From a clinician’s perspective, it would be gratuitous to say that an individual with “Borderline Personality Disorder” (BPD) engages in self-injurious and/or bulimic behavior. Further, the “borderline experience” is often beset with client reluctance, hostility, power struggles, and sporadic relapses in progress, reactive transference, and counter-transference. Since counter-transference addresses the therapist’s feelings toward a client it is imperative that the clinician working with this particular population consider his or her own emotional entanglement.
The nature of BPD, herein referred to as Complex Post-Traumatic Stress Disorder (CPTSD), demands a clinician to have steadfast awareness of her/his own process. And it is incumbent upon the therapeutic dynamic and the therapist him or herself to “hold the floor” in the midst of a client’s internal psychic distress that often results in emotional assaults and intense pushback with regard to the clinician.
As Bessel A. van der Kolk, M.D., so eloquently wrote, “compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one’s current life, rather than repeating trauma in action, mood, or somatic states, is the goal of treatment.” 
Within the CPTSD constellation, self-injurious acts are as consistent as the emotional inconsistency that drives them. In other words, a traumatized individual makes repeated attempts to gain control over feelings of being out of control. Concomitant with substance abuse and compulsive and/or impulsive sexual behavior is the exchange between one’s sense of victim and perpetrator that is chronically reenacted in pendulating measures of eating disorders (ED) and self-injurious (SI) behavior. Consider the following:
“I swore not again!!!! I should have just stopped, but no, I had to keep on going. What was it? Okay… um… it’s not too soon. No wait… it’ll be okay… give it a minute. Hot water…yeh, hot water. Just relax dammit, relax! That will do it—it always does. Don’t fail me now. No ice. Run, goddammit, run! Anything, do anything. Scoop it out; dig it out, shovel it… throw it up… NOW… before it’s gone—beyond my reach! Then I’m dead! I’ll die… no f—— way. I refuse. Drink water, hot water—break it down… get it up. I’m not stopping ‘til I’m done. Oh God, this can’t be… I’m expanding—I can tell… Yep, there I am. See it? My body is expanding… my thighs are puckering; dimpling… just disgusting. It’s revolting—I’m revolting… I hate them… I hate me. You loser… idiot! They’re ugly. You ugly things, you! I’d carve them out if I could but… No… There’s no time for that. Quick! Run… do something, NOW! What are you waiting for??? Slice it open, hollow it, deliver it like a caesarian—handfuls at a time. God, please let me throw it up.”
How a clinician addresses a client such as this, will be case-specific and vary according to the therapeutic relationship, client’s internal strengths and the therapist’s skill set. However, the first and most important rule of therapy is to “do no harm.” So, premature prying of a client’s well-cosseted defenses can result in the client’s precipitous flight from therapy. Early on in therapy it helpful to incorporate adjunct methods of self-expression since individuals who struggle with internal distress often view the world through the lens of an intense shame core, and that in turn fuels compensatory acts of self-violence and loathing. To offer a client an alternative method for cathartic expression other than a verbal recounting goes a long way toward building trust in the therapeutic connection and while extinguishing the client’s internal critic.
Counterintuitive as it may be, CPTSD clients will apply violent means to induce intrapsychic calm. And, as violent as the acts of self-mutilation may be, clients like “Anonymous” will likely adopt no lesser means to quiesce their internal tension with their ED behaviors such as uncontrollable bouts of purging by vomiting or laxative use.
Despite vulnerabilities for needles, wounds, and/or blood, therapists need be mindful of their client’s new or ongoing presence of cuts, punctures, tears or burns. So early on in the process it is advisable to take a physical inventory of self-mutilation (including the triggers that precipitated it) as evidenced by old and newer scars on the non-dominant arm( presumably, but not always, most acts against self are perpetrated by the dominant hand). By so doing, a therapist allows little to no room for previously unaccounted for SI or ED behavior. It is important for the therapist to not register broad facial reactions, since these clients are on high alert for the slightest hint of rejection or invalidation that might indeed confirm the client’s “truth” about their shame core as he or she has come to know it. Speak in matter-of-fact terms and discuss the events that led up to their need to self-harm or purge. A discussion about the underlying issues is more valuable than the fact that a client actually purged or self harmed at all.
So it is here, in our therapeutic relationships, that our clients may come to realize, perhaps for the first time, the potential for state change relief from their own negative internal experience. And, in the best of all outcomes, trait change relief, as well. But, in order to better address these issues, one must first understand how these compensatory behaviors came to exist and flourish in the first place.
