Q. I am a therapist working with a very intelligent, motivated and gifted client whom I believe has borderline "traits"...I have been working with her for about a year and has made some small, but very significant steps in treatment, especially regarding trust and tolerance for frustration cognitive development. I would not diagnose her a borderline: She has never made a suicide attempt, has a history of treatment compliance with her treaters and is able to tolerate some frustration when she perceives the "rejection" of others...However, she can be extremely demanding of others, needy, extreme difficulty trusting others and can sabotage her own treatment by "withdrawing" when extremely stressed and in crisis...She does have rage periods but also some healthy narcissism and appropriate entitlement regarding her self care....Her current diagnosis is PTSD and major depression...She has had chronic suicidal ideation but does reach out when in crisis...She has formed relationships well with her past therapists, if somewhat intense and demanding at times...Her intelligence, introvert personality, sense of humor and ability to put people initially at ease usually win people over quickly....Like many borderlines, it is the long term relationships she has the most difficulty with....Her father was a WWII veteran who abused her physically, emotionally and probably sexually....She has had 21 years of therapy and has worked very hard at overcoming her emotional difficulties, including a complete sobriety from alcohol for the past five years.....Any ideas/suggestions/resources on treating those with borderline traits/mild borderline personality disorder?...She doesn't "fit" the typical description of a borderline in many ways.

She is already on three antidepressants: Zoloft 150 mg, Neurontin 1300 mg, and Serzone, 600 mg....her Neurontin was increased recently to the 1300 mg.

  A. My forte is not therapy, but I will give you a few suggestions that may help. Keep in mind these are only suggestions.

First, borderline personality exists along a spectrum, just like all other biological diseases. Some have a little, some a lot. She may not be typical, but if she fulfills enough of the diagnostic criteria in DSM, it is what she has, along with PTSD and Depression. The chance of getting anyone completely better with any medical illness, besides infections, is virtually zero. You try to get them functioning as best as possible. Diabetics, heart attack victims, strokes, asthma, hypertension, and so on are all chronic diseases that result in a level of functioning that is less than not having the illness. Disease imposes restrictions in both level of function and recovery.

That said, she will likely never be totally well. As her therapist, you have to decide, with her input, where she wants to get to, and how to get her there. Since folks with BPD think differently than folks without BPD, you must frame the therapy in a way she can utilize it. Borderlines are logical. They wear coats in the winter, eat when hungry, like to drive nice cars, live in nice houses, do not urinate in their pants, and thousands of other things just like everyone else. In short, they learn to change things that make them uncomfortable in all other aspects of their lives. They understand that being naked outside in the winter is bad when it is 20 degrees, so they wear clothes. Your patient hates rejection, but is not learning from it. It is out of context with the rest of her life (she is successful overall as you suggest). She doesn't "get it" on the particular point of rejection. Therefore, as opposed to explaining the point as you understand it in your words, you have to present a very black and white descriptive method of change that she can understand as a borderline. Since borderlines tend to have black-white thinking, keep your descriptions black and white (for example) since it is how they think. Success is a varied thing. Not all athletes go to the Olympics. Help her get into a good as shape as you can, based on what she is capable of doing, not necessarily what you think she should strive for. Good luck