What you see is not what you get: multiple states and dialogues in borderline presentations

Abstract

The recently revised NICE guidelines on treatment and management of borderline personality disorder (BPD) (NICE, 2018) presents new evidence on psychological therapies being effective treatments for patients diagnosed with BPD. This article will describe some of the challenges we face as clinicians working with complex co-morbid presentations in a healthcare setting. It will briefly discuss the different modalities as suggested by NICE guidelines and expand on the implications of this guidance in relation to service development and constant restructuring, often acted out as an organisational procedure to avoid the harsh reality of limited resources within the NHS. The impact of this on patient care, organisational dynamics, the need for joined-up thinking, and contextual formulations will be discussed using case scenarios. Clinical examples will be used to highlight that pseudo hallucinations, core thoughts, self-to-self dialogues, which trigger "state shifts", can be understood and formulated using dialogic sequence analysis (Leiman, 1998) and concepts from cognitive analytic therapy (CAT). This article will offer some pointers as to how we as clinicians can build resilience, survive the powerful projections and countertransference reactions, recognise the importance of self-care, supervision, and personal therapy in order to be effective, minimise harm, and develop compassion for our patients.