WITNESSES OF THE WOUNDED SOUL: A PILOT EXPLORATORY MIXED-METHOD

STUDY ABOUT THERAPISTS’ EXPERIENCES WORKING WITH INDIVIDUALS

DIAGNOSED WITH BORDERLINE PERSONALITY DISORDER

by

Kaelyn Claire Langer

A dissertation submitted

in partial fulfillment of the requirements

for the degree of Doctor of Philosophy

in Clinical Psychology.

Sofia University/formerly Institute of Transpersonal Psychology

Palo Alto, California

April 5, 2013

I certify that I have read and approved the content and presentation of this dissertation:

________________________________________________ _________________
Ron Pilato, Psy.D., Committee Chairperson Date

________________________________________________ _________________
Jan Fisher, Ph.D., Committee Member Date

________________________________________________ _________________
Philip Friedman, Ph.D., Committee Member Date
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ii
 Abstract

Witnesses of the Wounded Soul: A Pilot Exploratory Mixed-Method Study About

Therapists’ Experiences Working With Individuals Diagnosed With Borderline Personality

Disorder

by

Kaelyn Claire Langer

This study explored therapists’ experiences working with individuals diagnosed with borderline

personality disorder (BPD). Further, it hypothesized that clinician spirituality might positively

influence their experience of working with this clinical population. An embedded mixed-

methods design was used in this pilot study. Participants were licensed clinicians currently

working with at least two clients diagnosed with borderline personality disorder. Participants

completed a semistructured interview, which was analyzed using thematic analysis, and were

administered two quantitative scales, the Spiritual Orientation Inventory (SOI) and the

Assessment of Spirituality and Religious Sentiments (ASPIRES). Quantitative data were

analyzed through SPSS (Version 17) for descriptions and correlations, and were used to support

themes that emerged from the qualitative semistructured interview analysis. Thematic analysis

resulted in twelve main themes specific to therapists’ experiences of working with individuals

diagnosed with borderline personality disorder. Specifically, therapists experienced this work as

challenging, rewarding, and providing a sense of meaning to their lives. Quantitative analysis

suggested that therapists sampled in this study were more spiritual as compared with normative

sample scores. Embedded mixed-methods analysis did not provide a significant correlation

between therapists’ experiences and their spirituality. Implications of this study include

validating and valuing therapists’ experiences in their work with this clinical population. Further,

iii
this research provided evidence that therapists found personal practices such as meditation,

mindfulness, and prayer to be supportive of their experiences working with individuals

diagnosed with borderline personality disorder.

iv
 Acknowledgments

I wish to acknowledge the many people who provided support, guidance, and

encouragement throughout this process. Thank you to my chair, Ron Pilato, for your dedication

and commitment to this project. Thank you to my committee members, Jan Fisher and Philip

Friedman, for your thoughtful and insightful contributions. Thank you, Renee Snow, for your

gracious time spent in support of my quantitative analysis. I wish to thank my clinical

supervisors at the University of Washington, Tacoma, Drs. Carter, Cook, and Kitaoka, for their

reassurance and humor, and Susan Bland and Nicole Trabold for their support in participant

recruitment. Thank you to my participants, who gave their time and their stories to this vision

and to my family for their patience and trust. Finally, it is with humble gratitude that I honor

Charlotte Whitaker Lewis, who guided me in the early phases of this process and whose presence

I have felt every step of the way.

v
 Dedication

In dedication to the grounding force in my life, Anthony, thank you for the pancakes.

vi
 Epigram

“How vain it is to sit down to write when you have not stood up to live.”

- Thoreau

vii
 Table of Contents

Abstract .......................................................................................................................................... iii

Acknowledgments............................................................................................................................v

Dedication ...................................................................................................................................... vi

Epigram ......................................................................................................................................... vii

List of Tables ................................................................................................................................. xi

Chapter 1: Introduction ....................................................................................................................1

Chapter 2: Literature Review ...........................................................................................................7

Introduction to a Diagnosis: Borderline Personality Disorder .............................................7

Key Symptomatology ..............................................................................................9

Stigma ....................................................................................................................27

Theoretical treatment model: Dialectical Behavior Therapy (DBT) .....................32

Spirituality and Well-Being ...............................................................................................35

Role of Spirituality and Religion in the Life of the Therapist ...........................................41

Summary of Literature Review ..........................................................................................46

Current Study .....................................................................................................................46

Chapter 3: Method .........................................................................................................................48

Participants .........................................................................................................................50

Recruitment ........................................................................................................................51

Instrumentation ..................................................................................................................52

Semistructured Interview .......................................................................................52

Spiritual Orientation Inventory ..............................................................................53

Assessment of Spirituality and Religious Sentiments Scale ..................................57

viii
 Procedure ...........................................................................................................................62

Treatment of Data ..............................................................................................................64

Chapter 4: Results ..........................................................................................................................67

Description of Sample........................................................................................................67

Qualitative Results .............................................................................................................69

Quantitative Results .........................................................................................................102

Mixed-Methods Results ...................................................................................................108

Chapter 5: Discussion ..................................................................................................................110

Discussion of Salient Themes ..........................................................................................110

Original Findings in This Study.......................................................................................115

Relationship Between Therapists’ Experience and Therapists’’ Spirituality ..................116

Limitations and Delimitations..........................................................................................119

Implications for Future Research .....................................................................................121

Clinical Implications ........................................................................................................123

Conclusion .......................................................................................................................124

References ....................................................................................................................................126

Appendix A: Spiritual Orientation Inventory (SOI) ....................................................................140

Appendix B: Assessment of Spirituality and Religious Sentiments (ASPIRES) ........................148

Appendix C: Demographic Information ......................................................................................152

Appendix D: Recruitment Flyer...................................................................................................155

Appendix E: Informed Participant Consent Form .......................................................................156

Appendix F: Semi-Structured Interview Script ...........................................................................158

Appendix G: Personal and Anecdotal Evidence ..........................................................................161

ix
Appendix H: Transcriber and/or Coder confidentiality Form .....................................................162

Appendix I: Second Coder’s Qualitative Analysis for Inter-Rater Reliability ............................163

Appendix J: Third Coder’s Qualitative Analysis for Inter-Rater Reliability...............................166

Appendix K: Phone Screen ..........................................................................................................179

x
 List of Tables

Table Page

1 Participant Demographic Information ................................................................ 68

2 Main Themes from Qualitative Thematic Analysis ............................................. 70

3 Quantified Data from Qualitative Thematic Analysis ......................................... 99

4 ASPIRES Normative Sample Versus Current Study Sample ............................ 103

5 Correlations Between SOI Total Score and Subscale Scores ............................ 103

6 Significant Correlations Between ASPIRES and SOI Measures ....................... 104

7 Significant Correlations between ASPIRES (26-45 years old) and SOI

Measures ............................................................................................................ 106

8 Significant Correlations between ASPIRES (46-94 years old) and SOI

Measures ............................................................................................................ 107

9 Quantified Qualified Data .................................................................................. 108

10 Correlations between Quantitative and Quantified Themes .............................. 109

xi
 1

Chapter 1: Introduction

This chapter provides an overview of the current study; specifically, it will briefly

explore and define the clinical diagnosis of borderline personality disorder and its prevalence

within the mental health community and in the general community at large. Further, it will aim to

introduce the current trends in literature specific to symptomatology, diagnosis, and treatment.

Secondary to this aim is the introduction of challenges clinicians might face when working with

individuals diagnosed with borderline personality disorder and ways in which these challenges

might be managed, specifically through spirituality. A brief contextualization of spirituality will

be introduced and connected to personal well-being. Finally, this chapter will introduce the main

research questions and hypothesis of the study. It is the intention of this research to better

understand therapists’ experience of working with individuals diagnosed with borderline

personality disorder and, specifically, whether these experiences are influenced by the therapists’

spirituality and/or religious beliefs.

Borderline personality disorder (BPD) is characterized as a “pervasive pattern of

instability of interpersonal relationships, self-image, and affects, and marked impulsivity that

begins in early adulthood and is present in a variety of contexts” (Diagnostic and Statistical

Manual of Mental Disorders [4th ed. text rev.; DSM-IV-TR]; American Psychiatric Association,

2000, p. 706). According to Zanarini (2009), individuals diagnosed with BPD make up 2-6% of

American adults. However, even with psychiatric interventions, a large percentage will return for

treatment and frequently require more mental health services than do those with other psychiatric

disorders (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). Given the likely recidivism of this

population, individuals diagnosed with BPD still receive relatively little treatment and fewer

rehabilitation options in comparison to those with other mental health diagnoses (i.e.,
 2

schizophrenia and bipolar disorder; Gunderson, 2009). Currently, funding for research on

borderline personality disorder is only about $6 million annually (Gunderson, 2009), while

individuals with a diagnosis of BPD generally make up 10% of psychiatric outpatient and 20%

of inpatient programs (Lieb et al., 2004), indicating that this amount reflects limited funding for

necessary services and treatment.

Current literature on borderline personality disorder maintains a focus on exploring

specific diagnostic criteria, including emotional dysregulation (Tragesser, Solhan, Schwartz-

Mette, & Trull, 2007), intense and unstable interpersonal relationships (Berdahl, 2010), suicide

ideation and self-harm (Brown, Comtois, & Linehan, 2002; Hunt, 2007; Miller et al., 2010;

Alston & Robinson, 1992), and aggressive behaviors (Lâtalová & Prasko, 2010), with minimal

focus on how therapists might experience these diagnostic symptoms in treatment.

In addition to diagnostic criteria, empirical research has primarily focused on the efficacy

of manualized treatment options for individuals diagnosed with BPD, specifically, Dialectical

Behavior Therapy (DBT; Linehan, 1993). DBT combines standard Cognitive Behavior Therapy

techniques with core mindfulness skills to support emotional regulation, distress tolerance, and

interpersonal effectiveness.

According to Fallon (2003), intense emotional instability, a key symptom of borderline

personality disorder, can create difficult therapeutic experiences, not only for the client but also

for the therapist. Aviram, Brodsky, and Stanley (2006) argued that individuals with high

emotional instability often become the totality of their problems, leaving the therapist unable to

regard these clients as neutral, and instigating in therapists a tendency to condemn the clients for

their behaviors. Further, therapists are likely to experience negative emotions due to the
 3

perceived volatile nature of this population and, because of this, “avoid – or actively dislike –

borderline patients” (Gunderson, 2009, p. 535).

According to Koekkoek, van Meijel, Schene, and Hutschemaekers (2009), professionals

working in community mental health experience this population as unstable in their attachment

styles and often feel demoralized in their capacity to work effectively with these clients. Further,

therapists might feel overwhelmed and triggered by their clients’ intense feelings, making a

healthy therapeutic relationship difficult to establish (Aviram et al., 2006). Research has shown

not only that therapists might experience difficulties working with this population but that

challenges show up in clients’ personal and intimate relationships, as well (Bouchard, Sabourin,

Lussier, & Villeneuve, 2009). Research has established that caregivers and family members of

individuals diagnosed with BPD were more often likely to experience depression, hostility, and

anxiety in their own lives (Scheirs & Bok, 2007).

It has been argued that the interpersonal, therapeutic relationship created by therapist and

client is essential for healing and can be an effective modeling tool for individuals diagnosed

with borderline personality disorder (Eskedal, 1998). These clients especially need individuals

who will model, and with whom they can learn to identify, healthy interpersonal skills. However,

if caregivers feel challenged, discouraged, and triggered while working with this population, as

has been recognized in the literature, what types of behaviors are modeled consciously or

unconsciously in treatment? As was discussed above, literature and research have only vaguely

explored therapists’ experiences of working with individuals diagnosed with BPD, focusing

rather on symptoms and therapy-interfering behaviors. Therefore, further exploration is needed

when it comes to understanding the experiences of therapists working with this population.
 4

One way of exploring therapists’ experiences further is through the lens of therapists’

spirituality. Research has explored the role spirituality plays in the lives of mental health

clinicians (Bilgrave & Deluty, 1998; Shafranske & Malony, 1990; Smith & Orlinsky, 2004;

Walker, Gorsuch, & Tan, 2004) but has yet to explore this relationship specifically with

clinicians who work with individuals diagnosed with BPD. Current research has, however,

explored the relationship between spirituality and physical and emotional well-being. Tuck,

Alleyne, and Thinganjana (2006) found that adults who believe in a higher power (e.g., have a

relationship with God or Spirit) are better able to form a foundation of psychological well-being

and create healthy lives.

It is assumed, for the purpose of this research, that the connection between individual

well-being and spirituality found in the Tuck et al. 2006 study would translate into increased

therapist well-being as it pertains to their personal spiritual belief system. If, under this

assumption, individuals who believe in a higher power were better able to form a foundation of

psychological well-being, might it be true that therapists who are grounded in some form of

spiritual belief system or practice would be better equipped to manage their own psychological

well-being, specifically when working with a challenging clinical population such as borderline

personality disorder? Given this question’s relevance to therapists working with BPD clients, the

central research questions for this dissertation are as follows: What are therapists’ experiences of

working with individuals diagnosed with borderline personality disorder? Further, how might

spirituality affect their experience of working with these individuals? It is hypothesized that

therapists who score higher on spirituality measures will describe more positive experiences in

their work with clients diagnosed with BPD than will those with lower scores. For the purposes

of this research, the term therapists will include licensed psychologists (Ph.D./Psy.D), licensed
 5

marriage and family therapists (LMFT), licensed clinical social workers (LCSW), licensed

masters in social work (LMSW), and licensed mental health counselors (LMHC).

Debate over an encapsulating definition of the term spirituality has created some

challenges in creating a succinct meaning for the term in the field of transpersonal psychology

(Nelson, 2009; Plante, 2008). In describing five therapeutic relationships, Antoniou and Blom

(2006) defined the transpersonal relationship as one in which the therapist focused on a

connection with the client through an expansion and creation of consciousness beyond ego

boundaries and limitations. In this relationship, the therapist is then capable of experiencing

clients as more than just their personality or behavior, but rather as an integration of all parts, a

constitution greater than the self. Further, spirituality has been described as having the capability

of connecting individuals to a larger reality and the ability to integrate human experiences as

sacred (Nelson, 2009).

This study will explore therapists’ experiences of working with individuals diagnosed

with borderline personality disorder from a transpersonal perspective, as such a perspective gives

key focus to the role spirituality plays in this experience. An embedded mixed-methods design

was used. Participants were licensed clinicians currently working with at least two clients

diagnosed with borderline personality disorder. Participants completed a semistructured

interview, which was analyzed using thematic analysis, and were administered two quantitative

scales, the Spiritual Orientation Inventory (SOI; Elkins et al., 1988) and the Assessment of

Spirituality and Religious Sentiments (ASPIRES; Piedmont, 2010). Quantitative data were

analyzed through SPSS (Version 17) for descriptions and correlations, and were used to support

themes that emerged from the qualitative semistructured interview analysis.

