trish, you continued to flag as concerning. I always brushed off my emotional over-reactions and interpersonal conflicts. It was always “I was tired,” or “She’s a jerk,” or “He was having a go at me!” or—that old chestnut—“They just don’t like me.” But slowly, the bells began to ring. The string of interpersonal sour notes turned into one long and all-too-consistent sad song, stuck on repeat. I was exhausted and increasingly hopeless of anything changing. My experience of being diagnosed in my 50’s came as both a shock and relief. It made sense of things yet felt like a heavy weight of failure.

Being diagnosed later in life has had both pros and cons: I lived my life not believing there was anything “wrong” with me. I knew I was “difficult,” moody, volatile at times. But there were other patterns I didn’t see: the inability to cope with even minor rejection, criticism, or perceived abandonment, the broken relationships, the hurt it caused both myself and others, the left jobs, the impulsivity, the difficulty in managing emotions. How big and consistent the constant roller coaster really was. I wonder now if I had been diagnosed in my teens (when I first saw some of these behaviours) how my life would have been different: would I (or others) have presumed that, having a mental illness, I would not achieve highly in my life? Maybe the label of a diagnosis would have resulted in self-limiting in a way that I haven’t done. Yet the obvious cons: a lifetime of detritus from all the broken things/relationships/attempts to connect, achieve, find love and belonging. We will never know, but in my case, Trish, when you finally took the risk to suggest to me that you were pretty certain I had something called borderline personality disorder, I was so exhausted and broken that I listened. And then I went home and read about it. And once I did that, I knew—like it or not—I had an explanation for why things just kept not working out the way I wanted them to.

Trish: As a counselor and psychotherapist, diagnosing is not part of my brief. For the most part, I am comfortable with this. I am not interested in pathologizing my clients, in looking at them through a lens of disorder or as the sum of the problems they experience. What do clients really want when they sit on the couch and reveal something of themselves? To be heard, to be understood, perhaps to be offered guidance. Irvin Yalom talks about the therapeutic relationship between client and counselor as being one of fellow travellers, in that we all experience “the inherent tragedies of existence” (3). In this picture, there is no expert sitting in judgement, waiting to bestow wisdom on the patient (or one who suffers). So when you share your life with me, in all its realness, I want you to experience the humanity that connects us to one another. And so over the years, we have built a strong alliance, one in which talking about disorders hasn’t really figured. But I can’t help but to see patterns. Over time I have listened to clients tell me multiple stories of trauma, suffering, and confusion. I hear the pain expressed and the despair experienced by many because of how hard it is to truly feel loved. I am told of an emptiness inside, a void that can never be filled. When partners, friends, or families reach out, it is never enough. Out of the emptiness comes a rush of emotion: anger, disgust, shame, sadness. The intensity is overwhelming, and relief is nowhere in sight. I know this has a name. Do I say it?

Long-Term Therapy as Holding

Trish: Working in a community-based counseling service for many years meant that I encountered people with a range of presentations. The service was made up of a mix of permanent staff, qualified volunteers, and students on placement, and had a rich culture of reflective practice. At the time this service, probably considered unique now, allowed therapists to engage in long-term therapeutic work (anything from six months to a couple of years) with clients if needed. When I think back on that time, I am aware of a feeling of gratitude. When clients take the brave step of asking for help, there is a path to walk, and it is helpful to know that you don’t have to take the short cut. Time might not heal all wounds, but time does allow the opportunity to co-create a space of acceptance, in which the narrative of distress and untold suffering can unfold and be made sense of so that a coherent story forms. With the help of an empathic other, traumatic experiences and the feelings associated with them can be integrated, helping to create a more stable sense of self (4).

At this counseling service I encountered a number of clients who had symptoms consistent with borderline personality disorder (BPD). The common experience amongst these clients was one of complex trauma, particularly traced back to early life. Many years ago, these clients might have been described as suffering from hysteria, a term pre-dating BPD that brings to mind the extreme and uncontainable emotions that are relentless in their power to overwhelm. If the term hysteria is bad, then borderline personality disorder seems no better, with many clients reporting feeling stigmatised and shunned in health settings due to being associated with this label. Fortunately, a more nuanced understanding of BPD is developing, with the recognition of the role that childhood trauma plays in the condition, with the emergence of the term “complex trauma disorder” as a more accurate descriptor (5).

