Episode 11: Working With Clients Who Have Borderline Style Personality with Tamra Sattler

Kayla: Welcome back to Your Clinical Supervisor’s Couch Podcast, and I’m your host, Kayla Das.

Whether you’re a new or seasoned therapist, sometimes working with different types of clients can feel intimidating, especially if it’s a new area of practice for you that you’ve had little previous experience.

In today’s episode, Dr. Tamra Sattler, Marriage and Family Therapist and Clinical Supervisor, shares strategies for how to work with clients who have borderline style personality specifically.

Hi, Tamra. Welcome to the show. I’m so glad to have you here today.

Tamra: Kayla, thank you so much for having me on.

Kayla: Tamra, before we dive into today’s episode, please introduce yourself and tell us a little bit about you, your practice and clinical supervision journey.

Tamra: As you said, my name, Dr. Tamra Sattler. So, I had a pretty successful career in Silicon Valley. And then with a bunch of kind of personal stuff that was happening, I went back and got my master’s, and then my PhD in East-West psychology. And became a therapist in 2003, as an intern therapist. And then got my license in 2008, completed my PhD in 2010.

So since then, I have specialized in borderline personality disorder, and the full range of borderline personality disorder, which includes borderline characteristics, type 4 Enneagram, the drama queen. So, yeah, that’s been for about the past 20 years, and I’ve had a real passion for it.

I wrote a book, I did a documentary, and yeah, so I’m here to help therapists put their toe in the waters and give them support and confidence to work with this very specialized population.

Kayla: So, for the purpose of this conversation, what is borderline style personality? And how does it differ from a diagnosis of borderline personality disorder?

Tamra: So, the diagnosis borderline person disorder, which is a pretty heavy diagnosis to get. Most therapists won’t go near that because of the client’s feelings about it. But basically, what that means in the Diagnostical Statistical Manual, the DSM is seven characteristics out of nine. Everyone can look that up.

It’s basically volatility and relationship, self-harm, self-sabotage. All of those kinds of instability and self-psychosis and neurosis. So that would be a very serious diagnosis. Last I checked, 10 percent of the U. S. population had this particular diagnosis. They end up in psych wards. They end up committing suicide. They raise heck for their family and for loved ones and for themselves. Very, very serious and on the rise from all our baby boomer parents. And just not being met in the sensitivity of these folks.

And then borderline style, I included that to have the full range. So even if you’re not super identified with the seven out of nine characteristics, maybe you have two or maybe four, and it’s not a cakewalk to be this kind of person. And they get really alienated and judged. And, which we’ll probably talk about a little bit, there is countertransference for the therapist and the loved ones, which is not fun.

Kayla: So how does countertransference show up? Let’s dive into that a little bit.  

Tamra: So as a therapist, so a lot of the original psychoanalytic, psychodynamic textbooks talk about it, there’s a few different ways it shows up. So, as you’re sitting with the borderline, let’s just say style, just an element of that, they have a watchful eye on you like almost like a third eye of like, does she like me? Is she judging me? Is she going to abandon me? Who is this woman? Therapist, me.

And basically, what happens, there’s kind of an alchemical exchange after working with someone. So, they’re transferring to me all of their abandonment, rage, anger, sadness, all of it. And sometimes what comes across, in Jungian terms is almost like an evil entity, like a very, very dark entity that if I haven’t worked with that before, as a therapist, I won’t ever want that energy back in me.

But because I have familiarity because I can hold it because I know it’s not me because I’m sitting in front of a human who really just wants love like the rest of us. I can work it through. So, it’s very, very, very serious. And if you have your own rage left unmet inside of you, get ready to feel it and get ready to feel collective rage too.

Kayla: I know you mentioned earlier in the episode that sometimes therapists avoid working with individuals who have borderline style personality. Can you tell us from just your experience why that might be?