 6

This study aimed to serve as a guidepost for struggling clinicians and normalize possible

countertransference experiences that might happen in therapy. Most importantly, this research

sought to engage clinicians in a dialogue and exploration of their own experiences of working

with this population. It is the hope that this research provides a shift in the way the field of

psychology and psychiatry currently view the diagnosis of borderline personality disorder.

Further, this research was an initial attempt to explore the ways in which therapists can most

appropriately and effectively manage their own personal struggles while working with this

clinical population.
 7

Chapter 2: Literature Review

This chapter will provide an overview of reviewed literature as it pertains to the central

research questions and hypothesis of this study, What are therapists’ experiences of working with

individuals diagnosed with borderline personality disorder? Further, how might spirituality affect

their experience of working with these individuals? It is hypothesized that therapists who score

higher on spirituality measures will describe more positive experiences in their work with clients

diagnosed with BPD than will those with lower scores. A brief historical context will be

discussed, introducing the diagnosis of borderline personality disorder, in addition to key

symptomatology and one of the current treatment modalities, Dialectical Behavior Therapy. This

review will also include a look at the current literature, which discusses the stigma associated

with the diagnosis of borderline personality disorder. Further, literature exploring how this

stigma might influence the perceptions caretakers, psychiatric nurses, and clinicians have of this

population will be reviewed. Attention will be paid to how working with this diagnosis might

influence clinicians’ well-being. Finally, this review will look at the relationship between well-

being and spirituality, and, more specifically, it will look at how therapists might incorporate

spirituality into their professional and personal lives to increase psychological well-being and,

thus, support working with individuals diagnosed with borderline personality disorder.

Introduction to a Diagnosis: Borderline Personality Disorder

The diagnosis borderline personality disorder (BPD) is relatively new to the field of

psychiatry and psychology (APA, 1980). However, the presentation of specific characterological

traits has challenged clinicians since the mid-1930s, when Stern first introduced the term

“borderline” to refer to those on the border between psychotic and psychoneurotic, not quite

falling into either category (Stone, 1986). For some time after Stern’s seminal lecture at New
 8

York Psychoanalytic Society, psychiatrists, clinicians, and researchers still struggled to find an

encapsulating term for clients who were highly difficult to manage in psychoanalytic therapy

(Gunderson, 2009). This struggle continued until the early 1970’s, when Kernberg (1967) used

the term “borderline personality organization” to characterize individuals who have “a specific,

stable, pathological personality organization” (p. 642). In these cases, the individual’s

personality state was not found to be transitory but rather to fluctuate between psychosis and

neurosis. Up to this point in the history of psychology, Freud’s psychoanalytic paradigm was the

dominant approach to the treatment of mental disease (Gunderson, 2009) and these individuals

were highly difficult to manage in traditional psychoanalysis, causing confusion and feelings of

helplessness for clinicians. Kernberg’s contribution to the understanding of borderline

personality organization promoted a major step toward a more integrated understanding of the

diagnosis (Hinshelwood, 1999).

Historically, borderline personality disorder has been referred to as borderline states,

preschizophrenic personality structure, psychotic characters, borderline schizophrenia, and latent

psychosis (Clarkin, Marzaili, Munroe-Blum, 1992; Kernberg, 1967). Further, individuals

exhibiting characteristics presently diagnosed with BPD were frequently referred to as suffering

from schizophrenic symptomology (Grinker, 1979). In a study designed to better understand this

differential diagnoses, 64 psychiatric inpatients were given primary diagnoses of either

schizophrenia (n = 22), neurotic depression (n = 11) or borderline (n = 31) (Gunderson & Kolb,

1978). Discriminate functional analysis with statement variables, derived from the Diagnostic

Interview for Borderlines (DIBs; Gunderson & Kolb, 1976) was used to compare qualities of

each group (i.e., flat/elated affect, devaluation/manipulation in interpersonal relationship). Based

upon eight statement variables, researchers were able to “discriminate the borderline sample
 9

from the sample of schizophrenic patients with 100% accuracy” (Gunderson & Kolb, 1978, p.

793). Specifically, individuals in the schizophrenic group were more likely to exhibit flat affect,

while devaluation/manipulation was much more evident in the borderline sample. Coinciding

and subsequent research suggested that devaluation and manipulation are forms of poor

interpersonal relationship skills developed by individuals with borderline personality disorder

(Bouchard et al., 2009).

Key symptomatology. In 1980 the term borderline personality disorder became part of

the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American

Psychiatric Association, 1980). Since that time, it has undergone revisions (DSM-III-R,

American Psychiatric Association, 1987; DSM-IV, American Psychiatric Association, 1994;

DSM-IV-TR, American Psychiatric Association, 2000) to better organize the qualities and

characteristics clinicians must assess in order to make such a diagnosis. It is of importance to

note that, at the start of this present research study, the Diagnostic and Statistical Manual of

Mental Disorders (5th ed.; DSM-5) was not yet in publication. However, the field of psychology

has now begun to reference this latest revision in psychological symptomatology and diagnosis,

which approaches BPD from slightly different diagnostic criteria. For the purpose of this

research, diagnostic criteria discussed will be in accordance to DSM-IV-TR. Borderline

personality disorder is characterized by affect instability/emotional dysregulation, self-harm and

suicidal actions or ideations, difficulty in interpersonal relationships, impulsiveness, angry

outbursts and aggression, and identity disturbances. Frequently, these maladaptive traits lead to

adverse interpersonal conflicts and relational consequences, creating distress for those who are

experiencing such symptoms (Tragesser et al., 2007). In order to better understand the key

symptomatology of BPD, four heavily researched diagnostic criteria will be discussed at length,
 10

specifically, affective instability/emotional dysregulation, suicide ideation and self-injury,

intense interpersonal relationships, and aggressive behaviors, each of which will be

contextualized. Further, a review of the literature will explore how each diagnostic presentation

might affect individuals who are in close, interpersonal relationships with individuals diagnosed

with BPD.

Affective instability/emotional dysregulation. Researchers believe that affective

instability, which is also referred to in the literature as emotional dysregulation, is the

cornerstone of the underlying features of BPD (Linehan, 1993). Affective instability can be

defined as the “tendency for emotional states to gain momentum and become increasingly erratic

and intense” (Tragesser et al., 2007, p. 604) and to cycle rapidly.

To better understand affect instability in borderline personality disorder, Koenigsberg et

al. (2002) studied 152 (42.8% female, 71.1% white) individuals from the Mood and Personality

Disorder Program in the New York City region who had been diagnosed with personality

disorders. Trained interviewers collected diagnostic information from each participant using

structured interviews and participants completed the Affective Lability Scale (ALS; Harvey,

Greenberg, & Serper, 1989), which assessed the degree to which participants’ mood shifted

throughout the day as compared to baseline, as based on a four-point scale. Participants were

also administered the Affective Intensity Measure (AIM; Larsen, 1984), which measured the

degree to which participants experienced their moods on a five-point scale. The AIM is

significantly correlated with BPD diagnostic criteria of affective instability (r = .40, p < .001). Of

the 152 participants, researchers found that 42 (27.6%) met the criteria for BPD. Results

indicated that participants who met criteria for borderline personality disorder scored

significantly higher on all subscales of the Affective Lability Scale (p<.004) and the Affect
 11

Intensity Measure (p < .02), indicating a greater likelihood that these individuals would

experience their emotions as frequently shifting and higher in intensity.

There has been a great deal of discussion with regard to rapid cycling of emotions in

relationship to individuals diagnosed with BPD, as opposed to healthy adults. These rapidly

cycling emotions cause the individual to get stuck in a positive feedback loop, continuously

ruminating about negative situations, an experience that requires high emotional reaction in order

to decrease intense vulnerability. It has been postulated that rumination, defined as the “tendency

to repetitively think about the causes, situational factors, and consequences of one’s negative

emotional experiences” (Selby & Joiner, 2009, p. 220), might be an underlying cause of

emotional dysregulation resulting in self-harm and intense interpersonal relationships. These

intense interpersonal relationships can challenge the therapeutic bond and have the capacity to

cause clinicians to struggle with their own emotional regulation (Selby & Joiner, 2009), making

the therapeutic alliance difficult.

Although research has provided strong evidence that individuals diagnosed with BPD

have challenges managing and controlling their emotions (Koenigsberg et al. 2002; Kuppens,

Oravecz & Tuerlinckx, 2010; Selby & Joiner, 2009; Tragesser et al., 2007) there is a common

misconception among care providers that individuals diagnosed with BPD can control their

emotions and that, because they are perceived as choosing not to, they are seen as engaging in

manipulating and controlling behaviors (Markham & Trower, 2003).

Previous understanding of borderline personality disorder has supported this

misconception, which has led staff to experience negative reactions such as anger and decreased

sympathy towards this clinical population (Sharrock, Day, Qazi, & Brewin, 1990). Markham and

Trower (2003) explored the ways in which a label of BPD might influence staff perceptions and
 12

attitudes related to sympathy, optimism, and personal experience working with individuals

diagnosed with BPD, versus working with individuals diagnosed with schizophrenia or

depression. Markham and Trower further hypothesized that staff would perceive their work with

individuals diagnosed with BPD as more negative compared to their work with individuals

diagnosed with schizophrenia or depression.

Using a within-participants quantitative questionnaire, Markham and Trower (2004) were

able to manipulate the independent variable, a diagnosis of either BPD, schizophrenia, or

depression, while measuring other variables. Participants, included 48 registered mental health

nurses (33 female, 12 male, 3 unidentified as to gender) with an average nursing experience of

12.7 years, were administered a modified version of the Attribution Style Questionnaire (ASQ;

Peterson, Semmel, Von Baeyer, Abramson, Metalsky, & Seligman, 1982) and were asked to

“imagine a patient with a specific psychiatric diagnosis (BPD, schizophrenia, depression)…then

[they were] presented with six short examples of challenging behaviors commonly exhibited by

patients” (Markham & Trower, 2003, p. 247). Participants were then asked to rank their

sympathy on a 7-point scale ranging from not sympathetic at all to extremely sympathetic.

Finally, to measure staff optimism of clients’ ability to change, participants were asked to rate

their level of agreement with four optimism statements.

Results indicated that staff rated their experiences as more negative with borderline

personality disorder patients than with patients diagnosed with schizophrenia or depression

(Markham & Trower, 2003). Further, it was noted that staff were not optimistic that individuals

with borderline personality disorder could change. Finally, it was found that staff members

perceived patients with borderline personality disorder to be more in control of negative events
 13

in their lives and, more importantly, that “the more control the patient was perceived to have, the

less sympathetic the staff were” (Markham & Trower, 2003, p. 251).

This study is of value to the current research study because it provided evidence that care

providers of individuals diagnosed with BPD might not feel sympathetic to emotional

dysregulation symptoms. Specifically, when staff members were under the impression that

individuals diagnosed with BPD were in control of their cycling moods, there was less sympathy.

Because the sample population in this study were limited to mental health nurses (Markham &

Trower, 2003), it is of interest to further explore how dysregulated moods, expressed by

individuals diagnosed with BPD, might affect therapists who treat these individuals in therapy

Specifically, this research will attempt to better understand how a sample of therapists

experience emotionally dysregulated clients during treatment.

Not only has emotional dysregulation/affective instability been shown to create

challenging interpersonal relationships, it has also been postulated that this diagnostic feature of

borderline personality disorder influences other symptoms of BPD, most specifically, suicide

ideation, self-injurious behaviors, and nonsuicidal self-injury (Links et al., 2007).

Suicide ideation, self- injurious behaviors, and nonsuicidal self-injury. Individuals

diagnosed with borderline personality disorder often experience high incidence of self-harm and

represent a 10% risk of suicide (Links et al., 2007). Such risks of self-harm might include drug

abuse, sexual promiscuity, overdosing, self-mutilation, and successful suicide attempts (Gardner

& Cowdry, 1985). Research suggested that these behaviors are maladaptive ways of regulating

intense emotions and not always intended to be manipulative or lethal (Brown et al., 2002;

Linehan, 1993).
 14

Brown et al. (2002) investigated the self-reported reasons for attempted suicide,

parasuicidal behavior, or nonsuicidal self-injury (i.e., self-mutilation) of women diagnosed with

borderline personality disorder. Parasuicidal behavior is defined as “deliberate self-injury or

imminent risk of death, with or without the intent to die” (Brown et al., 2002, p. 198), whereas

parasuicidal acts can be delineated into three categories: suicide attempts, ambivalent suicide

attempts, and nonsuicidal self-injury (NSSI). Nonsuicidal self-injury can be defined as the “self-

directed deliberate destruction or alteration of bodily tissue in the absence of suicidal intent”

(Hamza, Stewart, & Willougby, 2012, p. 483).

Brown et al. (2002) assessed 75 women (M age 30, 84% Caucasian, 90% with a high

school education) to indicate the degree to which they met criteria for BPD and suffered from

parasuicidal behaviors, using the Structured Clinical Interview for DSM-IV (SCID-II; First,

Spitzer, Gibbon, & Williams, 1997) and Parasuicide History Interview (PHI; Linehan, Heard,

Brown, & Wagner, 2001), respectively. Following this assessment, participants were asked in a

semistructured interview to describe reasons for their parasuicidal behavior. Results indicated as

reasons for this behavior included emotional relief, interpersonal influence, avoidance/escape,

and feeling generation. Further, participants were more likely to describe their suicide attempts

as efforts to make others better off, whereas nonsuicidal/parasuicidal acts were intended to regain

emotional equilibrium and normal feelings. This comprehensive investigation has some

limitations, such as the validity of self-report, in that participants might recall events differently

because of their awareness of participation in a study or the social desirability of their answers.

Additionally, this research does not account for possible confounding variables, such as current

life events that might trigger increased suicidal behaviors.

 15

This particular diagnostic criterion of self-injury, suicide ideation, and NSSI in BPD can

be challenging for clinicians, as it creates a sense of urgency to stop all harmful behavior and is

often misinterpreted by clinicians as manipulative behavior to gain attention (Hunt, 2007).

Clinicians who provide therapy to individuals who report recent self-harming behaviors tend to

have “higher levels of self-reported stress” in working with these clients (Miller et al., 2010, p.

229). This stress can manifest physiologically, activating the hypothalamic-pituitary adrenal axis

(HPA), which releases cortisol (C) into the blood stream. Additionally stress can manifest

through “activation of the locus ceruleus and the sympathetic nervous system with the rapid

release of catecholamines such as norepinephrine into the blood stream” (Miller et al., 2010, p.

229). These two indicators of stress can be measured by the activation of salivary C and salivary

alpha-amylase (AA), which relate to increased activation in the HPA and sympathetic nervous

system, respectively (Miller et al., 2010).

In order to compare self-reported stress to physiological reactions in the body, Miller et

al. (2010) examined pre-and postsession physiological well-being of therapists conducting

therapy with clients who had recently self-harmed and who had significant BPD character traits.