Anne: My ongoing therapy with you gives me the continuity and security of a fellow traveller who has known me over time, has seen me at my “worst” and still sticks with me, and with whom I can reflect on and compare my current circumstances with those of several years ago. You help me synthesise my past with my present, and, as you note, the relationship between therapist and client is the model for healthy relationships in the outside world, so sustaining this long-term relationship is particularly powerful for someone with BPD.

In your face in our many sessions, I could see your looks of sadness, kindness, powerlessness. I never felt judged by you. When things were hardest for me, when I was yet again sitting across from you talking about my latest blow up, the compassion in your face moved me, kept me tethered. Although I felt guilty about my behaviour, desperate at times, I never felt shame in your presence. Just the look on your face—not pitying me, exactly, but just wishing I could change, I think. That you didn’t judge me was transformative; it helped me want to change, believe I could change, and not just fall back into shame and self-loathing.

Trish: Anne, I am curious about my countertransference with you over the years. I know I have felt at times that I wasn’t helping you in the way you needed. I remember one time when you could not hold back the tone of sarcastic frustration at a suggestion from me that you might be less critical in how you spoke to someone close to you. You told me that the issue was the enormity of your feelings in that moment, and yet I was focusing on “how [you] pour the tea.” You have been defensive, but I haven’t experienced you as manipulative, a term often associated with BPD. Is it because you didn’t need me to see you any other way, other than who you were in that moment? And the next moment? I don’t feel like a parent to you, but what is it I am doing when I hold up a mirror to you and hope you see all that you are, and all that you can be?

I remember having a discussion with the manager of the community-based counseling service at which I worked about how to understand the strong countertransference that counselors sometimes experience with clients. Typically, something happens in your body; it might be a churning in the gut, or a sweeping shiver that moves from head to foot. My manager said that there is something being communicated from that client, and it seems to get right into your body as a felt sense. She said, “If this happens, the client probably has a personality disorder.” Countertransference is invariably helpful in the therapeutic process, but it can be experienced as unwelcome as well, as it can undermine the therapist’s sense of themselves as a professional who can provide help to the client in front of them.

Parental transference narratives in clients, like “I have to be good” are common for those with childhood trauma in therapeutic relationships, too. Sedgwick’s poem about her therapist Shannon, after some time of working together, when it feels “on track,” illustrates aspects of this dynamic:

     Not in love with a
     person -- but with the place the
     person inhabits

    and with the space of
    my friendly distance from him.
    nor insatiable

    but, in fact, content.
    nor demanding. Nor always
    to be frustrated--

    rather, to be pleased.
    Grateful, trusting, yes, tender.

                         Happy, therefore good. (pp. 83-84)

Trish: How do I hold you? I don’t want you to fragment. If you break into pieces, you can’t hear me. Shame comes creeping in and whispers horror stories in your ears. “Monster,” you once used to refer to yourself. I remember wincing at that. Anger is often your friend. It comes swooping in to get you away from those dementors. It stops you from sinking into that depressive story that wraps itself around your family. It activates the powerful part of you that wants to rise above it all, but it also threatens to derail what you want so much in your life. You have loving relationships, and you bring joy to a lot of people. But somehow, they also let you down; they just can’t fill up the space. I want you to turn your gaze away from the others and look inwards. Let’s quiet that part that speaks the story of shame and rally the others, the ones that might falter but won’t fall when they remember the hard stuff. They know you can be imperfect and fuck up. Let them tell you that you are worthy. It brings to mind the Mary Oliver poem “Wild Geese” (6):

    You do not have to be good.

    You do not have to walk on your knees

    for a hundred miles through the desert repenting.

    You only have to let the soft animal of your body

    love what it loves.