Origins of Trauma Repetition
Repeated exposure to chronic adverse childhood experiences induces behavioral and physiologic changes. It is known that the developing brain under extreme inexorable distress will undergo changes in neurotransmitter activity. Children, particularly newborns and infants “who have been exposed to severe, prolonged environmental stress, will experience extraordinary increases in both catecholamine and endogenous opioid responses to subsequent stress.” 
We also know that a newborn’s attunement to the world is externally focused. The incoming stimuli is stored in and controlled by the lower segments of the developing brain such as the thalamus and the amygdala. The amygdala, considered to be a part of the limbic system, performs the crucial and fundamental role in the establishment of memories associated with emotional events. The system’s primary function is to maintain appropriate levels of arousal; too little stimuli and the neurons cannot register. If there is too much stimuli, the newborn’s sensory signals become overloaded, thus inducing system disorganization and temporary “collapse.”
In brief, a newborn’s caregiver must regulate arousal states until the infant’s developing system can self-regulate internal and external states of arousal. As a result of early uncontrolled arousal states, abused children tend to manifest a higher threshold of stimulation of the endogenous opioid system in order to self-soothe. This is in comparison to those whose early developmental experiences were met with consistent early nurturing.
Reframing a Diagnosis for a Working Therapeutic Narrative
It is at this point and often sooner that the clinician can confront and reframe a narrative for therapy. Further, it is incumbent upon the clinician to address what typically tends to be avoided at all costs; disclosure for a working diagnosis of CPTSD vs. BPD.
Arguably, there may be few providers among us who would contest this notion; the notion of withholding informative disclosure to a client. To do so would be counterintuitive to what therapy is all about and, being clinicians, we are in the priority position to educate, reframe, and offer insightful guidance to those who seek an understanding of self. Further to the point, therapeutic progress or stagnation is often set by a clinician’s inability or unwillingness to challenge or confront issues.
However, all too often the clinician hesitates to confront her/his own reluctance in working with the CPTSD label and, therefore, still tends to withhold divulging this working diagnosis. We perhaps fear wounding the very individual with whom it is shared, as the “news” might be received as a scarlet moniker that chars that individual’s identity ‘til death do they part’. On the whole, the therapeutic community still cowers in the naïve belief that truthful information can only be more harmful to the client and, therefore, do more harm than good to posit a label such as CPTSD.
While this complicity among therapists is not openly verbalized, there is silent acknowledgement in the belief that to be confrontational or challenging with truth is too difficult or harmful for the client. However, the clinician is presumably the very person with whom the client comes up against her or himself without judgment, prejudice, or hostility as s/he learns to experience and grow. The very essence of therapy is a modeling for an intimate relationship and indeed calls for the very courage that most clinicians are afraid to summon, but nonetheless ask for, in their client.
A new sculpt for a client’s healthier core-belief begins with the therapeutic alliance and sets the foundation for safe exploration and inner change out in the world.
When working directly with the cycle of victim and victimizer, openly addressing intrapsychic hostility will go a long way toward relieving the relational tension in the proverbial room. ED behaviors numb emotions and/or create euphoria to displace negative emotions. “There are expressive functions served by the self-harm cluster around several themes including: conflicts between the inner and outer self, good and evil, penance and rebirth, purity and filth, and shameful secrecy and rageful disclosure.” 
As the clinician whittles away at the shame to which the client is bound, psychic tension can be channeled away from self-harm and toward the grist for the therapeutic mill. From this one therapeutic platform alone, many clients will come to experience a level of emotional calm previously unknown. Upon this therapeutic foundation, a client has a better than certain outcome for change. A clinician’s work in addressing developmental deficits can only happen once that foundation is forged.
At the onset of therapy, progress may proceed in fits and starts. The role of therapist tends to take on the task of addressing earlier parental neglect and parental limit-setting. Within this dynamic, the therapist must have a willingness to tolerate appropriate “emotional pushback” that will ultimately assist the client in building trust and a sense of safety. The therapist can address these behaviors by being consistently supportive yet unyielding in boundaries and self-containment.
It is common in working with the CPTSD client that a therapist is greeted by lengthy email missives complete with details of the individual’s internal process post-session. Solid, clear boundaries need be set at the outset of therapy for two specific reasons. The first reason helps clarify what is and what is not acceptable behavior as defined by the therapist. The second reason (which lends credence to the first) is to process all emotions in the moment, during the session, and without an escape hatch via email, fax, text, or phone to manipulate therapist involvement. Outpatient therapy is exactly that; outpatient. All too frequently a therapist will find herself entangled in exchanges of fervid text messaging into the early evening in order to “lend” support.