Miller et al. (2010) hypothesized that physiological indicators of stress (HPA and C) in clinicians

would increase between presession and postsession with clients and that this increase in stress

would be directly related to the difficulty of each session and inversely related to good

therapeutic alliance. Six participants were therapists in training at a west coast university

counseling center; 4 were female, 2 were male, and their education level included that of a

psychiatry resident, a postdoctoral level therapist, a masters counseling psychology student, and

3 clinical psychology trainees. Participants were asked to select two clients who met BPD

criteria and whom they were treating in individual therapy and to provide saliva samples 10
 16

minutes prior to the start of their session and 5 minutes after the end of their session. Thirty-six

measurements were requested, three for each participant, one at the beginning, one in the middle,

and one at the end of treatment sessions with each of that participant’s two selected clients.

However, only twenty-three measurements were completed and only 2 therapists completed all

six measurements. This was likely due to professional demands and time constraints experienced

by therapists in training (Miller et al., 2010). Saliva samples were examined at the Salimetrics

Laboratory for the presence of increased alpha-amylase and salivary C.

In addition to submitting to testing for physiological signs of stress, therapists were asked

to complete, immediately following each session, a questionnaire that explored the therapists’

working alliance with the clients and the difficulty level of each session. The Working Alliance

Inventory – Short Form – Therapist Version (adapted from WAI-sh-T; Tracey & Kokotovic,

1989) is a “12-item questionnaire for therapists to complete [in order] to examine the therapist’s

perception of the working alliance with a given client” (Miller et al., 2010, p. 231). Therapists

were also asked to rate their impression of session difficulty, as based on a 5-point Likert scale

(1 = not at all difficult, 5 = extremely difficult).

Data were analyzed using linear mixed models and ruled out any chance that treatment

type might affect physiological responses. Results indicated that AA and C levels declined for all

therapists pre- and postsession, indicating a decrease in stress-related physiological reactivity

from beginning to end of session. Interestingly, and counter to the researchers’ original

hypothesis, “therapists experienced higher levels of physiological stress prior to therapy sessions

relative to post-session stress” (Miller et al., 2010, p. 232).

Results indicated that therapists experienced higher physiological stress before the start

of therapy versus after session (Miller et al., 2010). It is suggested that this might be because of
 17

the uncertainty presession of what a client might present in session and the therapists’ anxiety

arising from not knowing. Results comparing therapists’ self-report of session difficulty and

physiological symptoms showed that the greater perceived difficulty of a session was related to a

larger decline in AA levels, while a stronger alliance was positively correlated to lower C levels.

Results might suggest that the decreases in AA and C levels reflects a reaction to the relief or

satisfaction of completing and managing a potentially challenging therapy session.

In addition to the small sample size, another significant limitation to this study is that

there was no control group to establish a baseline for therapists’ physiological reactions to

providing individual therapy in general. For instance, perhaps therapists might feel anxious with

all their clients, given that participants were primarily clinicians in training? It would be of value

to see how their physiological responses differed depending upon their clients’ clinical

presentation. However, though given these limitations, this study has implications for the current

research study in part due to the potential for therapists to feel anxious or have an increased

stress response prior to their work with individuals diagnosed with BPD, especially if their

clients present with self-injurious behaviors. The current research study will attempt to better

understand how licensed therapists experience their clients who exhibit self-injurious behaviors.

On a more interpersonal level, previous research has supported the theory that care

providers have negative attitudes towards self-harming patients with BPD characteristics. These

negative attitudes might create anxiety for the clinician and further cause a lack of empathy in

the working relationship (Alston & Robinson, 1992; Commons, Treloar, & Lewis, 2008).

Commons et al. (2008) were interested in further exploring attitudes as between mental

health and emergency medicine professionals in their work with individuals diagnosed with BPD

who exhibit deliberate self-harming (DSH) behaviors. Researchers hypothesized that gender,
 18

occupation, service setting, education, years of experience, frequency of clinical contact, and

BPD training would all influence the attitudes of care providers working with individuals

diagnosed with borderline personality disorder who self-injure (Commons et al., 2008). In this

study, registered health professionals in Austria and New Zealand (n = 140; 92 female, 48 male,

90 mental health professionals, 50 emergency medicine professionals) completed a demographic

questionnaire that assessed gender, years of experience, education completed, occupation, and

average clinical contact with BPD patients.

Participants were also administered the Attitudes Toward Deliberate Self-Harm

Questionnaire (ADSHQ; McAllister, Creedy, Moyle, & Farrugia, 2002), a 33-item, four-point

Likert Scale that measures attitudes towards individuals who exhibit deliberate self-harming

behaviors. The questionnaire includes four factors that reflect attitudes toward DSH, perceived

confidence in assessment and referral, ability to effectively deal with DSH patients, empathy

towards DSH patients, and hospital regulations that guide practice. Reliability, based upon

Cronbach’s α for each factor is 0.71, 0.74, 0.67, and 0.57, respectively. ADSHQ scores range

from 33 to 132, with higher scores indicating more positive attitudes.

According to demographic analysis, 67% (n = 97) of participants were in the nursing

profession, 17.1% (n = 24) were allied health professionals [i.e., psychology, 14; social work, 7;

occupational therapy, 3] and 13.6% (n = 19) were medical professionals. Forty-five (32.1%)

participants indicated having between 0 and 5 years of clinical experience, while 43 (30.7%) had

16 or more years of clinical experience. Fifty-one participants had completed an undergraduate

degree, 68 held a postgraduate degree, and 21 participants had hospital training only. Regarding

clinical contact with clients diagnosed with BPD and who deliberately self-harm, 47.1% (n = 66)
 19

had daily contact with their patients. 43.6% (n = 61) had weekly contact, 11.4% (n = 16) had bi-

monthly contact, and 18.6% (n = 26) had contact only once a month or less.

Statistical analysis and results indicated that “mental health clinicians had a significantly

more positive attitude score towards BPD patients” (Commons et al., 2008, p. 580) who engaged

in deliberate self-harm versus care the attitude that prevailed among providers in emergency

medicine. Specifically, analysis of mean differences showed that mental health professionals had

more positive attitudes versus those of emergency medicine professionals (p < .001).

Additionally, women were significantly more likely than men to rate their experience as more

positive (p = .02). Further, participants in both professions who also received training on BPD

had significantly more positive attitudes (p = .003). No statistical significance was shown

between education level and positive attitudes (p = .86), and no statistical significance was

shown between years of clinical experience and positive attitudes (p = .399). However, there was

a statistically significant difference between occupations relative to attitude, with allied health

professionals reporting more positive attitudes (p = .015) than did medical professionals (p =

.048). More specifically, psychologists (n = 14) who participated in this study with no previous

training in BPD showed high mean scores on the ASDHQ (94.69), and those who had received

some training had an increased mean of 97.75.

The study by Commons et al. (2008) offers an interesting perspective of professionals’

experiences of individuals with BPD who deliberately self-harm. This present study has

implications for the current research in that it has begun a cursory exploration into the objective

measurement of health care professionals’ attitudes towards individuals diagnosed with

borderline personality disorder. Results were significant on multiple levels, indicating the

importance of training and education on the influence of positive attitudes towards BPD and
 20

DSH. However, Commons et al. (2008) surveyed a broad range of health professional

participants, with only 21 of the total 140 participants representing psychologists and social

workers. The current research study aims to directly assess the opinions and experiences of

licensed therapists who work with this clinical population. Further, this study by Commons et al.

(2008) was limited by investigating the views of international mental health professionals. It

might be that borderline personality disorder is understood differently internationally, as

compared to perceptions of mental health providers in the United States. The current study was

interested in the experience of American licensed therapists, only.

Hauck, Harrison, and Montecalvo (2013) approached a similar hypothesis to that of the

study by Commons et al. (2008), using the ADSHQ (McAllister et al., 2002) with psychiatric

nurses in the United States. Specifically, researchers were interested in the relationship between

deliberate self-harm in individuals with BPD characteristics and perception of such individuals

by mental health professionals.

Participants included a convenience sample of 83 psychiatric nurses (75 women, 8 men)

working on behavioral health inpatient units. The age range for participants was 21 to 65 (M =

47) with an average of 9 years of experience in psychiatric service. Forty-one percent (n = 34)

held an associates degree, 27.7% (n = 23) held a diploma (unspecified), 26.5% (n = 22) held a

bachelor’s degree, and 4.8% (n = 4) held a master’s degree. Participants were administered the

ADSHQ (reliability can be determined from information in the above review of Commons et al.

(2008) to assess for attitudes towards patients who deliberately self-harm and have a diagnosis of

borderline personality disorder (Hauck et al., 2013). Reliability of the ADSHQ was calculated

using Cronbach’s Alpha coefficient, while Pearson correlation analysis was used to further

explore the relationship between years of nursing experience and general attitudes toward
 21

deliberate self-harm/BPD. Results found no significant relationship between nurses’ experiences

and overall attitudes (p > .05). However, results showed a significant relationship between years

of experience and the nurses “ability to deal affectively with deliberate self-harm patients” (p <

.05) (Hauk, Harrison, & Montecalvo, 2013, p. 26). Further, there was not a strong correlation

found between nurses’ experience and empathy (r = -0.122, p > .05).

Counter to results of previous research (Alston & Robinson, 1992; Markham & Trower,

2003) yet similar to findings by Commons et al. (2008), the Hauck et al. (2013) results indicated

that attitudes of psychiatric nurses with regard to self-injurious behavior were surprisingly

positive, but only slightly (ADSHQ score, M = 53.9 out of 133). Most interestingly, the majority

of nurses (86.7%) indicated that further education on the diagnosis of borderline personality

disorder and deliberate self-harm would be helpful. Specifically, skills training workshops,

education about self-injury, evidence-based practices, and referrals for this clinical population

were of importance for nurses working with individuals diagnosed with BPD (Hauk et al., 2008).

Hauk et al. (2013) have provided a strong theoretical base indicating that nurses who

provide psychiatric support to individuals who have been diagnosed with BPD and who

intentionally self-harm report positive attitudes towards this clinical population, particularly

when they have received training and support around understanding the diagnosis and the self-

injurious behaviors. However, results for that study were limited due to the exclusion of

qualitative data, with the focus trained only on how psychiatric nurses quantitatively rate their

experiences of treating individuals who are diagnosed with BPD and who deliberately self-

injure. The current research study will include an experiential view of how deliberate self-injury

and BPD characteristics in a client might affect the treating clinician.

 22

It is of importance to note that the majority of participants in the above empirical reviews

were not therapists, but psychiatric nurses. In fact, in the study by Commons et al. (2008) only

24 participants were allied health workers, which included social workers, psychologists, and

occupational therapists. Due to the differing outcome research on care providers’ experiences

with individuals who self-harm and who demonstrate BPD characteristics (Alston & Robinson,

1992; Commons et al., 2008; Hauck et al., 2013; Markham & Trower, 2003) and the lack of

empirical research on how this behavior might influence the treating therapist, the current

research study will attempt to explore how licensed therapists are affected by deliberate self-

injurious behaviors by their clients.

Intense interpersonal relationships. A third diagnostic characteristic of borderline

personality disorder is a pattern of unstable interpersonal relationships, which can be

characterized as an individual’s attempt at a dichotomous response that includes the cycling of

both idealization and devaluation of the other (APA, 2000). This instability can cause emotional

discord and interpersonal difficulties for individuals diagnosed with BPD, creating challenges for

them in sustaining lasting and meaningful relationships (Bouchard et al., 2009).

In a study to examine the role of borderline personality disorder in connection with

interpersonal relationships, Bouchard et al. (2009) compared psychosocial functioning of couples

in committed relationships. Participants included 35 clinical couples and 35 nonclinical couples

(control group). Participants in the clinical group were heterosexual couples dating (n = 6),

cohabitating (n = 21) or married (n = 8) with average time in their relationship equaling 5 years

and 11 months. Participants in the control group were either cohabitating or married and had

been in a relationship an average of 16.5 years. The female in the clinical group had a diagnosis

of BPD, and participants in the control group showed no acute mental health diagnosis. All
 23

participants were administered several assessments, including the Structured Clinical Interview

for DSM-IV (SCID-II; First, Spitzer, Gibbon, & Williams, 1997); the Experiences in Close

Relationships Questionnaire (ECR; Brennan, Clark, and Shaver, 1998) to assess attachment

styles; the Conflict Tactics Scale (CTS-2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) to

assess intimate violence within a couples’ relationship; Psychiatric Symptom Inventory (PSI-14;

Ilfeld, 1978) to assess psychological distress; and Dyadic Adjustment Scale (DAS-8; Spanier,

1976) to assess the level of relationship satisfaction.

Results (Bouchard et al., 2009) indicated that 68.7% of their clinical couples reported a

pattern of relationship instability. In attachment styles, women diagnosed with BPD were more

likely to be fearful and preoccupied in their relationships (p <.001, p < .01, respectively)

compared to the nonclinical sample of women. In addition, women diagnosed with BPD scored

higher in avoidance of intimacy (p < .001) versus women not diagnosed with BPD. Interestingly,

men in the clinical group reported significantly higher rejection anxiety than did men in the

nonclinical group (p<.01) and statistically significant higher levels of avoidance of intimacy (p <

.05). Women in the clinical group exhibited more physical violence (p < .01) as compared to

women in the nonclinical group, while the partners of women diagnosed with BPD experienced

higher physical and psychological violence (p < .001 for each). Constructive communication

skills were lower in women in the clinical group (p < .01), compared to women in the nonclinical

group. Finally, couple satisfaction was significantly lower in clinical couples as compared to

nonclinical couples as rated by both women (p < .001) and men (p < .05). Notably, 49% of

women with borderline personality disorder and 40% of men in relationship with them were

clinically depressed, potentially indicating overall dissatisfaction in the relationship (Bouchard et

al., 2009).
 24

A limitation of this research was the small sample size in addition to possible

confounding variables that might influence the results. For instance, although clinical couples

seemed to report more challenging interpersonal relationships, it might be the case that the

dynamic symptomatology reported by the partner (their own presence of Axis I or II diagnosis)

might have influenced the relational discord. Bouchard et al. (2009) suggested a longitudinal

study to further parse out how the partners’ possible diagnostic features could influence the

relationship.

Despite these few limitations, this research suggested that unstable interpersonal

relationships, as defined by avoidance of intimacy, fear, and rejection anxiety, might negatively

affect couples. For the purpose of this study, it was of interest to know if these reported intimate

relational patterns would also show up in the therapeutic relationship and, further, how these

relational patterns might influence the experience of therapists working with individuals

diagnosed with borderline personality disorder.

As a training doctoral psychologist, Bot (1997) explored her own personal experience of

working with “Tina,” who had personality characteristics suggestive of borderline personality

disorder. In this case study, Bot’s exploration into the treatment and therapeutic relationship led

her to reflect on Tina’s emotions and emotional instability that had challenged the interpersonal

relationship created in therapy.

