Q. As a clinical social worker, I have had opportunities to work with clients diagnosed as BPD. Currently, I am working in a group home setting in which 4 of 5 clients are diagnosed as BPD. Generally, the treatment team and I have found that disengaging from interactions with our clients who are escalated or experiencing cognitive distortions facilitates the most successful outcome. However, I have a client who is ENRAGED when we disengage and it appears that her reaction is, in part, an abandonment issue and a sense of staff rejecting her anger/frustrations. I know, from my experience, that there are clients with BPD who do not benefit from disengaging. I have found that I can work with her when she is angry and support her as she finds productive ways to calm herself.

However, as I make efforts to train the staff with whom I work, there is resistance, frustration, and a sense that this client is receiving "special treatment". Any suggestions for how I can convey to the staff the purpose behind the alternative treatment of this client, and, perhaps you have suggestions for what I can teach the staff to help them remain calm, cool-headed, and disconnected from this client's rage?

  A. Borderlines act like they are supposed to act based on their chemistry. Perhaps they are even hard-wired differently. In any case, if they could change their behaviors they would. One would hope staff can change and realize that any single form of therapy is not like flip-flops where one size fits all (which it does not). Different people need different things, and some need different types of therapy. The inability to change by staff shows counter-transference issues on their part, which are detrimental to patient care. I would tell the staff this flat out, and have them think about it for a while, and then talk it over. Flexibility is needed, and you are really not asking for a lot of change.