Anne: Does it matter what we call things? Certainly it does. This personality disorder is arguably in the midst of being re-characterised as complex trauma disorder) or emotional dysregulation disorder. For those of us who have lived decades without a “diagnosis,” we understand deeply the power of narratives of damage, deficit or hope. It is one thing to have a lot of problems, and another altogether to have a mental illness. Once I began to deal with what it meant to understand myself and my history through the lens of BPD, I connected with others with the disorder, mostly (but not only) through online groups. The pain I found there was unfathomable. I learned a lot about the gender bias in diagnosis, the youth orientation, the desperation of both those with lived experience and their loved ones and family members (not all “carers”). I also found incredible humour, deep empathy, powerful kinship, and resilience beyond what I could imagine. I have so much respect for others with BPD, all along the spectrum. It was also amazing and encouraging to me to find that so many in those groups are in compassionate and respectful long-term relationships of one kind or another, many married. I think this is very different to the narratives you see online when you google “BPD,” or in many of the therapeutic resources which suggest that people like me simply don’t have ongoing relationships of any kind. This is something I wish could have a fuller and more accurate representation in the medical and popular literature, and if a change of label and discourse about this disorder helps to break down the widespread aversion and marginalisation of those who suffer, I’m all for it.

Trish: During my time working at this counseling service, I took some leave for a holiday and arranged for a colleague to see clients in my absence if need be. There was one client in particular who really needed to be held during this period, given the recent suicide ideation he had been expressing. Upon my return and during a handover discussion, my colleague, who had seen this client, used the term “manipulative” in his reflections about my client’s presentation. I had a problem with the use of that word in that context, and still do. Does the therapist have the right to presume the intention of the client? If someone is acting out their debilitating pain, are they deliberately trying to evoke a particular reaction in someone else? The answer is probably “sometimes.” I believe that it is more helpful for therapists not to see themselves as puppets in the client’s drama, but rather as witnesses. In client-centred practice, bracketing our personal reactions or countertransference allows us to then recognise the need that is being expressed by the client—“See my pain, make it go away, tell me what to do…” It makes me wonder, if the younger version of a client could have asked this to a reliable figure in their lives who could have listened and understood and then soothed them, could it have been different?

Sedgwick describes the relief of having her shame held by Shannon in interpersonal ways, but also through the kinds of powerful symbolic imagery that “holding” (in Winnicott’s famous image of therapeutic relation) would suggest.

Anne: I found my diagnosis something like an exhale: I knew something was wrong, had always been wrong, I have worked so hard to make it right, and yet my frustration at being a “capable” person working assiduously at these problems and not being able to solve them was infuriating. My rage grew. What (or whom) I could trust diminished over time. Somehow, Trish, you were there. I realised, after so many years of your gently, periodically suggesting I might have some work to do with shame, that shame might be the corrosive foundation of it all. I have come to see that freedom is on the other side of that terrifying doorway. Hard to walk into shame, through the shame, but the liberation that comes with facing it is too hopeful to ignore.

Sedgwick describes an exchange with Shannon that reverberates with Anne, in the deep sense of being held, the absence of shame, the possibility of resting:

 

 “A moment’s realization, startlingly clear. ‘I’ve figured out what it means when I complain to you about things,’ I tell him. ‘Or to anybody. When I tell you how bad it is, how hard I’ve worked at something, how much I’ve been through, there is only one phrase I want to hear.

  

 

                 “Which is:

                                                       ‘That’s enough now. You can

                                                 Stop now.’

                                                         Stop: living, that is.

                               And enough: hurting.
 

        “Like, ‘I didn’t realize how hard it was for you; you’ve done well; you’ve been through plenty; you’re excused.”

That’s enough; you can stop now. Isn’t this the blessing into whose enfolding arms every complaint of suffering bounds - in its dreams?” (p 69)

Anne: Trish, how can I thank you for taking that risk in raising BPD with me? I never think of therapists as “at risk,” being a lifetime client (but of course as a teacher I’m aware of how teachers are also at risk with students, and how students rarely imagine it so). I feel that my life literally started over that day in your office. Not just that I found a way to make sense of things which offered some relief—dare I say hope?—and not just to stay alive, which seemed hard at that time when everything was falling apart (and several times since then). But my life started over in a way I find hard to describe. Mindfulness teacher Tara Brach says one can look at the self stuck in trance, limited by limbic brain, from the perspective of the future self, the evolved self, what she sometimes calls the sea. Identifying with the ocean, not the waves. Though not completely, that’s what happened like a snap on that day in your office when you took that trusting leap. I got just that bit of distance—the pause. Enough to stay alive, enough to try something new. And enough to stop believing my self-destructive thoughts and behaviours were inherently “me.” Getting two, then three, psychiatric confirmations of this diagnosis after you first made the leap confirmed what we already knew, but it also brought me the ambivalent feelings of both brokenness (which brought grief) and compassion (which brought gentleness). The diagnosis didn’t make the waves stop, of course, but it gave me the perspective to understand why and to some extent when they would come. DBT is giving me the behavioural skills to manage the waves, and daily mindfulness practice and ongoing therapy with you help me to accept but not identify with the waves when they rise.