Tina challenged me in many other ways, as well. She was often late for her appointments
or would cancel at the last minute. She frequently forgot her money to pay for her
sessions. She also usually became quite upset toward the end of her appointments,
making it difficult for me to close the session on time. I had been teaching other women
how to assert themselves in various areas of their lives, and here I was struggling to set
my own boundaries. I worried that I would offend Tina or that I would not meet her
needs. (Bot, 1997, p. 128)
 25

She further recalled, “I experienced her rage as intimidating . . . her tears did not evoke

compassion as those of my other clients but rather repulsed me . . . I often felt angry at her for

not conforming to more moderate behavior that I could tolerate better” (Bot, 1997, p. 129). In

addition to interpersonal challenges that Bot (1997) faced, Tina’s aggressive behaviors had a

negative influence on the therapist and therapeutic relationship created in treatment. This case

study is one specific example of how a therapist might be triggered and challenged in working

with clients diagnosed with BPD. The current research study attempted to expand this research

by interviewing multiple clinicians to gain a sense of the more collective experience of this work.

Aggressive behaviors. According to Lâtalová and Prasko (2010), “aggression against the

self or others is one of the core components of the borderline personality disorder” (p. 239).

Researchers have shown interest in the management of such aggressive behavior in this

population, mainly because of the effects such behavior might have on caregivers, family

members, and treating clinicians. This aggression, which might be present in session with

therapists, could become overwhelming and make it challenging for therapists to sit with clients

while fearful of their own safety (Gallop, Lancee, & Garfinkel, 1989; Gallop & Wynn, 1987).

Research has shown a relationship between negative affect and aggression in individuals with

borderline personality disorder characteristics (Siebert-Hatalsky & Wilson, 2011). Further,

negative affect, which can include sadness, anger, shame, and anxiety, can influence and increase

aggressive behaviors.

In a pilot study, which assessed assault histories of individuals diagnosed with BPD in

the psychiatric inpatient setting, Sansone, Barclay, and Gaither (2005) theorized that inpatients

with borderline personality disorder would report higher instances of assault histories compared

to other psychiatric patients. Of the 34 inpatients who participated, 12 met the criteria for BPD.
 26

Thirteen were male and 20 were female with an age range of from 18-58 (M = 33.38). Seventy-

three point five percent were White, 20.6% were African American, one participant was Native

American, and one participant indicated “other.” One participant had below a junior high

education level, 1 had a junior high education level, 16 participants had high school educations,

11 attended junior college, 1 attended a 4-year college, and 1 had a graduate education.

Participants were administered an on-site interview, which assessed demographics and

assault histories. Participants were also assessed for borderline personality disorder, based upon

the DSM-IV diagnostic criteria. Assault histories were obtained by asking participants if they had

ever been charged with assault, convicted of assault, incarcerated for assault, broken another

person’s bones in a fight, or caused permanent damage to another person in a fight (Sansone et

al., 2005). Participants were simply instructed to respond with a yes or no to each statement.

Results indicated that 12 participants met criteria for BPD (Sansone et al., 2005).

Compared to the non-BPD participants, those inpatients meeting criteria for BPD had fewer

assault histories to report: 3 non-BPD participants reported being charged with assault, as

opposed to 1 BPD participant. Further, more non-BPD participants (n = 12) reported assaulting

someone they knew versus BPD participants (n = 6). Over all, of the 22 non-BPD participants,

there were fifty-two endorsements of some type of assaultive behavior, whereas, of the 12 BPD

participants, there were twenty endorsements of assault. However, results were not statistically

significant, with p-values ranging from .15 (assaulting someone of the same sex) to .83 (causing

permanent damage to another person in a fight). Due to the statistical insignificance, these results

must be taken with caution.

One limitation to the Sansone, et al. (2005) study is that it did not account for any

confounding variables. There is no discussion of differential diagnosis within the non-BPD

 27

participant sample as it might pertain to increased aggression or assaultive behaviors. A study on

aggression as it might link to BPD would be valuable if individuals diagnosed with BPD were

compared to mentally healthy individuals within the community. This would allow for a broader

exploration of how aggression might appear in BPD clients as compared to a nonclinical

population. However, it is important to note that BPD participants did indicate some type of

aggressive/assaultive behaviors overall, which might have an effect on their interpersonal

relationships with care providers, specifically mental health professionals. To date, there is no

current, substantial research that explores how licensed therapists experience aggression in

clients diagnosed with borderline personality disorder. Therefore, this current research has

attempted to better understand how therapists experience aggressive behaviors while working

with this clinical population.

Stigma. A great deal of literature explores the stigma associated with a diagnosis of

borderline personality disorder (Aviram et al., 2006; Gallop & Wynn, 1987; Hinshelwood, 1999;

Lewis & Appleby, 1988). According to Aviram et al. (2006), stigma is the “perception of a

negative attribute that becomes associated with global devaluation of the person” (p. 249). These

negative attributes might cause individuals to be perceived as having less value and to be,

therefore devalued in society. Within the scope of the mental health system, perhaps partially

because of this stigma, borderline personality disorder has received relatively little scientific

attention. Further, there is a paucity of literature exploring therapists’ experiences of working

with this population.

Research has explored the responses of psychology professionals in relationship to the

treatment of individuals diagnosed with BPD (Gallop & Wynn, 1987; Koekkoek et al., 2009;

Lewis & Appleby, 1988), but results are preliminary, at best. Early literature took a stance in the
 28

belief that personality disorders were not a mental illness and that those diagnosed had control

over their emotions and actions (Lewis & Appleby).

In an empirical exploration, Lewis and Appleby (1988) were interested to see whether

psychiatrists used personality disorder (PD) as a pejorative term and further explored the

hypothesis that psychiatrists believed those diagnosed with a PD were thought to be in control of

their actions. One-hundred fifty-one psychiatrists from England, Wales, and Scotland

participated in this study and were randomly assigned to one of six case histories. Each case

described a client with only one or two differentials, as follows: Case 1—client had a previous

diagnosis of PD; Case 2—client had no history of a previous diagnosis; Case 3—client had a

previous diagnosis of depression; Case 4—client had a previous diagnosis of PD, but

psychiatrists were asked “not to let themselves be influenced by previous labels” (Lewis &

Appleby, 1988, p. 45); Case 5—client had a previous diagnosis of depression and was female;

Case 6—no previous diagnosis was given and patient was identified as a solicitor. Psychiatrists

who received Case 1 or 4 were distinguished as the PD group due to the presence of a personality

disorder diagnosis for those cases and psychiatrists who received Cases 2, 3, 5, or 6 were

distinguished as the NoPD group, due to the absence of a personality disorder diagnosis among

those cases.

After reading a randomly assigned case study, psychiatrists were given a 22-statement

questionnaire assessing these psychiatrists’ attitudes towards the patient in the case study.

Statements were based on a six-point scale, with the higher scores indicating a more rejecting or

negative attitude towards the patient. Upon completing the questionnaire, psychiatrists were

asked to select a diagnosis of their own, despite a previous diagnosis that may have been given to
 29

the client by another psychiatrist, from this list: depression, anxiety, adjustment reaction, drug

dependence, personality disorder, and neurasthenia.

Results, based upon individual one-way analysis of variance, supported a significant

difference between the personality-disorder and no-personality-disorder groups (p-values ranged

along these descending figures: <.05, <.01, <.001). For instance, the mean score of the PD group

was higher on all but one statement as compared to the mean scores for the NoPD group. (i.e.,

for the item Manipulating Admission, PD, M = 3.41; NoPD, M = 2.75), which supported the

original hypothesis that psychiatrists would view clients less favorably when under the

impression there was a diagnostic history of personality disorder. Psychiatrists who received the

PD vignette believed clients were more likely to manipulate admission, pose as a difficult

management problem, be not mentally ill, and to be unlikely to comply with advice/treatment

(Lewis & Appleby, 1988). Further, participants in the PD group were more likely than those in

the NoPD group to make a diagnosis of adjustment disorder (p < .001). Results indicated that a

diagnosis of depression was associated with the least critical attitudes and that, the more

experienced psychiatrists were, the less critical were the attitudes they had towards patients.

These results are interesting, in part because psychiatrists had no personal, face-to-face, clinical

experience of the client and based their diagnosis on another practitioner’s clinical opinion.

It is important to note, however, that this study took place in the late 1980s, when the

then latest revision of the Diagnostic and Statistical Manual for Mental Disorders (3rd ed. text

rev.; DSM-III-TR; American Psychiatric Association, 1988) had just recently added personality

disorders to the lexicon of diagnoses. Many psychiatrists were still using antiquated conceptual

theories and practices significantly influenced by the medical model, which did not recognize

personality disorders as a mental illness (Lewis, 1974). Further, Lewis and Appleby (1988)
 30

explored the attitudes of psychiatrists only. Traditionally, psychiatrists do not provide individual

therapy to clients and function more on a crisis and medication management level. Therefore, it

would be interesting to explore how mental health professionals conducting therapy (i.e.,

psychologists, social workers, marriage and family therapists, and mental health counselors)

might experience this population, given their increased experience providing individual therapy.

The current research study addressed this gap and explored how therapists who have a regular

therapeutic relationship with individuals diagnosed with BPD might experience this work.

Finally, Lewis and Appleby (1998) did not delineate specific personality disorders within their

study. The current research study aims to focus specifically on how a diagnosis of borderline

personality disorder influences therapists’ experiences and behavior towards their clients.

Even more than 20 years later, stigma associated with personality disorders, and,

specifically, borderline personality disorder, still exists in the general and mental health

communities (Aviram et al., 2006). Psychiatric nurses and residential medical doctors in the field

of mental health often refer to individuals diagnosed with BPD as manipulative, demanding,

violent, complaining unnecessarily about pain, draining, and devouring (Gallop & Wynn, 1987).

These representations tend to “challenge the therapist’s self-identity as a ‘help provider’ by

causing concern, anxiety, and the feeling of being out of control. . .there will be either a self-

protective emotional retreat by the therapist or, perhaps, an angry accusation about the patients’

efforts to control the therapist” (Aviram et al., 2006, p. 253). Hinshelwood (1999) argued that

therapists found this population the most difficult to work with because they felt as though the

professional values they offer to the client were not appreciated. Further, therapists were

concerned that they were unable to provide what they assume the client needed. The therapists’

potential intense feelings of invalidation and lack of movement towards recovery might cause
 31

more harm than good in the treatment process. Often, the intensity of working with this

population can cause emotional and physical problems to manifest in those who are in close

relationship with individuals diagnosed with BPD (Scheirs & Bok, 2007).

Scheirs and Bok (2007) explored the influence of borderline personality disorder

symptomology on the psychological well-being of caregivers and relatives of individuals

diagnosed with BPD. Sixty-four participants (44 women and 20 men) were recruited from

support groups and via advertisements. Participants received the Symptom Check List (SCL-90;

Arrindell & Ettema, 2003), a self-report rating scale that screens for psychopathology. The SLC-

90 consists of 90 symptoms in which participants are asked to indicate, on a 5-point Likert scale

(1 = not at all, 5 = extremely) the degree to which they were bothered by each symptom in the

previous week. The SLC-90 screens for eight symptom dimensions: anxiety, agoraphobia,

depression, somatization, distrust and interpersonal sensitivity, insufficiency of thinking and

acting, sleep problems, and hostility.

Participant scores were compared to that of the general Dutch population (Scheirs & Bok,

2007). Results showed that caregivers scored higher on all symptom dimensions (p-values

ranging from .019 to < .001). Specifically, somatization was shown to be a prominent symptom

of biologically related caregivers versus nonbiologically related caregivers (p = 008), whereas

non-biologically related caregivers indicated more symptoms of hostility than did biologically

related caregivers (p = .032). This study is limited in its relevance for the current research due to

the Dutch nationality of the sample population. Results from Scheirs and Bok (2007) cannot be

generalized to the participant sample of this current study. However, it is of interest to further

explore a possible connection between challenges in interpersonal relationships with individuals

diagnosed with borderline personality disorder and their providing therapist.

 32

As has been described, caregivers, family members, and health professionals such as

psychiatric nurses, medical doctors, and psychiatrists experienced individuals diagnosed with

borderline personality disorder as challenging (Aviram et al., 2006; Gallop & Wynn, 1987;

Hinshelwood, 1999; Lewis & Appleby, 1988; Scheirs & Bok, 2007). The current research took

findings from this empirically reviewed literature and expanded it to include psychologists,

marriage and family therapists, licensed social workers, and licensed mental health counselors, to

explore their experiences in working with individuals diagnosed with BPD.

Theoretical treatment model: Dialectical Behavior Therapy (DBT). Various

theoretical orientations of psychology explore the etiology and treatment of borderline

personality disorder. However, Dialectical Behavior Therapy (DBT; Linehan, 1993) is one of the

most widely used and studied treatment models in the field (National Alliance on Mental Illness

[NAMI], n.d.)

As based upon Millon’s (1987) thesis on the social learning theory of borderline

personality disorder, Linehan (1993) further conceptualized the importance of “biological and

social learning influences in the etiology of the disorder” (p. 10). According to Linehan (1993),

BPD is first a dysfunction of emotional regulation, which results from biological traits and

environmental factors that are likely invalidating. Emotional dysregulation is defined as an

innate propensity for high emotional vulnerability coupled with an inability to regulate rapidly

cycling intense emotions. Emotional vulnerability often causes an increased sensitivity to

emotional stimulation with a slow return to baseline. According to this theory, individuals

diagnosed with BPD tend to react quickly and impulsively to emotional stimuli, and it is likely

that these reactions affect the cognitive level, making return to baseline difficult.
 33

Further, Linehan (1993) explained that the childhood social component of emotional

dysregulation is that of an invalidating environment, one “in which communication of private

experiences is met by erratic, inappropriate, and extreme responses” (p. 49). This invalidation

does not allow children to be seen for who they are nor does it acknowledge or accurately mirror

their experiences, and it likely creates a feeling of vulnerability towards and mistrust of others.

According to Linehan (1993), this blend of biological and environmental factors contributes to

the emotional instability of adults diagnosed with BPD, creating vulnerability and mistrust and

leading individuals to express their emotions in heightened forms in order to feel understood and

validated. One way in which these intense emotions can be regulated is through Dialectical

Behavior Therapy (DBT; Linehan, 1993).

Dialectical Behavior Therapy is grounded in the belief that borderline personality

disorder is “primarily a dysfunction of the emotional regulation system; it results from biological

irregularities combined with certain dysfunctional environments, as well as from their interaction

. . .over time” (Linehan, 1993, p. 42). Rooted in the biosocial theory of personality disorders,

DBT examines the clients’ experience of emotional dysregulation and attempts to regulate

intense affect through core mindfulness skills, which support emotional regulation, ability to

maintain healthy boundaries and relationships, and skills for effectively coping with self-

injurious behavior. In addition to this, it is assumed, although not required, that therapists also

engage in some type of mindfulness practice when providing DBT treatment to their clients.

Although therapists are not required to have a personal mindfulness practice, its use is

encouraged to help therapists manage this stressful work and to become familiar with the

mindfulness skills taught to their clients (Dimidjian & Linehan, 2003).