Tamra: Yeah, I mean, it’s so sad. So, when I was in San Francisco, I was kind of the only one to work with these clients. And then now in Boulder, I’m pretty much the only one. So, I don’t even have people to refer to. So basically, most humans and therapists cannot deal with someone having suicide ideation, having suicide threats in the middle of the night, doing self-harm, cutting, dramatic episodes of all kinds of destruction and harm.

And so, the therapist nervous system can’t handle it. And therefore, they will just pass because we can take whomever we want. It’s a real missed population and psychiatrists will try to give them various medications, but because this is a personality disorder and a split. There is only medication for the symptoms, nothing to repair the actual personality. So those are some of the reasons.

And as a matter of fact, just a little aside, I was grieved, which means someone went after my license. I was sued. So, I actually, Minimize my intake of borderline personality disorder. And yet I still have a passion for these clients. Every time they come in, my heart opens up the size of the sun. And I get so much out of working. So, I’m back to taking maybe a quarter of my caseload.

Kayla: Well, first of all, I’m glad to hear that you’re back doing the things that you love. And I think that that is one of the fears that show up for therapists is, and this is regardless of the type of population that we work with is, what if my license is on the line? What if I get sued? And unfortunately, when we have more complex clients, the risk increases.

Tamra:  Right now, the number one and two from last I heard, grieved diagnoses are, let’s see, child custody and BPD, borderline personality disorder. So, if you are working with those two things, make sure you have malpractice insurance, because my insurance paid for everything. It went up to, I think, about $5,000 to $10,000. I don’t even know how much it was in the end. And also, yeah, make sure you know what your state licensing is all about.

And also, have a lawyer on hand that other therapists may see in your state so that you can go over your informed consent. So that your container, your ethics, your legalities, because it is no joke.

Kayla: When therapists are working with clients who have borderline style personality, are there specific considerations to keep in mind, specifically for new therapists, potentially just coming out of university or just receiving licensure or registration?

Tamra: Great, great question, Kayla. So much to consider. First of all, definitely have a supervisor that specializes, well, not a lot of people are going to specialize in this particular, just have a really good supervisor so you can bring your cases because, again, there’s a lot of countertransference.

I was told way back when by a psychodynamic supervisor, two years as good mother, according to Winnicott, a theorist, and then start introducing the bad mother. So, for about two years, which thankfully is easy for me. I validate, I cheerlead, I receive, I attune, I allow everything to unfold. And this is really what they did not have by any stretch. They usually had an unemotional mother, sexual abuse, trauma, CPTSD. So that guides me and number two that I’ve told my past supervisees and this is a little morbid You may have to go through someone taking their own life and that is just the reality of working with these clients. Thus far I’ve had plenty of hospitalizations and so far. No one has taken their life in our work. I was lucky.

Lots of self-care for yourself before and after session. They can be pretty feisty, so, expect getting your hands slapped, expect getting criticized. Accept your own imperfection. But basically, keep in mind that for any of us that hasn’t had a lot of love in this culture or from our parents. Just fricking love them. Deepen into your own self love and love them. They don’t need any more judgment. They don’t need any more criticism. Just love them.

And probably the most critical thing is boundaries. So, boundaries in the container. And that’s really where I lean to my container. At the end of 50 minutes, they’ll always have a doorknob something. Can you help me with this? Nope. Next session. I definitely can. Let’s not forget about that. Boundaries and phone calls. 10 minutes. I will hang up on them at minute 11.

Protocol with suicide calls or crisis calls. I have 24 hours to return your call. Otherwise, call a crisis center or go to ER. Boundaries. Boundaries. Boundaries. Probably less boundaries in myself in the space because I want my energy and love to come through. But all kinds of boundaries around the container, our office setting, and all the protocol. And make sure you have them sign something at the beginning.

Kayla: When we think of boundaries specifically, because I have worked previously with individuals with borderline style personality, and I know that the boundaries are very important. I know you mentioned phone calls, like having those conversations and those boundaries around the phone calls.

