Being a psychologist is a deeply rewarding and meaningful profession, but it is often tinged with a sense of loss and a lingering concern over my clients. I regularly form complex, genuine and caring relationships with a multitude of clients, but these same people can and often do disappear from my life, leaving me to ponder how they are faring and whether they are safe and taking care of themselves.

One client in particular returns often to my mind; I wonder if he gained some semblance of control over his substance abuse issues, whether he was able to resist prostituting himself again for his food and rent, or whether he was alive at all.

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As with the other clients I work with who have severe borderline pathology, it was challenging to determine which serious, self-destructive behavior to begin treating first. Should I focus on his growing weed, alcohol and amphetamine addiction? What about the self-harm scars adorning his arms and legs? Or the chronic, suicidal thoughts that had consumed him since he was 10 years old?

The smiling young man in his twenties who greeted me in our first session was attentive but difficult to connect with. He responded to my initial queries with short, practiced responses. He had already visited with multiple therapists and been hospitalized several times beginning at a young age, and he understood his role to be compliant but not forthcoming. Those early sessions forced me to slow down my typically quick therapeutic pace and to meet him where he was. The focus was simply to get him to trust me, to validate his pain and to reframe his self-destructive behavior as an understandable, albeit unhealthy, coping mechanism. He had experienced a great deal of shame because of the various traumas he had endured, so it was soothing for him to feel understood and accepted.

One of the struggles in working with clients with borderline pathology is that there is often a different crisis that has transpired each week that threatens to become the focus of the session, crowding out the larger, more pervasive patterns and issues. I would try to spend some time each session dealing with whatever had happened over the previous week, while focusing on behaviors and thought patterns that were impediments to his health. An ongoing theme of our work was self-esteem, which I have found undergirds many mental health issues. If a therapist can effectively improve a client’s sense of self-worth, issues such as depression, anxiety and self-destructive behaviors often begin to improve.

In those early sessions, I had explained to my client that self-esteem can manifest as an internal, critical voice. We can recognize that voice because it tends to be vague and it disparages our basic personality and worth. For example, if my client ate too much at a meal, his inner critic might say, “You are disgusting and have no self-control.” Or if he was avoiding a task and laying on the couch instead, it would yell, “You are so lazy.” I encouraged him to pay attention and to try and notice this critical voice, and then to yell back at it. I told him that when he heard the critic in his heard criticizing him, he should say, “Shut up critic, go away!” I explained that through repetition, noticing and responding to the critic in this manner, he would diminish its intensity and frequency, and feel better about himself.

In addition to his self-esteem, we also worked diligently on his distress tolerance. This client, like many of those with borderline pathology, felt emotions intensely but didn’t know how to manage them. Since he couldn’t express them in a healthy way and didn’t feel justified doing so, he would internalize them, manifesting as self-harm or binge eating. We worked on identifying and accepting his emotions and then discussed ways to self-soothe. Due to his intense self-hatred, he often struggled to justify treating himself kindly or performing otherwise self-calming activities. In time though, he would occasionally come into a session and report back on something he had done to feel better, earning much praise and support from me.

Over the two years we worked together in weekly sessions, I developed a great deal of sympathy and concern for this client. Even at his young age, his life had already been exceedingly difficult, and I worried about his future. How would he find and maintain work? Would he meet a partner who would treat him well? Would he go back to school? With each new crisis, my apprehension for him grew. The worry morphed into sadness, as I grew to acknowledge to myself how little control or influence I had over my client’s life. I could provide compassion, strategies and tools, along with a safe environment, but I couldn’t save him, despite how much I wished to.

Eventually, my young client moved out of his home and found his own place, though he moved several more times within just a few months, as he struggled with landlords and finding money for rent. The frequency of our sessions diminished, and often several months would pass before an email would arrive, requesting a session.

It has now been a year since I have heard from him. In our last session together, my client was struggling to maintain his new job at a coffee shop. He was also feeling lonely and drinking too much. We discussed ways for him to feel better and explored options in his community where he could receive further support. Whether he followed through on these recommendations, I don’t know.

In my more hopeful moments, I reassure myself that my young client likely availed himself of at least some of the resources that we had discussed, given his desire to get healthy and improve his life. Surely, he wouldn’t have gone through with all of our therapy sessions if he didn’t harbor some optimism for a better future. Yet my worry and doubts remain to this day. All I can do is hope that wherever he is, he is safe and knows that I am here if he needs me.  

File under: Musings and Reflections