 34

Mindfulness is the practice of “paying attention to direct experience, at the level of pure

sensation, without concepts or categories” (Dimidjian & Linehan, 2003, p. 231) and is

traditionally contextualized within, but not always specific to, Eastern religions and spiritual

traditions and Christian contemplative practices. Within the clinical setting, these spiritual

undertones are often stripped away from mindfulness skills taught in session, with the focus

remaining on the attunement and “awareness simply of what is at the level of direct and

immediate experience, separate from concept, category, and expectations” (p. 229). However,

research has shown a link between mindfulness and spirituality.

Palmer and Muse-Burke (2012) showed a positive relationship between spirituality and

mindfulness (p < .001). Participants in their study were students and practicing clinicians, who

were primarily women (76.1%) and Caucasian (85.4%), with education levels ranging from

Bachelors Degree (31.2%), and Masters Degree (56.6%) to Doctoral Degree (11.2%). Nineteen

percent reported having no religious affiliations, and the rest of the sample reported various

religious affiliations: Catholicism (17.1%), of Christian denomination (16.1%), Agnostic (8.3%),

Atheist (7.3%), Jewish (4.4%), Lutheran (3.9%), and Protestant (3.9%).

Participants completed the Inclusive Spirituality Index (ISI; Muse-Burke, 2005),

Mindfulness Attention Awareness Scale (MAAS; Brown & Ryan, 2003), Empathy Quotient

(EQ; Baron-Cohen & Wheelwright, 2004), Marlowe Crowe Social Desirability Scale MCSDS

(Crowe & Marlowe, 1960); and demographic information. Results indicated a positive

relationship between spirituality and mindfulness (p < .001) in addition to a significant

relationship between spirituality and empathy (p < .001). In addition, multiple regression

analysis supported the claim that mindfulness was “the most significant predictor of spirituality”

(Palmer & Muse-Burke, 2012, para. 6). Limitations of this study include sample and
 35

methodology, as it was unclear how demographics might have influenced participants’

mindfulness practices and, therefore, spirituality. Given this small limitation, however, this study

nevertheless supports a correlation between spirituality and mindfulness (Palmer & Muse-Burke,

2012).

As was stated previously, very little research explores therapists’ experiences of working

with individuals diagnosed with borderline personality disorder. Further, only one article was

found to take even its cursory look at how therapists are affected by their clients diagnosed with

BPD, and it was specifically related to when the therapist was providing Dialectical Behavior

Therapy (Bedics, Atkins, Comtois, & Linehan, 2012). However, regarding the importance of

mindfulness in DBT, in a direct communication with staff members at the Behavior Research

and Therapy Clinic (BRTC), Linehan’s research clinic at the University of Washington, Seattle,

Linehan said that her mindfulness practice makes her more compassionate towards individuals

diagnosed with BPD (direct email communication, BRTC, February 27, 2013). Thus, assuming a

correlation between spirituality and mindfulness (Palmer & Muse-Burke, 2012), might it be that

mindfulness based practices like DBT could influence therapists’ experiences of working with

individuals diagnosed with borderline personality disorder? The current research attempted to

build on these initial correlations between spirituality and mindfulness (Palmer & Muse-Burke,

2012) by exploring whether therapists describe mindfulness as a part of their experiences in

working with this clinical population and how their mindfulness practices might influence these

experiences

Spirituality and Well-Being

Empirical literature has defined spirituality in a variety of ways: a sacred connection to a

concept, belief, or higher power (Plante, 2008); the capacity to go beyond the ego and see the
 36

sacred in every living thing (Chandler, Holden, & Kolander, 1992); transcendence of the self

(Driver, 2005); quest for meaning (Thoresen, 1999); a multi-faceted belief system (Garcia-

Romeu, 2010); part of one’s inner being that relates to the divine Source (Lines, 2002); holding

onto the power of something larger than oneself while interpreting suffering within a meaning-

making context (Delgado, 2005); relationship with God (Tuck et al., 2006); something giving

meaning and purpose to life (Baker, 2003); union beyond the self (Shaw, 2005); and deep unity

between body, soul, and the collective (Giordan, 2009).

According to Baker (2003), spirituality has the capacity to provide a way to “review and

interpret . . . events . . . to make sense out of it and to come to terms with and develop a sense of

integrity” about who we are as individuals (p. 55). This sense of meaning and mastery promotes

both physical and psychological well-being (Baker, 2003). In a seminal paper about spirituality

and well-being, Ellison (1983) explored the relationship between well-being and spirituality by

incorporating a fourth human need, the transcendent, which creates a sense of well-being through

a “non-physical dimension of awareness and experience which can best be termed spiritual” (p.

331). The transcendent dimension refers to an experientially based belief about a “natural

extension of the conscious self into the regions of the unconscious or Greater Self” (Elkins et al.,

1988, p. 10).

According to Baker (2003), spirituality provides a space within which to review and

interpret events in life and to make sense of these events. This capacity to make meaning of

experiences allows individuals to “develop a sense of integrity about [who] they are as a human

being” (p. 55). Further, spirituality allows for individuals to empower themselves and to take

responsibility for their actions and decisions. The concept of meaning-making, purpose, or

calling in one’s life, indicates that a person experiences his or her work “as beyond instrumental
 37

goal seeking, beyond job or career, and instead as one that is perceived as one’s purpose in life”

(Singhal & Chaterjee, 2006, p. 170). This could be conceptualized as a calling or desire for

interconnectedness to the greater collective.

Altruism can be defined as the “prosocial behavior toward another person that is aimed at

enhancing the well-being of another” (Huber & MacDonald, 2012, p. 4). Altruism has been

associated with love, or agape, which is the sense of the sacred, as opposed to romantic love

(Koss-Chioino, 2006). This sense of the sacred informs the helping of others “without

expectation of benefit to oneself” (p. 887). Altruism from a spiritual, healing perspective

supports the idea that the “intention must be to benefit another person; the altruistic act cannot be

a secondary consequence” (Koss-Chioino, 2006, p. 888). It is from this place of healing and

intention that altruism will be focused for the purposes of this research.

Although the current research study did not attempt to measure the relationship between

altruism and spirituality (Elkins et al., 1988; Huber & MacDonald, 2012), it did assume that

altruism, spirituality, and well-being are related (Post, 2005). The current research incorporated

altruism, as a dimension of spirituality and further explored its influence on therapists’

experiences of working with individuals diagnosed with borderline personality disorder.

Motivation and motivating factors of altruism, such as desirability, have the capacity to

change the intention and dynamic of the altruistic act itself. Motives that are altruistic in nature

require the giver to have no desire for return or reward for their giving (Game & Metcalfe,

2009). Further, Post (2005) supported the idea that altruism creates more social connections and

enhances meaning and purpose in one’s life. This way of viewing altruism is particularly

relevant when viewed through the relationship of therapist and client. Game and Metcalfe (2009)

argued that altruism could be viewed as a gift relation, with the “experience of grace and gratuity
 38

where there are no distinct givers and receivers” (p. 266). It is with this perspective that altruism

is not an act of doing, but an act of being. It is through this lens that altruism is viewed, in

exploring the therapists’ ability to work with individuals diagnosed with borderline personality

disorder.

Individuals diagnosed with borderline personality disorder often present as a totality of

their symptoms, (Avirm et al., 2006). The feeling of hopelessness this presentation engenders

might challenge therapists to provide their most effective and empathetic treatment in therapy

because of the degree to which these clients suffer. Previous research has shown that an

awareness of tragic and intense suffering can be managed better and integrated by individuals

who consider themselves spiritual (Wright, 2008; Drescher & Foy, 2010). For example, clergy

members have a deep capacity to sit with those who suffer deeply (Dreschner & Foy, 2010).

These individuals are aware of the human condition of pain and suffering and, as opposed to

attempting to alleviate this condition, often allow themselves to just sit with others in this pain

(Drescher & Foy, 2010). It is theorized that this capacity to be aware of the tragic “enhances the

spiritual persons’ joy, appreciation, and valuing of life” (Elkins et al., 1988, p. 12), of which the

suffering client and, subsequently, the therapist, might have lost sight during this challenging

time.

Research has supported the concept that there is a correlation among religion, spirituality,

and mental health (Hall & Brokaw, 1995; Koenig, 2010; Rippentrop, Altmaier, Chen, Found, &

Keffala, 2005). In fact, studies have shown religiosity “to be associated with lower levels of

many kinds of psychological problems” (Nelson, 2009, p. 351).

Powers, Cramer, and Grubka (2007) explored the relationship among stress, spirituality,

and well-being to better understand whether affect is influenced by spiritual beliefs. Participants
 39

were 136 undergraduate students from a Catholic, mid-Atlantic liberal arts college. Thirty were

male, 105 were female, and 1 was unidentified as to gender. The majority of participants were

Caucasian (93%) and Catholic (80%) and ranged in age from 17-22 (M = 18.82). The Beck

Depression Inventory (BDI; Beck et al., 1961) was used to assess participants for depression

symptoms (r = .73 to .92). The Undergraduate Stress Questionnaire (USQ; Crandall, Priesler, &

Aussprung, 1992) measured stress levels specific to university-aged participants. Powers et al.

(2007) reported that the USQ had “acceptable internal consistency, split-half reliability, and test-

retest reliability” (p. 237), but did not report the related statistical data. The Positive and

Negative Affect Schedule (PANAS; Watson, Clark, & Tellegan, 1988), a ten-item positive affect

and ten-item negative affect scale, measured participants’ positive and negative moods as based

on a 5-point Likert scale (1 = very slightly/not at all characteristic of me, 5 = extremely

characteristic of me). Alpha reliability of the PANAS is statistically significant (.84 to .90).

Finally, the Spiritual Involvement Scale (Fenzel, 1996) is an 18-item scale measuring spirituality

in two realms, Spiritual Life Integration (SLI, r = .95) and Social Justice Commitment (SJC, r =

.75), using a five-point Likert scale (0 = not at all true of me, 5 = definitely true of me). The

Spiritual Life Integration shows good validity and reliability. The SLI is positively correlated

with Faith Maturity (r = .76, p < .001) and negatively correlated with depression (r = -.32, p <

.01) and hostility (r = .00). The SJC is also positively correlated with Faith Maturity (r = .36, p <

.01) and negatively correlated with depression (r = .18, p < .01). Participants were administered

these four measures in a classroom setting.

Results were reached through hierarchical regression and explored the role of stress and

spirituality on well-being (Powers et al., 2007). First, zero order correlation showed a significant

correlation between negative affect and symptoms of depression (r = -.559, p < .01), and there
 40

was a strong positive relationship between social justice commitment (the feelings of the

importance of the effort to improve the welfare of others) and positive affective states (p = .01).

Spiritual life integration was positively correlated with positive affect and social justice

commitment (p < .01) and social justice commitment was positively correlated with positive

affect and negatively correlated with negative affect and depressive symptoms (p < .01). This last

result is the most salient and interesting for the current research study due to the relationship

between social commitment, altruism, and well-being.

Plante (2008) discussed several religious traditions and practices that might support

psychological well-being. One of these practices is social justice, defined as “activities to help

the poor and marginalized of society and working to make the world a more humane and just

place” (p. 438). As was previously discussed, altruism is also connected to the sacred,

particularly through the form of helping others without expectation of help in return (Koss-

Chioino, 2006).

Results from Powers et al. (2007) were discussed relative to the significance of social

justice, indicating that individuals who participate in more acts of kindness (based upon criteria

from social justice commitment) would show more positive affect, less negative affect, and less

depression symptomatology and that, further, individuals who do not participate in these acts

might show higher levels of negative affect.

However, some research has not fully supported the correlation between higher levels of

spirituality and lower levels of depression and negative affect (personal communication, Philip

Friedman, Ph.D., April 5, 2013). The Powers et al. (2007) study was limited in that participant

bias was likely high. Moreover, given the demographics (young age, majority Catholic in
 41

religious affiliation) of its participants, it would be interesting to see the relationship between

spirituality and well-being for a more generalizable sample.

However, given the connection between participation in social justice activities, altruism,

spirituality, and positive affective states (Koss-Chioino, 2006; Plante, 2008; Powers et al., 2007)

results from Powers et al. (2007) still have implications for the current research study. If, as

some researchers have shown, spirituality can be associated with positive affect (specifically

when providing support for others) might it be that therapists who consider themselves more

spiritual report more positive affective states when providing therapy to this clinically

challenging group?

Role of Spirituality and Religion in the Life of the Therapist.

Research has explored the importance of and ethical obligations relative to therapists’

awareness of clients’ spiritual and religious belief systems in session (APA Ethics Code, 2002;

Miller, 2010; Richards & Bergin, 2005; Shafranske & Malony, 1990), but what consideration

should be made regarding therapists’ personal relationship with religion and spirituality?

Research has supported evidence that mental health professionals are less committed to

religious affiliations, as compared to the population at large (Bergin & Jensen, 1990; Bienenfeld

& Yager, 2007; Bilgrave & Deluty, 2002). For example, when given the statement “my whole

approach to life is based upon my religion” (Bienenfeld & Yager, 2007, p.178), only 46% of

mental health providers agreed, as compared to 72% of the general public. This is not surprising,

given the fundamental split between psychology and religion early on, influenced by seminal

clinicians and researchers such as Freud, Ellis, and Skinner (Bilgrave & Deluty, 2002). However,

equally influential theorists such as Allport, James, and Jung have suggested that religion is an

“agent of potent psychological transformation and integration” (Bilgrave & Deluty, 2002, p.
 42

246). To this end, several studies have explored religiosity, spirituality, and religious belief

systems of psychologists (Bergin & Jensen, 1990; Bilgrave & Deluty, 1998; Bilgrave & Deluty,

2002 ; Shafranske & Malony, 1990; Smith & Orlinsky, 2004).

James introduced the term “Weltanschauung” to the English language, a term that quite

literally means the way in which each culture views their world or the way in which individuals

make sense of their world and experiences (Hebel, 1999). Weltanschauung, in relation to how

therapists experience their religious and spiritual belief systems, might influence the process by

which they provide therapy to their clients.

Based upon reviewed empirical literature, Shafranske and Malony (1990) suggested that

“religious variables affect the utilization of psychological services and may influence the process

of psychotherapy” (p. 72). Shafranske and Malony were further interested in exploring clinical

psychologists’ religious and spiritual orientations and how these professionals’ orientations

might affect their practice of psychotherapy. They randomly selected for a study 1000 clinical

psychologists from APA Division 12 (Division of Clinical Psychology), and 409 participants

responded. Participant demographics included 107 females, 299 males, and 3 unidentified as to

gender. The majority of participants held a doctoral degree in psychology (96%) and most

indicated their theoretical orientations as either psychodynamic (33%), cognitive (30%), learning

theory (17%), heuristic (12%), or eclectic (7%), with 5 indicating they had espoused no

theoretical orientation (Shafranske & Malony).

Participants were administered a 65-item questionnaire that included demographics and

an ideology orientation scale, asking participants to select a belief that most represented their

own, ranging from “God or the Transcendent are illusions” to “a belief in a personal God” (p.

