The Challenge of Treating (and Supervising) Patients with Borderline Pathology in a Residents' Clinic

Outpatients with borderline personality disorder (BPD) comprise up to 20% of psychiatry clinics, to which they are usually referred for treatment, not of their Axis II pathology but for comorbid Axis I conditions. The complex and intense transference and countertransference dynamics that patients with even “secondary” BPD evoke in psychotherapy treatments require careful handling and supervision. Cases can quickly lose focus, with resultant morbidity for both patient and treater alike. Little literature exists to guide supervision of psychiatry trainees treating outpatients with BPD and Axis I illness. We describe a case of a young woman with BPD with a comorbid major depressive episode (MDE) who was treated by a third-year psychiatry resident with a mixture of supportive and dynamic psychotherapy and medication management. The treatment rapidly became chaotic, with escalating levels of patient acting out and resident dissatisfaction. We outline suggestions for supervision of resident treatment of patients with comorbid or primary BPD, including importance of careful intake assessment and treatment formulation, the establishment of a clear-cut frame and/or treatment contract, and the need for contextualizing expectable transference and countertransference reactions. Last, we discuss the pros and cons of mixing psychotherapy techniques within the same treatment.