Conclusion

Anne: Hope is tied so inextricably with vulnerability. The vulnerability of wanting, of imagining. For me, the rusty edge of hope was need. I hate to think of myself needing you, Trish, or anyone. It feels too vulnerable. But it wasn’t until this client-counselor relationship with you that I understood if I don’t allow myself to let you see my need, as well as my hope, that I’m limiting what you—and our relationship—can bring me.

I spent something like 40 years really believing mostly others were wrong. It’s difficult to admit, but it’s true. So why didn’t I go into my usual denial and just walk out and say, “You’re wrong! How dare you.” But I didn’t. It never occurred to me to do that, because my trust in you by then was so strong. How can that kind of trust be developed in the usually short-term treatments that seem most common here? One thing I know from experience is that deep and ongoing trust between therapist and client accumulates over time, and in this case, that is what probably made me able to hear you when that critical moment came. I’m sure I rejected or ignored many other suggestions from you over our years together, and probably still do. But what matters is that in this instance—this most critical of moments, when I was at my most desperate—I could hear you and I could take it in and trust your judgement. And let’s face it: BPD is a disorder of separation. Trish, you have given me an ongoing experience of connection and belonging.

Trish: You said something in a recent therapy session, and it hit me that you never would have said that a couple of years ago. It was about how you could see a negative spiral coming, and you were able to cut it off at the pass. I’ve been noticing that a lot. You’re flexing a new-found set of muscles and getting stronger. You’ve changed. It makes me wonder what you might say now to your earlier or former self, Anne. The one who held little hope for things ever being different. The one who needed to push away then rise above, only to find themselves in anguish again. Would you tell them to hang in there, to trust, to persevere? Would you let them know that in making space for the grief, you were re-imagining the past and letting it create a different present? I hope that you tell them that with great courage and determination, you have found your way through the murkiness and are emerging into the light.

Anne: What I would say to my younger self is this: persist, keep reaching out until you find the help you need, because you deserve to live a better life. There is help available, even when it seems too expensive or hard to find. Once I understood even the beginnings of the ways in which my thinking and my emotions are impacted by this disorder, I could change. I was no longer so attached to my thoughts. It took the pressure off, released me from trying to fix the world, to control things. Once I began to work on my own acceptance of things as they are, things started to improve. What a gift! A much smaller task than changing the whole world. Marsha Linehan, whom most of you will know as the developer of DBT, suggests that healing requires the dialectical work of both radical acceptance as well as embracing the need for change. That is no easy task, but I also experience that as a kind of relief or freedom. To me, it means that I don’t have to change everything today, or be perfect, or stop having BPD, I just have to accept my current circumstances and keep the focus within. This helps me not blame, attack, or leave others for not meeting my needs, even if that’s my therapist. And when I am able, I work on better interpersonal relationships. Combined, they are freedom, or what Marsha calls “building a life worth living.”

The expertise and insights that those with lived experience of BPD could bring to research into this area continue to largely be excluded from much BPD scholarship. Clinical BPD studies position medical practitioners as singular “credible knowers,” who interpret and draw meaning from clients’ behaviours through a still-persistent objectivist biomedical lens. Clients’ inclusion in these texts continues to most frequently take the form of short case studies or vignettes recording their behaviours. We offer this collaborative essay as one contribution toward expanding that body of knowledge for both travellers—the client and their therapist.


References

(1) Sedgwick, E. K. (1999). A dialogue on love. Beacon Press.

(2) Yalom, I. (1991). Every day gets a little closer: Twice-told therapy. Basic Books.

(3) Yalom, I. (2002). The gift of therapy. Piatkus Books.

(4) Eckert, J., & Biermann-Ratjen, E-M. (1998). The treatment of borderline personality disorder. In L. S. Greenberg, J. C. Watson & G. Lietaer (Eds.), Handbook of experiential psychotherapy. The Guilford Press.

(5) Herman, J. L. (2001). Trauma and Recovery. T J International Ltd. Padstow.

(6) Oliver, M. (2004). The wild geese: Selected poems. Tyne and Wear, Bloodaxe Books LTD. 

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