73). Additionally, the questionnaire included an external and an internal quest scale, which
 43

addressed how the social environment influenced personal religiousness (external quest) and

how religion might provide a means to answer existential questions (internal quest). The

questionnaire also measured attitudes and practices about specific counseling interventions and a

case study for their commentary with which to explore possible clinician bias towards a religious

client.

Results indicated that 40% endorsed a personal, transcendent God orientation, 53%

believed that it was generally important and desirable for individuals to have religious beliefs,

and 65% reported spirituality as personally relevant. Of responding psychologists, 97% reported

having been raised in some type of faith tradition. However, only 18% reported that organized

religion played an important role in their current conceptualization of spirituality. Further, more

than half of the respondents (n = 207) agreed that their spiritual beliefs were of the type

characterized as “an alternative spiritual path which is not part of an organized religion”

(Shafranske & Malony, 1990, p. 74). Results further indicated that psychologists believed that

spiritual/religious issues were relevant to their psychotherapeutic work.

Of highest interest, and what has implications for the current study, is the relationship

between the therapists’ endorsement of spiritual/clinical competency and religious dimensions.

For example, therapists who tended to believe that their religion/spirituality was a way of

“providing clear answers to existential questions” (Shafranske & Malony, 1990, p. 75) also

indicated a high level of competency in their own spiritual/clinical skills (p < .001). This

relationship might indicate that therapists who are comfortable and secure in their religious/

spiritual beliefs might have a more attuned awareness for religious/spiritual issues in therapy

with clients. Shafranske and Malony (1990) went on to say that religious/spiritual beliefs might
 44

“function as a metatheory that significantly influences psychotherapy in both implicit and

explicit ways” (p. 77).

A limitation of this study might be that, of the initial 1000 randomly selected participants,

the 409 who responded might have upon recruitment considered themselves more

religiously/spiritually oriented and, therefore, more inclined to participate in the study. A second

limitation is the lack of reliability and validity reported in the results. Although the data reported

is encouraging, it is unclear how valid the results are when compared to those with other groups.

The findings from Shafranske and Malony (1990) are contrary to findings in previous literature

(Bienenfeld & Yager, 2007) regarding minimal religions and spiritual orientation within the

mental health community. Although still not representing as large a percentage as has been

reflected in findings from the general public, this research provides evidence that psychologists

do, in fact, hold religious and spiritual values in their work.

To better understand the possible implications of religious/spiritual beliefs and

psychotherapists’ theoretical orientations, Bilgrave and Deluty (1998) administered to doctoral-

level clinical and counseling psychologists a 65-item questionnaire that assessed multiple

variables, including demographics, membership in religious institutions, frequency of attending

services, therapeutic orientation, degree of perceived spiritual support, degree of agreement with

religious beliefs, and degree to which religious beliefs influenced their practice of

psychotherapy.

Participants included 237 doctoral level clinical or counseling psychologists, 156 male

and 81 female. The majority of participants (90%) were European American and practiced as

clinical psychologists (59%). Based upon initial demographics, 66% reported a strong or very

strong belief in God or Universal Spirit, while 74% reported religion to be moderately to
 45

extremely important in their lives. Theoretical orientation was as follows: humanistic/person-

centered/existential, 40%; cognitive-behavioral, 34%; psychodynamic, 22%; and existential, 4%.

Participants were administered a 65-item questionnaire (validity and reliability not

provided by authors) that included 33 items that assessed for specific religious beliefs—for

instance, belief in god, belief in the divinity of Jesus, support for interpretations of the Bible, and

belief in the subjective importance of religion. Finally, the questionnaire included items

interested in assessing spiritual support and intrinsic religion (Bilgrave & Deluty, 1998).

In relationship to religion/spirituality and its influence on therapists’ practice of

psychotherapy, psychologists were asked to what degree they agreed with the questions, Do you

believe your religious beliefs have influenced your practice of psychotherapy? (Bilgrave &

Deluty, 1998, p. 339). Results indicated that there was a high correlation between psychologists

who identified as Eastern/Mysticism in spirituality (p < .00005) and Orthodox Christianity (p <

.00005) and the degree of influence of religion/spirituality in their work. Further, psychologists

who reported feeling as though their religious belief system influenced their psychotherapy

practice believed that their religious view was personally important (p < .00005) and indicated

that they experienced a high level of spiritual support (p < .01).

This study is relevant to the current research study in part because it draws a clear parallel

between psychotherapists’ religion/spirituality and psychotherapists’ clinical work. Further,

Bilgrave and Deluty (1998) suggest that future research in this area should include mental health

professionals, which this current research study aimed to accomplish. Although Bilgrave and

Deluty provided a solid foundation regarding the relationship between psychologists’

spiritual/religious orientation and their practice of psychotherapy, there was no discussion related

to how therapists integrate these spiritual/religious beliefs into psychotherapy, nor was there an
 46

exploration into how spirituality/religion might influence their work with clients (i.e., their

ability to be more grounded, having a sense of reverence, etc.). The current research study aimed

to explore in depth both of these considerations that had represented limitations to

generalizability in the Bilgrave and Deluty study.

There is no known, published literature that currently explores the effects spirituality

might have on therapists who provide individual psychotherapy to individuals diagnosed with

borderline personality disorder. Therefore, this research is the first of its kind to attempt to

explore how spirituality might influence therapists’ experience of working with this clinical

population.

Summary of Literature Review

This literature review has explored current, published, empirical research pertaining to

the central research questions of this dissertation: 1) What are therapists’ experiences of working

with individuals diagnosed with borderline personality disorder? and 2) How does a therapist’s

spirituality affect his/her experience of working with these individuals? This review discussed

the history of BPD, including key symptomatology and the theoretically based treatment model,

Dialectical Behavior Therapy (DBT). Further, it explored the challenges caregivers, psychiatric

nurses, psychiatrists, and family members might experience while interacting with this clinical

population. This review also discussed the relationship between spirituality and well-being as it

pertains to the broad, general population, as well as how psychotherapists’ spirituality and

religion is incorporated into their clinical work.

Current Study

To date, little literature has explored therapists’ complex experience of working with

individuals diagnosed with borderline personality disorder. To add to this, no research has been
 47

found that explores how therapists’ spirituality affects their experiences of working with clients

diagnosed with BPD. This is in part due to the challenges of providing a succinct, conceptualized

definition of spirituality and religion. Historically, in the literature (Elkins et al., 1988; Gomez &

Fisher, 2003; Kapuscinski & Masters, 2010; Nelson, 2009), the term spirituality has been

difficult to define with one general definition, in part due to its multidimensional, personal

meanings (Smith & Orlinsky, 2004). Additionally, most research on spirituality focuses on the

general population rather than on clinicians, while no research has yet attempted to explore the

relationship between spirituality and the experiences of clinicians who work with individuals

diagnosed with borderline personality disorder.

Based upon previous literature that has studied the positive physical, emotional-health,

and general wellness benefits of spirituality (Baker, 2003; Ellison, 1983; Hall & Brokaw, 1995;

Koenig, 2010; Post, 2005; Powers et al., 2007; Rippentrop et al., 2005; Singhal & Chaterjee,

2006;), this study sought to extend the body of literature and further explore the extent to which

spirituality might create more positive experiences for therapists in the work of treating their

clients diagnosed with borderline personality disorder.

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Chapter 3: Method

The central research questions for this pilot study are: What are therapists’ experiences of

working with individuals diagnosed with borderline personality disorder? Further, how might

spirituality affect their experience of working with these individuals? It is hypothesized that

therapists who score higher on spirituality measures will describe more positive experiences in

their work with clients diagnosed with BPD than will those with lower scores. Spirituality is left

intentionally undefined but placed within parameters discussed in the literature review in order

that it encompass a transcendent dimension, meaning and purpose of life, altruism, and

awareness of the tragic (Baker, 2003; Dreschner & Foy, 2010; Elkins et al., 1988; Huber &

MacDonald, 2012; Post, 2005; Singhal & Chatergee, 2006).

Due to the small sample size (n = 10) of participants, this research serves as a pilot study

in which an embedded mixed-methods design was used. In this design, one data set provides a

supportive, secondary role in a study based primarily on the other data set (Creswell & Plano

Clark, 2007). According to Creswell, Plano Clark, Gutmann, and Hanson (2003), collecting two

forms of data might “neutralize or cancel out some of the disadvantages of certain methods” (p.

211) and can further strengthen the study’s validity. Oftentimes, in transpersonal psychology,

quantitative methods are not used because they are thought to be reductionist in method and do

not account for the “inherent richness, complexity, and often ineffability of subjective human

experience” found in qualitative approaches (MacDonald & Friedman, 2002, p. 104). However,

both quantitative and qualitative research can be valuable for transpersonal research because it

couples the lived, human experience with tangible assessment tools. If the field continues to

favor qualitative methods over quantitative, MacDonald and Friedman (2002) argued,

transpersonal psychology could be in “jeopardy because of the gross underutilization of

 49

recognized technologies in verifying theory,” such as psychometric testing and scales (p. 106).

Most importantly, such tests might help to support and verify much of the transpersonal theory

established in the qualitative literature.

The complexities of research in the social sciences are great and mixed-methods might

help the researcher to gain a better understanding of such complexities. Central to mixed-

methods design is the combination and integration of different methods (Creswell et al., 2003).

The primary method for qualitative data collection used in this study was a heuristic research

method (Moustakas, 1990). Qualitative data was then explored through thematic analysis (Braun

& Clarke, 2006) and was further supported by two quantitative scales, the Spiritual Orientation

Inventory (SOI; Elkins et al., 1988; see Appendix A) and Assessment of Spirituality and

Religious Sentiments (ASPIRES; Spiritual Transcendence Scale, Piedmont, 2010; see Appendix

B). The intention behind this particular method of choice was to explore the theoretical questions

of interest through a qualitative lens and further test a specific hypothesis through two

quantitative scales.

According to Moustakas (1990), heuristic research “refers to a process of internal search

through which one discovers the nature and meaning of experience” (p. 9) and further explores

the nature of a question or problem that the researcher seeks to answer. According to Sela-Smith

(2002), the “Moustakas method of heuristics invites the conscious, investigating self to surrender

to the feelings in an experience, which carries the research to unknown aspects of the self and the

internal organizational systems not normally known in waking state consciousness” (p. 59). This

form of qualitative research requires engagement by both the researcher and participants to

deeply explore the experience of all those involved. Heuristic research requires six phases of

engagement in order to fully come to a deep understanding of the phenomenon being studied:
 50

initial engagement, immersion, incubation, illumination, explication, and creative synthesis

(Moustakas, 1990).

Heuristic research is an excellent theoretical frame for this research because it requires a

relationship between the researcher and the participants. In this case, the researcher is a training

clinician who has worked with individuals diagnosed with borderline personality disorder in

individual and milieu therapy; therefore, there is a shared experience with each participant

(clinicians working with those diagnosed with BPD) that lends itself naturally to a connected,

shared understanding in which the question will be explored through “self-inquiry and dialogue

with others aimed at finding the underlying meanings of important human experiences”

(Moustakas, 1990, p. 15). As a secondary measure, two quantitative assessments will be

administered to glean statistical data specifically pertaining to participants’ spirituality (SOI;

Elkins et al., 1988; ASPIRES; Piedmont, 2010) and to support the hypothesis that therapists who

are more spiritual might describe their experiences of working with individuals diagnosed with

borderline personality disorder as more positive.

Participants

A convenience sample of 10 participants who are licensed clinicians residing in the

Seattle metropolitan, San Francisco Bay, or Rochester, New York areas were recruited. There

were four requirements of participation in this pilot study. First, participants were required to be

licensed, practicing clinicians (i.e., Masters in Family Therapy, MFT; Doctor of Philosophy in

Psychology, Ph.D.; Doctor of Psychology, Psy.D; Licensed Masters in Social Work, LMSW, or

Licensed Mental Health Counselor, LMHC). Second, participants were required to currently be

providing individual therapy to at least two clients diagnosed with borderline personality

disorder, according to the 9 criteria in the DSM-IV-TR (American Psychiatric Association, 2000;
 51

i.e., frantic effort to avoid real or imagined abandonment; a pattern of unstable and intense

interpersonal relationships alternating between idealization and devaluation; identity disturbance:

persistent unstable self-image and sense of self; impulsivity in at least two areas that are self-

damaging: spending, sex, substance abuse, reckless driving, binge eating, recurrent suicidal

behaviors; gestures of, threats of, or actual self-mutilating behaviors; affective instability and

reactivity in mood; feelings of emptiness; inappropriate or intense anger or difficulty controlling

anger; and transient, stress-related paranoid ideation or dissociation). In order to confirm a

diagnosis of BPD, therapists assessed their clients with diagnostic measures—for instance, the

Structured Clinical Interview for DSM-IV (SCID-II; First, Spitzer, Gibbon, & Williams, 1997),

BPD Symptom Check List (BSL-23; Bohus et al., 2009), or using the DSM-IV-TR diagnostic

criteria.

Third, participants were required to have worked with their clients diagnosed with BPD

for at least 1 year. Fourth, participants were required to be over the age of 21 in order to legally

consent to participation in the study. No preference was given to gender, therapists’ theoretical

orientation, or length of time as a practicing clinician. However, this information was gathered

and coded using an initial demographic questionnaire (see Appendix C).

Recruitment

For recruitment purposes, in-person, electronic (via email), and phone contact was made

with various clinics, agencies, and private therapy practices in the Seattle, San Francisco Bay,

and Rochester, New York areas. In addition, fliers (Appendix D) were distributed at the

University of Washington, Seattle; University of Washington, Tacoma; the University of

Rochester Medical Center in Rochester New York; and Sofia University, formerly the Institute
 52

of Transpersonal Psychology, in Palo Alto, California. Finally, mental health professionals were

encouraged to refer their qualified and interested colleagues to the study.

Interested participants were asked to fill out a demographic questionnaire, which included

study inclusion criteria (see Appendix C). If a participant met the four inclusion criteria, the

researcher scheduled a convenient time to meet with the participant. In addition, the researcher

obtained contact information, for the purposes of future communication. Upon meeting,

participants completed an informed consent form (see Appendix E). For the privacy of each

participant, all identifying information was kept on a password-protected computer used only by

the researcher.

Instrumentation

A semistructured interview was employed qualitatively and two quantitative

measurements were given to each qualified participant.

Semistructured interview. The primary aim of this research study was to better

understand therapists’ experiences of working with individuals diagnosed with borderline

personality disorder. To this end, the researcher conducted semistructured interviews (see

Appendix F) with each qualified participant. These semistructured interviews attempted to gain

insight into therapists’ experiences, allowing for the most organic flow of information to come

forward, and paying specific attention to therapists’ clinical and personal experiences with this

population. From a transpersonal lens of analysis and based upon the heuristic research method

in this study, it was important that the stories shared in this study were honored and respected

and that each participant felt welcomed and safe to explore her or his experiences (Braud &

Anderson, 1998). To facilitate this, the researcher performed a personal and private meditative
 53

ritual prior to meeting each participant for the semistructured interview, calling upon Spirit to

create a safe, welcoming place for further exploration and insight into this topic of interest.

