It's no secret that therapists who work with patients who have borderline personality disorder (BPD) experience stress, but despite this there is very little written about therapist stress reduction. While some psychotherapy models explicitly address the high level of stress inherent in treating individuals with BPD, others do not address these issues.
Therapist Stress Reduction - Why It's Critical If You Work with a BPD Population
Therapists who work with individuals who engage in high-risk behaviors, such as deliberate self-harm or suicide attempts, consistently report a high level of occupational stress. These behaviors are very common in individuals with BPD; people with BPD have some of the highest rates of deliberate self-harm and suicidality among psychiatric populations.
This high level of stress can affect a therapist in a variety of ways. It may impact the quality of the therapy you are providing -- a therapist under a a high degree of stress is unlikely to be able to attend to the session, maintain an empathic stance, or develop a strong alliance with a client as well as a therapist who is not stressed out.
This stress may also affect you outside of the therapy room: worrying about high-risk clients, ruminating about difficult sessions, or managing between-session contact from patients may interfere with all aspects of your life outside of work.
There may even be physiological affects of managing challenging clients. A recent study demonstrated that even well-trained therapists exhibited elevated alpha-amylase and cortisol levels (two physiological markers of stress) in anticipation of sessions with recently suicidal clients with borderline characteristics.
Some Ways To Reduce Therapist Stress - the DBT Model
Even if you do not provide dialectical behavior therapy (DBT), this treatment model suggests some practices that may help combat therapist stress and burnout.
Work As Part of a Team
If you work with clients who have BPD, it is critical to work as part of a team. If you are not in a setting that already provides an interdisciplinary team environment, you may need to create the team by fostering communication between existing treatment-givers or by building additional treatment outlets into your client's treatment plan. Psychologists, psychiatrists, social workers, substance abuse counselors, nutritionists, and a variety of other professionals may be appropriate team members depending on your client's needs.
Once there is a team in place, make sure that everyone on the team is communicating frequently (and if possible, in person). Establish regular meeting times to facilitate communication.
In addition, should make sure that you do not treat BPD patients in isolation; consider ways to build diversity in your practice population. This may require sometimes referring patients with BPD if your caseload already includes a large number of BPD patients.
Set Limits, Make Them Explicit, and Make Them Firm
It is very important that as a BPD therapist you are able to set limits. These will be personal -- all therapists will have different practices that they are comfortable with. The key is that you need to decide what your limits are and then be able to communicate those limits clearly.
This is not to say that you need to set limits with BPD clients that are stricter than with other clients. Some professionals will recommend this, but the DBT model allows for more flexibility with BPD clients because they will often need your help outside of therapy sessions. For example, DBT provides the opportunity for phone coaching with BPD clients. However, the DBT model also proposes that if a client is using phone coaching too often or inappropriately, you need to communicate this to them explicitly.
Consult With Colleagues
All DBT therapists are part of a consultation team that meets weekly to discuss issues that come up with clients. This aspect of the DBT model is a reflection of the fact that it is not good practice to work with clients with BPD on your own -- you will need support and consultation with colleagues. Even if you are not doing DBT, you can build a consultation network for yourself, just don't forget to actually use it.
Other Ways to Reduce Therapist Stress
A growing literature on therapist stress and burn-out suggests that a key to reduce stress is by living a balanced life. This is advice that we give to our clients all the time, but we sometimes fail to practice what we preach.
Living a balanced life means making room for all of the activities and behaviors that nourish and sustain you. For example, a recent study of work satisfaction in psychologists revealed that the following behaviors were rated by therapists most helpful in improving therapist functioning:
- Spend time with your partner/family
- Maintain balance between personal and professional lives
- Maintain a sense of humor
- Maintain self-awareness
In this same study, some additional strategies predicted greater satisfaction among psychologists, including the need to vary work responsibilities. This is probably a wise consideration for anyone working with high-risk clients -- making sure you are seeing a variety of clients with a range of problem behaviors and problem severity may be critical to good performance.
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