Organizing and Shaping a Treatment Toward Change

Abstract

This case captures several key principles of working with a patient with BPD. The first is to consider the interpersonal context for the symptoms. Symptoms reduce with increased support (though this can lead to regressive treatments), and they increase with transitions and interpersonal stressors. Grounding a treatment in the expectation of functional progress is a key principle, given the troubling data that most patients with BPD improve symptomatically but not functionally. Moreover, such an approach also helps steer clear of complicity with avoidance-based symptom improvement. Families are a key to treatment. They have many of the same concerns and reactions as treaters do, and helping them learn skills to decrease their own reactivity can be extremely helpful. The case also emphasizes practical, here-and-now approaches which are not incompatible with deeper interpretations but which are accessible and help anchor and stabilize the work.