Spiritual Orientation Inventory. The Spiritual Orientation Inventory (SOI; Elkins et

al., 1988) is an 85-item questionnaire, which includes nine spiritual subscales: Transcendent

Dimension, Meaning and Purpose in Life, Mission in Life, Sacredness in Life, Material Values,

Altruism, Idealism, Awareness of the Tragic, and Fruits of Spirituality, and explores spiritual

orientation, minimizing possible confounding variables like conventional religion and religiosity

(MacDonald & Friedman, 2002).

According to Elkins, et al. (1988), spirituality is a human phenomenon that can be more

than just traditional (externalized, ritualized) religion and religiosity. In their attempt to better

understand the constructs and measures of spirituality, Elkins et al. explored the clinical

dimensions of spirituality so that it could be easily addressed and measured. Elkins et al. were

interested in creating a scale to measure spiritual orientation, as they found that individuals had

an “intuitive sense of what is meant when someone is described as ‘very spiritual’” (p. 13). In

order to quantify what spirituality actually was, Elkins et al. reviewed several published

measures of spirituality and religiosity, for example, Allport’s (1967) Religious Orientation

Scale, Yinger’s 7-Point Non-Doctrinal Religious Questionnaire (Yinger, 1969), and Hood’s

(1970) Religious Experience Episodes Measure. However, these scales were developed from a

more traditional religious lens, whereas the Elkins et al. researchers were more interested in

conceptualizing the humanistic definition of spirituality, in addition to traditional religiosity. As

has been reviewed in chapter 2, spirituality was taken to encompass more than just religion and

religiosity, and, therefore, the SOI seemed a viable scale with which to measure the complex,

multidimensions of spirituality.
 54

In the first phase of development for the SOI, Elkins et al. (1988) reviewed literature

from seminal scholars such as James, Jung, Maslow, Otto, Dewey, Allport, Fromm, Frankl, and

others to best conceptualize spirituality from a phenomenological perspective. Through this

initial review, spirituality was found to be a seemingly dynamic, complex, and multidimensional

construct with nine factors that were core to spiritual experiences: (1) Transcendent Dimension,

the belief in something more than what can be seen; (2) Meaning and Purpose in Life, allows for

the authentic sense of meaning in life, which often can be specific to each individual; (3) Mission

in Life, a sense of responsibility and calling in one’s life; (4) Sacredness of Life, the belief that

all life is holy and sacred; (5) Material Values, with a value toward material positions but

without ultimate happiness being placed upon this ownership; (6) Altruism, an ability to be

touched by the pain and suffering of others and wholeness of the human experience; (7)

Idealism, a desire to better the world and see the good in all individuals; (8) Awareness of the

Tragic, being conscious of the tragedy in life without losing sight of the depth of spiritual joy;

and (9) Fruits of Spirituality, ways in which spirituality permeates all parts of life to create a

connection to the whole.

These nine components of spirituality were subsequently tested by interviewing

individuals who self-reported as being highly spiritual and were drawn from Buddhist, Catholic,

Protestant, and Jewish faith traditions. Participants (n = not given) were given the list of these

nine components and asked to evaluate each, based upon their experience and understanding of

spirituality. Participants validated this list with their own personal experience of spirituality,

responses that subsequently provided Elkins et al. (1988) with a humanistic definition and

description of spirituality using these nine validated categories.

 55

For the second phase in the SOI development, Elkins et al. (1988) tested these nine

components for content validity. Initially 200 items were presented to 5 psychology and

spirituality experts. Participants were asked to rate each item on a Likert-type scale (1 =

unacceptable; 2 = poor; 3 = average; 4 = good; 5 = excellent) for which rating process they were

asked to consider the clarity, readability, goodness of fit, and relevance to spirituality for each.

Items that received less than an average rating of four were removed, leaving 157 remaining

items, each of which reflected one of the nine spiritual components. Further delineation of

statements finalized the current version of the SOI, which consists of 85 items, each ranked on a

similar 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree), with higher scores

indicating stronger spiritual orientation.

The SOI is currently available in public domain and not frequently used in quantitative

research. Previous research indicates small reliability (n = 25, r = 0.75 to 0.94; Elkins et al.,

1988). In a larger sample, unpublished raw data showed a higher alpha reliability (r = 0.81 to

0.98) based on a review of 96 administrations of the SOI (Elkins, 1987). In a direct email

exchange of this present researcher with Elkins, he stated that “numerous studies were done

using the SOI to distinguish between groups, but to do the norming needed was very expensive

and I was not able to move forward with that. So the SOI can be used to distinguish between

groups based on its theoretical founding and the limited statistical data available” (personal

communication, August 10, 2011).

Few studies have used the SOI to measure spirituality as defined by Elkins et al. (1988).

For example, in a validity study, scores from 24 “highly spiritual” participants were compared

with scores from 96 psychology graduate students. Researchers believed that the highly spiritual

participants would “score significantly higher on the Spiritual Orientation Inventory than the
 56

graduate students” (Elkins et al., 1988, p. 15). Results from a one-tailed t-test supported this

theory, indicating that eight of nine subscales differed significantly between groups, with the

“highly spiritual” group scoring higher on the SOI as compared with the graduate student group

(Elkins et al.). For stronger validity, it would have been beneficial to compare two, similar,

highly spiritual groups as opposed to one highly spiritual group and a group of graduate students.

It is because of this significant difference between samples in Elkins et al.’s study, the SOI still

has questionable validity.

A second study (Zainuddin, 1993) used the Spiritual Orientation Inventory to further

explore factors of spirituality. Teachers from Aligarh Muslim University in India (n = 219) were

randomly selected to participate. Zainuddin (1993) calculated reliability on the SOI prior to

administering the scale in this study (r = 0.75 to 0.91) and further validated it against Wuthnow’s

Test (Wuthnow, 1978), which measures incidents of peak experiences. Scoring the SOI required

a summation of numbers circled by participants, with negatively scored items being reversed in

value to reflect the opposite positive. Generally, a higher number indicates a higher spiritual

orientation.

Results were reached through principle axis method and rotated with varimax technique

(Zainuddin, 1993). Factor loading indicated that spiritual dimensions of the SOI fell into two

groups: Factor I (philosophy) included mission and purpose in life, meaning in life, sacredness,

altruism, and idealism; Factor II (experiential) included transcendent dimension and fruits of

spirituality. Results further indicated that individuals might experience the philosophical nature

of spirituality (Factor 1) but not the experiential component (Factor II). Again, reliability and

validity of these results were not provided; therefore, implications of this study are limited as

they might relate to the use of the SOI in the current study.
 57

The researcher is aware of the multiple limitations and lack of validation of the study,

but, because it explores spirituality on a dynamic, phenomenological level, it was chosen as one

of the scales for this research. It is with this kind of limitation in mind, that the researcher also

selected the Assessment of Spirituality and Religious Sentiments (ASPIRES; Piedmont, 2010), a

highly validated, normed, and often used scale, to further explore the quantitative measurement

of spirituality in the lives of therapists. Using the ASPIRES measure provided insight into initial

reliability of the SOI, as will be further discussed in the results and discussion chapters, 5 and 6.

Assessment of Spirituality and Religious Sentiments scale. The Assessment of

Spirituality and Religious Sentiments scale (ASPIRES; Piedmont, 2010) was established to

explore how spirituality is measured and whether spiritually orientated variables are different

from traditionally measured psychological variables. It was first introduced as the Spiritual

Transcendence Scale (STS; Piedmont, 1999), developed to capture the “fundamental aspects of

spirituality” (Piedmont, 2010, p. 6).

In order to psychometrically evaluate the STS, Piedmont (1999) performed a joint factor

analysis of the Transcendence scales (Connectedness, Universality, and Prayer Fulfillment) with

the Five Factor Model (FFM; Tupes & Christal, 1961) to further establish independence of

personality domains. Hierarchical multiple regression was used to determine predictive strength,

in addition to factorial invariance, confirmatory factor analysis, and cross-observer convergence

to further support the validity of the scale. Piedmont (1999) used two population samples in this

study: first, a development sample (n = 379) and second, a validation sample (n = 356). The

development sample participants were administered several scales, including the Bipolar

Adjective Scale (McCrae & Costa, 1985, 1987), Perceived Social Support Scale (Insel & Roth,

1985), Prosocial Behavior Inventory (De Conciliis, 1993, 1994), Sexual Attitudes Scale (Fisher,
 58

Byrne, White, & Kelley, 1988), Vulnerability to Stress Scale (Miller & Smith, 1987), Internal

Health Locus of Control Scale (Wallston, Wallston, & De Villis, 1978), Attitudes Toward

Abortion Scale (Parsons, Richards, & Kanter, 1990), Interpersonal Orientation Scale (Swap &

Rubin, 1983), and Faith Maturity Scale (Benson, Donahue, & Erickson, 1993). The validation

sample participants were administered the NEO Personality Inventory Revised (Costa &

McCrae, 1994), Spiritual Transcendence Scale (Piedmont, 1999), Bradburn Affect Balance Scale

(Bradburn, 1969), and Demographic Questionnaire (Piedmont, 1999). In addition to these

measurements, the validation sample participants were asked to enlist two other individuals

whom they had known for at least 3 months. These individuals served as observers and received

similar scales as did the participants, except that questions were formed in the third person, to

test for rater reliability.

In order to ensure the Spiritual Transcendence Scale measured its construct to the closest

ability, several theological experts identified aspects of spirituality common to all faiths. These

aspects were then analyzed within the context of the FFM (Tupes & Christal, 1961) and were

shown to be independent of personality differences (Piedmont & Leach, 2002). Further, STS

responses were correlated with scores from the Bipolar Adjective Scale (McCrae & Costa, 1985,

1987) and Faith Maturity Scale (Benson, Donahue, & Erickson, 1993). Items that correlated with

the personality scales, in addition to those “that were more strongly related to the personality

variables relative to the spirituality scales” (Piedmont, 1999, p. 997) were deleted. Results of this

factor loading indicated three clear facets, as have been previously mentioned: Connectedness,

Universality, and Prayer Fulfillment, with alpha reliabilities of .65, .85, and .85 respectively.

Concern over the generalizability of the Spiritual Transcendence Scale required

researchers to further explore the validity of the scale as it pertained to several different samples.
 59

Piedmont and Leach (2002) questioned whether the STS, originally sampled in the United States

with a population of mainly Christians, could be generalized to non-Western cultures across

multiple religions. Participants included 369 students from India (273 female, 96 male; 87

Christian, 218 Hindu, 64 Muslim) and were administered several scales similar to the procedure

in Piedmont’s (1999) original study. Confirmatory factor analysis was used to determine whether

the scale conformed to internal structure, a measurement resulting in a Chi-Square of 635.63 (p

< .001), with a Goodness of Fit (GFI) at 0.91 and a Comparative and Incremental Fit Index of

0.80. Lower CFI and IFI might be attributed to the lack of strong validity with regard to the

Connectedness Facet. When this facet was removed, Chi-Squared equaled 250.69 (p < .001) and

GFI, CFI, and IFI all greater than 0.90, indicating strong validity support for Universality and

Prayer Fulfillment in this particular sample with regard to spiritual transcendence. Further,

construct and incremental validity showed significant convergence with measures of religious

behavior and practice, spirituality, and well-being, which was consistent with results from the

normative sample. Most importantly, this study concluded that “spirituality does not arise out of

specific religious practices or affiliations but rather represents a singular quality of individuals

that transcends culture and context” (Piedmont & Leach, 2002, p. 1898).

To further support the use of the STS, Piedmont (2007) had the original scale translated

into the Filipino language of Tagalog with intent to evaluate the psychometric integrity across a

larger, more diverse sample. Two bilingual individuals translated the STS and changes were

made as necessary for context. Two population samples were used in this study. The validation

sample participants (n = 654) were administered several of the original scales used for the STS

development (see Piedmont, 1999) and requested to provide two individuals who would be used

as interraters for validity. The retest sample (n = 220) were directed to complete several scales 7
 60

days apart from one another. Scales for the retest group consisted of the STS (in both English

and Tagalog), Bipolar Affective Rating Scale (McCrae & Costa, 1985, 1987), Purpose-in-Life

Test (Crumbaugh, 1968), Self-Actualization Test (Jones & Crandall, 1986),

Individualism/Collectivism Scale (Dion & Dion, 1991), Altruism Scale (Rushton, Chrisjohn, &

Fekken, 1981), and Materialism Scale (Belk, 1985).

Confirmatory factor analysis was used to examine scale structure. Results indicated that

data fit the original model (Chi-Squared = < 3, NFI and CFI > 0.90), thus supporting researchers

attempt to further generalize the STS and provided evidence that “concepts of spirituality that

underlie the STS represent psychological phenomena that are relevant across different cultural

contexts” (Piedmont, 2007, p. 101).

Given the extensive research with the STS, Piedmont (2010) still encountered limitations

with generalizability due to the length of the scale and the complexity of its sophisticated

language. Therefore, a modified version was created. The revised STS (Piedmont, 2010) was

normed on a sampling of 466 undergraduate students, consisted of 23-items, and was broken into

four subscales, Prayer Fulfillment (r = 0.95), Universality (r = 0.82), Connectedness (r = 0.68),

and Total Score (r = 0.89), and correlated significantly with the original STS (Prayer Fulfillment,

r = 0.83, Universality r = 0.89, Connectedness r = 0.55, Total r = 0.87; p -values not given by

author).

The current ASPIRES scaleset is now made up of the revised STS, with 23 items that

measure three correlated areas, as were mentioned above. Participants rate each item on a Likert-

type scale with a range of from 1 = strongly disagree to 5 = strongly agree. Normative data

produced a significant age effect (p = < 0.001), indicating that aspects of spirituality might shift

over the lifespan. In addition to age, gender differentials existed (p = <0.002). Therefore,
 61

Piedmont (2010) explained the necessity for comparing scores by gender and age, and the

scoring manual accounts for these effects.

The second part of the ASPIRES scale is the Religious Sentiments Scale, which has been

used to test convergent validity for the STS. Specifically, the Religious Sentiments Scale

assesses the degree to which one is committed to his/her beliefs and whether participants have

had a sudden faith increase. These two components of the Religious Sentiments Scale provide

insight into how “religion and spirituality impact psychosocial functioning” (Piedmont, 2010, p.

9). The last four items of the Religious Sentiments Scale assess for religious crisis and challenges

individuals might experience with their religious doctrine or belief system. Participants in this

study were administered the entire ASPIRES measure; however, because this current research

was interested in assessing for spirituality and not religious crises or challenges, only the STS

subscales were analyzed in this data set.