It behooves the therapist to hold previously discussed boundaries that no doubt will be challenged, tested and retested anew by the client. Should the client be unable or unwilling to maintain self-care that results in a retaliatory act of self-harm, then a higher level of treatment might be necessary. At the very least, a therapeutic contract can be drawn between therapist and client.
In those cases, the therapist need reaffirm the boundaries and subsequent consequences that were previously established for therapeutic work in out-patient therapy. If and when it is appropriate, incorporate humor to communicate that only in an emergency (i.e., ‘morbidly stated’ the severing of a body part or any such incident from the list of established criteria) will a phone call be accepted.
Treatment of SI and EDs
Since the previously discussed biological and psychosocial risk factors are at the heart of developmental deficits in the CPTSD population, effective treatment must address brain change from dysregulation to regulation. In order to accomplish this change, the following domains must be addressed:
- Self-reflective information processing
- Traumatic experiences integration
- Relational engagement
- Positive affect enhancement
However, and of particular note, the clinician must “know thyself”; know one’s strengths and, more importantly, know one’s deficits. We need remain mindful of our counter-transference. It is not enough to just be able to tolerate emotional pushback in the session but to be willing to foster acceptance and positive regard for the wounded inner child, as well.
Early on in the bonding process, there may be a need for meeting the client where the client is with every episode of emotional bombing as a testing of the treatment waters. To not engage the defenses but to engage the wounded child will be the clinician’s true path toward client trust and therefore, potential change and success.
While we as clinicians may choose to address these domains in a therapeutically and orderly fashion the client may choose to process these domains similarly to how one processes grief and loss—in a not-so-linear cycle. Therefore, the clinician and client may visit and revisit these domains as is necessary.
When treating and integrating previous traumatic events, it is crucial to note that the client most likely will experience intensified self-negative emotions that may lead to an increase in ED behaviors and/or self-mutilation. And, as a result of addressing those ED/SI behaviors, the clinician need understand that clients are “abandoning” their long-held process of empowerment and means toward emotion regulation. In many cases, this dysfunctional behavior has been the only time-held reliable “friend” or course of action with which they have survived, and our asking our clients to abandon their defensive measures is akin to asking them to go to battle without armor and protection.
As a result of working with the trauma and by association, addressing the compensatory ED behavior, the client’s SI behavior may intensify. Conversely, when treating trauma and addressing the compensatory SI behavior, the client’s ED behavior may intensify. This see-saw effect is difficult to manage with simple Cognitive-Behavioral Therapy (CBT).
Along with medical and psychiatric support when necessary, experiential therapies such as Eye Movement and Desensitization (EMDR), Somatic Experiencing® (SE), and experiential grief/anger work are particularly effective modalities and most often a necessity for a client’s growth in regulation and modulation of their own internal affect states.
While there is no therapeutic value in igniting a client’s “all-too-ready-for-reaction” anger, there is great value in accessing, processing, and releasing old stored energy and emotions. These modalities will not inflate a client’s rage. Used appropriately, a client will experience channeled physical and physiological release and resultant intrapsychic calm.
When more comprehensive and contained care is necessary, residential or inpatient options can offer a secure and safe environment in which a client can explore and process trauma. Within peer process and adaptive therapy groups, clients learn self-regulation and containment. In addition behaviors previously held as long guarded secrets can become normalized which leads to a reduction or extinguishing of maladaptive coping skills.
If extreme self-regulating behavior was adopted as a means to survive what may have been extreme inexorable stress, it is by way of a consistent, albeit slowly, and healthy therapeutic relationship that our CPTSD population can find restorative calm and healing. The best of techniques and therapeutic modalities can deliver healing, but it will ultimately be within the context of a secure and trusted therapeutic dynamic that an individual will know and come to experience self-acceptance and growth.
Despite our best practices and skill set that we bring to the proverbial table, it is perhaps with our compassion, boundary-setting and acceptance that a client’s self-injury and ED behaviors become old and unnecessary acts of self-care and nurturing.
van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatric Clinics North Am 1989;12(2):389-411
van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatric Clinics North Am 1989;12(2):389-411
Sharon Klayman Farber, Self-Medication, Traumatic Reenactment, and Somatic Expression in Bulimic and Self-Mutilating, http://www.mhsanctuary.com/Borderline/artindex.html (November 2009).
4Richard J Moldawsky, review of The Psychological Trauma and the Developing Brain: Neurologically Based Interventions for Troubled Children, by Phyllis T Stien and Joshua C Kendall, http://xnet.kp.org/permanentejournal/fall04/trauma.html (November 2009)