“BPD”: three letters that in sequence strike fear and doubt in even the most seasoned clinician. A diagnosis that for the addiction counselor yields the same anxiety as an unannounced visit from state regulators would for a treatment center’s director of operations.
A Sept. 21 preconference session at the National Conference on Addiction Disorders (NCAD) gave equal consideration to training in the topics of borderline personality disorder, narcissism and psychopathic disorders, but it became clear in a spirited show of hands from the more than 30 addiction professionals in attendance that borderline personality remains the personality type that is most vexing for clinicians to address.
Evan Miller, PhD, program director for Sober Living by the Sea’s Newport Beach, Calif., men’s program called The Landing, told the group that clients with BPD and co-occurring addiction will often find a way to make clinicians withhold critical information from the rest of the treatment team, and may evoke constant fear that they will report the counselor to the local licensing authority. “We often work harder than the client,” Miller observed.
He urged colleagues not to combat these clients’ frequent outbursts of anger by lashing out angrily themselves. He said instead that clinicians need to search for the comparatively tranquil moments when these individuals might be more receptive to the messages that counselors deliver.
Sober Living by the Sea held Miller’s talk in conjunction with a tour of its two-phase women’s residential treatment program in Newport Beach called The Rose, in one of three off-site continuing-education events held on the day prior to the Sept. 22 opening of the main NCAD meeting in Anaheim.
Miller, who presented an Addiction Professional webinar on the subject of personality structure and addiction earlier this year, explained that according to psychodynamic theory, the presence of narcissism, borderline traits and psychopathic traits is not an “either-or” proposition in individuals, but a matter of “how much” along a continuum. He cited examples of well-known individuals who have exhibited some of these traits, and added that while most BPD diagnoses are in women and narcissistic personalities identified with men, he sees plenty of examples of the converse.
He said that the defense most commonly used in borderline clients is “splitting,” or seeing everything as all good or all bad with no middle ground. This means the client will want to meet with the clinician at one particular time or never, for example.
Miller used a demonstration with a session attendee to illustrate how the client also will at turns separate and get closer to the clinician, in a constant push/pull that can be exhausting for the counselor. “This makes you question your clinical skills,” he said.
Miller cited psychodynamic theory in explaining much of the causation linked to these personality types, saying for example that BPD clients often have been affected by an upbringing where they received the opposite of what they needed when they sought either love or greater independence. He added that sometimes these clients will project onto their counselor how they perceived to be treated by their primary caregiver, even though that might not have been exactly what happened in their formative years.
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