Proceso histórico de formación

One of the factors that seem to influence a therapist‟s abilit y to mana ge difficult clients has to do wit h their training :

Inte rvie we r: Ok ay. So, it sounds as t hough your experience and your t raining has helped you t o be in t his posit ion where you f eel more comf ortable wit h them?

Participant4 : Ja,(yes,)I mean it doesn‟t really help in privat e pract ice though, you k now, because, lik e I had a lot of ex perience

73 wit h Schizophrenia and Bipolar. Ja(yes), it is not necessarily t hings

in priv at e pract ice you want t o do t herapy wit h you know, and running groups for Borderline is a lot nicer in a gov ernment hospital-t ype frame.

Ca mbanis (2012) stated that cha llenges regarding clients with BPD are often

ma gnified for trainee psycho logists. This is based primar ily, on the lack of experience in imp le ment ing treat ment plans as well as their still develop ing understanding of under lying personalit y dyna mics. However, as partic ipant 4 infor ms us, that hospital training and experience may be the best context for experience to be ga ined.

Experie nce gained at governme nt facilit ies aside, the participa nts shared intere sting observations about clie nts wit h BPD that they picked up through the ir interactions in hospital settings. These stereotypes are important to understand, as they ma y set the tone for the interaction between the therapist and clie nts wit h BPD.

Partic ipant 2 said:

I learned interesting stereotypes of Borderline that I didn‟t know before.… we work ed quite closely with one of these big psychiatric experts in t he forensic sett ing. She always said, „you spot a

Borderline long before you hav e spok en to t hem. They come with their nails paint ed green and t he hair is died blue and t hey hav e their high heels with their Lycra sk i pant s. You can spot t hem because t hey are f lashy‟.

Partic ipant 6 added that at the hospital, during ward rounds, they would : hear certain t hings such as att ent ion -seek ing behav iour,

mut ilation, saying, „I f eel empt y inside‟.„If you feel empt y inside‟, is one of m y quest ions that I always ask, „How do you f eel inside?‟ They almost always say, „I j ust f eel empty and dark ‟. When they say that and you can see mut ilat ion has been formed and you can see clot hes being inappropriat e, this boundary t hing .

Snowden and Kane (2003) states that clients wit h BPD being labelled as “attentio n seeking” or “time wasters”, may contrib ute to trainee psycholo gists developing

74 attitudes towards certain groups of clients. Specifica lly, Proctor (2010) indicate s that those who are diagnosed with BPD are often stigmat ised and margina lised and the result of this, is an impaired standard of care for the clie nt.

Partic ipant 1 said that, “the biggest st ereot ype is t he DSM”. This was quite an interesting state ment and as the conversation continued, partic ipant 1 clar ified :

the diagnosis f alls wit hin t hat context. In it self, for me, it is where the f irst challenge lies, because, obv iously, t he DSM w orks on a medical model, and… then the difficulty or the disorder is seen wit hin a medical model. It is seen as an illness which f or me is t he first difficulty of, it limits… If you see it in that context it limits the pot ent ial possibilit ies of what t o do wit h it .

Partic ipant 1 imp lies that not only are trainee psycho logists exposed to the

stereotypes of BPD held by other psycho logists and medica l professio nals, but that also, the diagnostic classification syste m ut ilised, see ms to keep the client in the role of client, perma nent ly. This in itse lf presents cha llenges as in many ways, the BPD diagnosis is a life long one and the imp licat ions for the therapist and client, is the establishme nt of a relat ionship that is lo ng- term. And, as per the sympto ms that define the disorder, the therapeut ic relat ions hip in itself will not be cons istent, but will rather shift and change.

However, as expla ined by Participant 6, “many of t he stereot ypes are correct” and that they are “based on those (crit eria), but I t hink many of t hose crit eria are actually correct ”. Firstly, patients with BPD are regularly stereotyped by health professionals and often assumed to be manipulative and attention-seeking (Brooke & Horn, 2010; Fallon, 2003). This is common amongst the BPD population and as such, these stereotypes carry consequences. As suggested by participant 6, many of the stereotypes are based on the criteria for diagnosis, that is, the defining behaviour that characterises the client with BPD. As such, the stereotypes are not „made up‟, but rather based on the experiences that other therapists and med ical practitio ners may ha ve had wit h such clients. It has been noted in the literature that many of the negative ideas regarding an individual with BPD are linked to the characteristics of the disorder itself (Aviram et al., 2006; Trelor, 2009). This may include the intense anger, chronic suicidal ideations, self- injury and suicide attempts

75 (Aviram et al., 2006). In addition, due to the fluctuations in the level of functioning, treatment for BPD is seen to be a slow process and this in itself may have contributed to the stereotypes that exist (McAllister et al., 2002; Perseius et al., 2007; Commons Treloar & Lewis, 2008).

Stereotypes ma y, in many ways, influence therapists‟ reactions to the ir clients, especially, if they are trainee psycholo gists. This is based on the trainees‟ lack of experience and the reliance on the experie nces of more seasoned practitio ners. However, participants of this study alluded to the fact that the stereotypes of clients wit h BPD are linked directly to the symptoms the y displa y. According to Commons Treloar and Lewis (2008) impulsivity, issues with abandonment, poor self- image, and feelings of emptiness are seen to contribute to self- harming behaviours as well as difficulties in treatment. These are symptoms that are typically associated with BPD. It is further noted that negative attitudes by the clinician toward the client as a result of the self- harming behaviour can have an adverse effect on therapy.

To this effect, all the participants of the study indicated that o ne of the most effect ive ways of ma naging diffic ult c lie nts wit h BPD is prior itis ing ma naging therapeut ic

boundaries as clie nts wit h BPD “are more intrusive” (Partic ipant 3). In light of boundaries emerging as a the me through all the interviews, as an effect ive strategy to ma nage clients with BPD, the sectio n belo w highlights what the participants vo iced.