I know for some therapists, especially new therapists coming out of university, may have difficulty just hanging up on a client. Do you have any advice or insights or even personal stories that could be helpful in showing how creating these boundaries not only support the therapist and their emotional health, but also the client and their progress.

Tamra: Yeah. So, when someone does not have clear boundaries from child through adolescent, adult, they will do what they can to get loved. So, this is for the client and for the therapist. So, when I first started working with these folks and they started coming to me, I didn’t even know who they were. Didn’t even know the diagnosis.

And as most of us are as therapists, this caretaking, loving, wanting to help self. I was overridden by excessive phone calls. They are creative enough and sometimes manipulative enough to get what they want, so you are helping them and yourself by having it really, really solid. They need to learn this. It’s all about healing. So hopefully that answers it to some degree.

Kayla: It does. Cause I think, as individuals in the helping profession we really want to help our clients and sometimes, creating specific boundaries can be challenging for our own selves because we want to be there. We want to support. But I love that you highlighted that by creating these very strict boundaries is in the benefit of the client.

Tamra: Absolutely. Absolutely. Otherwise, you might as well hand over your life because you will get calls, emails, texts around the clock. And for new platforms that allow texting, good luck with this type of client. I think you have to have protocols. or whoever works with them will be overridden. And that’s not helpful to anyone.

Kayla: As we’ve mentioned, some new and even seasoned therapists avoid working with clients who have borderline style personality, sometimes due to lack of confidence or skills in a specific practice area. Do you have any additional advice, insights, or tips for listeners who may want to build their confidence and skills when working with clients who have borderline style personality?

Tamra: Yeah, so, Marsha Linehan, who apparently said that she had borderline personality disorder herself. She offers a lot of trainings for DBT, which is a group-based module, for BPD. Then also, like I said clinical supervisors, if they do have expertise in this perfect. Other ways, great self-rituals, working with all of your own stuff is always helpful with your own seasoned therapist.

If you can pull together a peer consultation group, always helpful as well. And then the books out there, and podcasts like yours, and others. I think I’ve done maybe nine podcasts this year already talking about this particular cluster of disorder. So, wherever you can Walking on Eggshells is definitely a big book that a lot of people read. Hey, I love you. You don’t leave me. So, there’s a lot of theorists and authors. I wrote a book called Too Much and Not Enough: Healing the Borderline Style and Type Four. So, hands on theoretical, kind of all those.

Kayla: I love that. So, tell us a little bit about your book and how it can help listeners and their clients.

Tamra: Yeah, so it was really something that I wrote as a companion guide during COVID, so it kind of came out of me as just a must for this type of population. So, it was both a theoretical, so I include a lot of theory, A memoir, because I’m a type 4, which is the cluster of BPD, from healthiest to unhealthiest.

Also, a narrative, because since I’ve worked with this population for 20 years, a lot of narrative stories to give you a true feel of what it’s like. And, yeah, so far, and I got published by a publisher in England. But so far three of my clients got a hold of my book without me telling them since it was a little memoir. I didn’t really want to advertise it. And, I’ll just quote one of my longest client said, “Wow, I now feel understood.” Number two, “I have hope for myself in the future.”

And, so that was really all I needed to say thank goodness I wrote this book. And, yeah. And I’m pleased to see what the numbers will look like for the end of this year. So, we’ll see.

Kayla: Wow. It sounds like a great book, and I encourage any listener to check it out.

So, to check out Tamra’s book, Too Much and Not Enough, check out canadianclinicalsupervision.ca/tamrasattlerbook.

Or, you can also connect with Tamra at her website tamrasattler.net.

Or you can simply scroll down to the show notes and click on the link.

Tamra, thank you so much for joining us on the podcast today to discuss how to work with clients who have borderline style personality.

Thank you so much, Kayla. Really appreciate it.

Thank you everyone for tuning into today’s episode and I hope you join me again soon on Your Clinical Supervisor’s Couch Podcast.

Until next time, bye for now.