Convergent validity of the ASPIRES (Piedmont, 2010) scale is high (p = < 0.001), a

result confirming that “spiritual and religious constructs can be measured with a comparable

level of accuracy as other personality traits” (pp. 25-26). Further, religiosity is positively

associated with Spiritual Transcendence (p = <0.001) and negatively associated with religious

crisis (p = <0.001). Factor analysis of the ASPIRES scale as compared with five personality

dimensions (neuroticism, extraversion, openness, agreeableness, and conscientiousness) revealed

a low correlation (r = -0.14), indicating that the ASPIRES scale captures aspects of an individual

independent of personality characteristics. Finally, the ASPIRES scale correlates significantly

with prosocial criteria (i.e., Purpose in Life was negatively correlated with religious crisis, r =
 62

-0.49, p = <0.001, and positively associated with prayer fulfillment, r = 0.38, p = <0.001).

The significant correlation between the APSIRES scale and positive psychosocial variables

makes this scale an ideal choice for the current study.

As was previously mentioned, this researcher chose to couple the phenomenologically

oriented Spiritual Orientation Inventory with the strongly validated tool, the Assessment of

Spiritual and Religious Sentiments with the aim that robust quantitative data would emerge to

help support the study’s original hypothesis, which was that therapists who score higher on

spirituality measures will describe more positive experiences in their work with clients diagnosed

with BPD than will those with lower scores.

Procedure

After participants were screened for inclusion criteria and completed the demographic

questionnaire electronically, the researcher scheduled a convenient time to administer the

semistructured interview and quantitative scales. Upon arrival at the office, participants

completed the informed consent (see Appendix E). In order to remain blind to the identities of

the measures being administered to a particular participant, prior to the start of participant

recruitment, the researcher assigned random 4-digit research IDs to ten of the SOI and ASPIRES

measures. These research IDs were then randomly matched to participant numbers, 001 to 010,

and were kept in a private journal away from all data analysis. Upon scheduling interviews with

participants, the researcher assigned each recruit a participant ID (001-010) used to identify his

or her semistructured interview and demographic information. Participants were offered their

choice of meeting places; however, it was recommended that participants meet in an office

setting, either their own or one established by the researcher for the purposes of this study. This

office was dedicated to the privacy and safety of the participant.

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Each one-hour, semistructured interview was audio-recorded. Participants were also

informed about the nature of their participation in this study, along with the benefits and risks of

their participation. The semistructured interview consisted of several open-ended questions

regarding the therapist’s experience of working with individuals diagnosed with BPD (see

Appendix F).

Once the semistructured interview was completed, participants spent approximately 30

minutes completing two quantitative scales: the Spiritual Orientation Inventory (SOI; Elkins,

1988) and the Assessment of Spirituality and Religious Sentiments scale (ASPIRES; Piedmont,

2010). Participants completed these scales in the privacy of the chosen meeting place. Upon its

completion, participants were thanked, informed of their opportunity to receive communication

regarding the outcomes of the final study, and asked whether they would like to refer any other

professionals to participate in the study.

Based upon the heuristic model of this research, it was essential that the researcher be as

actively involved in the research process as were the study participants. This researcher actively

participated in the cultivation, excavation, and incorporation of her own experiences as a training

clinician and researcher on borderline personality disorder. During the first phase, initial

engagement, the researcher deeply explored and reflected on her personal experiences as a

training clinical psychologist working closely with individuals diagnosed with BPD. This

personal experience led to the provision of a solid foundation relative to the initial research

question (see Appendix G). In the second phase, immersion, the researcher spent a great deal of

time journaling about her experience, often engaging in difficult self-reflective questions and

processes. For the third phase, incubation, the researcher took a conscious step away from

interacting with the central research question and began to cultivate knowledge of the borderline-
 64

personality-disorder diagnosis. This deepening of understanding of the diagnosis allowed for

further questions and ideas with regard to the central research question to evolve, naturally,

without effort.

The last four phases of heuristic research continued to shape and change as this research

was pursued. The phase of illumination happened continuously as the researcher gained a better

understanding of the research and nuances involved in theory development and practice.

Illumination, explication, and creative synthesis developed and shifted as the researcher

interviewed participants and analyzed data. The researcher took a reflective stance and continued

to journal about her process in order to continue to fully engage in the experience alongside the

participants.

Treatment of Data

All semistructured interviews were audio-recorded. Transcriptions of each session were

made by the researcher. Due to the heuristic lens of this research, it was important for the

researcher to be aware of potential research bias (Appendix G). To this end, this researcher

engaged with the data in several ways. First, interviews were audio-recorded so that verbal cues

might be attuned to in the initial replaying of the interviews. After the researcher had transcribed

each session, she went back and listened, deeply, to each session so as to get a felt sense of the

participant’s experience. Two additional unaffiliated analysts, who had agreed to sign

confidentiality forms, (see Appendix H), reviewed two random participant transcripts and

provided codes and meaning units for thematic analysis so as to increase reliability of qualitative

data gleaned from semistructured interviews.

In order to protect the identity of the participants, all recordings and transcript

information were kept on a password-protected laptop. Personally identifying information was

 65

kept in a separate file for the purpose of research confidentiality and was not used in any way. So

as to not bias the research, thematic analysis of the semistructured interview was conducted prior

to analysis of quantitative scales. For one transcript, a recording malfunction during the

semistructured interview required the participant to free-write responses to the first several

questions. These responses were unedited and were analyzed as if they were part of the original

interview.

According to Braun and Clark (2006), thematic analysis is a “method for identifying,

analyzing and reporting patterns (themes) within data” (p. 79). This analysis followed Braun and

Clark’s six phases: familiarization with data, generalized initial codes, search for themes,

reviewing themes, defining and naming themes, and producing final analysis and report (p. 87).

Qualitative data was then separated into two categories (a) positive experiences/descriptions and

(b) negative experiences/descriptions. This process was carried out in accordance with the

Creswell & Plano Clark (2007) method for transform qualitative data into quantitative data,

which included, “counting codes, counting themes, or both. The procedure involves: 1) analyzing

the qualitative data for codes and themes. 2) Counting the number of occurrences of the codes

and themes. 3) Entering these numbers into a spreadsheet or quantitative data analysis program”

(p. 138).

After thematic analysis and quantification of qualitative data were completed, this data

was set aside, and the researcher entered all quantitative data into a Microsoft Word Excel

spreadsheet. After the data were organized, the researcher matched quantitative scales (based

upon research IDs) to qualitative thematic analysis (based upon participant IDs) and quantified

qualitative themes. Data were merged in Microsoft Excel and analyzed using SPSS (Version 17)

with a focus on correlational and descriptive analysis to explore possible relationships between
 66

quantitative data. Correlations, using Pearson’s r, were run between: (a) ASPIRES total and

subscale scores and the SOI total and subscale scores, and (b) ASPIRES normative sample

versus the current study’s sample. Descriptive analysis was done on the (a) SOI total and

subscale scores, (b) ASPIRES total and subscale scores, and (c) quantified qualitative data

(positive and negative themes, codes, meaning units). Finally, mixed data analysis was

completed through correlational analysis, using Pearson’s r, as between the quantified qualitative

data with the SOI total and subscale scores and ASPIRES total and subscale scores. Results of

qualitative, quantitative, and mixed-methods analysis is presented in chapter 4 to further explore

main themes and important findings of this research.

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Chapter 4: Results
Description of Sample

Ten licensed mental health professionals participated in this research study.

Demographics (Table 1) were collected from each participant at the beginning of each interview.

Participants ranged in age from 31 to 62 (M = 42.6), with an average of 7.75 years’ experience as

licensed practitioners. There were 6 females, 3 males, and 1 identified transgendered participant.

Three participants were from Rochester, New York, 1 from the San Francisco Bay Area, and 6

from the Seattle metropolitan area. Four participants were licensed mental health counselors

(LMHC), 1 holds a doctorate in psychology (PsyD), 2 hold doctorates in philosophy in

psychology (PhD), 1 is a licensed marriage and family therapist (LMFT) and 2 are licensed

masters in social work (LMSW). Five participants identified multiple practices within their

theoretical framework (DBT; CBT; Humanistic, ACT), while 4 participants identified

themselves as DBT therapists, 1 as having a British Object Relations theoretical orientation, and

1 with a behavioral orientation. All but 1 participant identified as white/Caucasian. Four

participants work in Community Mental Health, 5 participants work in private practice, and 1

participant works in a University Counseling Center setting. All participants were currently

treating at least 2 individuals diagnosed with borderline personality disorder at the time of the

interviews and met additional participation criteria. However, 1 participant conceptualized

borderline personality disorder as a set of characteristics, states of mind, and developmental

process of the client, as opposed to defining it in strict adherence to DSM-IV-TR criteria.

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Table 1

Participant Demographic Information

Age Average Age: 42.6; Age Range 31-62

License Type Licensed Mental Health Counselor (LMHC): 4

Doctor of Psychology (Psy.D.): 1

Doctor of Philosophy (Ph.D.): 2

Licensed Marriage and Family Therapist (LMFT): 1

Licensed Masters in Social Work (LMSW)

Gender Female: 6, Male: 3, Transgender: 1

Type of Practice Community Mental Health: 4

Private Practice: 5

University Counseling Center: 1

Theoretical Orientation Multiple/Eclectic (DBT, CBT, Humanistic, ACT): 5

Dialectical Behavior Therapy (DBT): 3

British Object Relations: 1

Behavioral: 1

Race/Ethnicity White/Caucasian: 9

Asian/Polynesian: 1

Location Rochester, NY: 3

San Francisco Bay Area: 1

Seattle Metropolitan Area: 6

(Table 1 continues)
 69

(Table 1 continued)

Clients on Caseload with BPD Average number of clients diagnosed with BPD: 6

Number of clients diagnosed with BPD (range): 2-20

Total Clients on Caseload Average number of clients on caseload: 23.6

Number of clients on caseload (range): 5-40

Has Received Personal Therapy? Yes: 9

No: 1

Qualitative Results

Participants were asked a series of open-ended, semistructured questions pertaining to

their experiences of working with individuals diagnosed with borderline personality disorder.

Interviews were then listened to, transcribed, and further analyzed using thematic analysis

(Braun & Clarke, 2006). Thematic analysis produced twelve themes, which emerged from

qualitative data (Table 2). Further, based upon review of unaffiliated inter-raters’ coding

(Appendix I & Appendix J), codes did not deviate significantly from original thematic analysis

done by the researcher.

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Table 2

Main Themes from Qualitative Thematic Analysis

Theme Codes

THEME 1: Therapists experience their  Anxiety, fear, helplessness regarding

work with individuals diagnosed with client safety and self-harm
borderline personality disorder as  Feelings of helplessness; nothing is
challenging good enough
 Hatred, Fury, Anger, Disgust
 Fear associated with the personal
safety of the therapist

THEME 2: Therapists experience their  Therapists find joy, enjoyment, and

work with individuals diagnosed with gratitude in this work
borderline personality disorder as  Therapists find pride toward
rewarding themselves and their clients
 Therapists experience hope,
optimism, and encouragement when
clients show progress
 Therapist find it rewarding to be
recognized for their contribution to
their clients’ recovery
 Therapists find it rewarding to see
progress in their clients

THEME 3: Therapists describe ways in  Therapist participate in a personal

which they manage their own internal practice: clearing the space,
process and experience while working grounding, contemplative, sensory,
with their clients diagnosed with BPD mindfulness, and self-care
 Therapists rely on consultation to
remain aware of their own personal
triggers and to validate their
experiences
 Therapists have an awareness of
their own personal influence on
therapy, paying attention to counter-
transference and their own personal
process in session

(Table 2 continues)
 71

(Table 2 continued)

Theme Codes

THEME 4: Therapists experience a strong  Control vs. No Control: Power

dialectic component in their work with struggles, tension, willfulness, giving
individuals diagnosed with borderline solutions
personality disorder.  Refreshed vs. Exhausted: adrenaline,
stimulating, exhilarating,
overwhelmed, burn-out, more effort
 Idealization vs. Devaluation
 Compassion vs. Impatience
 Intimacy vs. Objectification
 Good vs. Bad
 Validation vs. Challenge
 Sitting in ambiguity

THEME 5: Therapists question their own  Therapists question their clinical

competency and clinical skills when competency
working with individuals diagnosed with  Therapists feel inadequate or
borderline personality disorder. incompetent
 Therapists experience a lack of
confidence and self-doubt in their
skills
 Therapists experience
disappointment, shame, regret, and
guilt

THEME 6: Therapists indicate that  Treatment expectations, benefit of

boundaries are an important part of the the client, benefit of the therapist,
work with clients diagnosed with and clarity in treatment
borderline personality disorder.  Personal vs. professional boundaries
 Providing structure and consistency
in treatment

(Table 2 continues)
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(Table 2 continued)

Theme Codes

THEME 8: Therapists experience the  Measuring improvement requires

importance of measuring improvement perspective and can be small and
and change in therapy based upon the based upon symptoms of the
context of the diagnosis and the clients’ individual
capacity to change.  Measuring improvement should be
based upon the client’s expectations
 Understanding the diagnostic
elements is important to measuring
success
 Not all clients diagnosed with BPD
are challenging
 It is important to measure change,
growth and behavioral change based
upon the client’s standards and
baseline
 It is important to be flexible and
creative in measuring effectiveness
of therapy.

THEME 9: Therapists experience a  Somatic experiences of the therapist

somatic component to their work with
individuals diagnosed with borderline
personality disorder.

THEME 10: Therapists experience this  Meaning

work as providing meaning and purpose to  Purpose
their lives.  Calling

THEME 11: Therapists experience a  Mastery and Competency

development of mastery and competency
when working with individuals diagnosed
with borderline personality disorder.

(Table 2 continues)
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(Table 2 continued)

Theme Codes

THEME 12: Therapists experience stigma  Stigma

connected to the diagnosis of borderline  How stigma affects the clients
personality disorder.  How stigma affects the therapists
 Misunderstanding
 Stigma within the
system/community
 Power differential

Theme 1: Therapists experience their work with individuals diagnosed with

borderline personality disorder as challenging. The most salient, central theme to emerge

across all 10 participant interviews was that therapists experienced their clients diagnosed with

borderline personality disorder as challenging. Challenges ranged from feelings of frustration, to

fear, helplessness, and anxiety. For instance, therapists reported feeling anxiety, fear, and

helplessness regarding their clients who participated in self-harm and suicide ideation.

Participant 001 discussed the helplessness associated with clients’ self-injurious behaviors,

describing a sense of “helplessness . . . of not being able to . . . save her from her self-harm . . .

and realizing that you can’t make a person want to live” (p. 5). Further, Participant 003 described

the anxiety she feels when working with BPD clients who self-harm:

I get anxious, you know I get anxious that they are going to die. Or that they are going to
do something that’s going to harm themselves and put them in a lot of damage. I get
anxious also . . . mostly if I have a client who has some scary self-harm behaviors or if I
have a severely suicidal client . . . I get anxious.

Similarly, Participant 004 explained the anxiety created by having to manage the therapeutic

relationship while struggling with clients who self-harm:

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If there is an element of risk in the harm, I feel the anxiety and there is a conflict that
goes on inside me about anxiousness about safety and . . . figuring out the boundaries or
figuring out how to hold the therapeutic relationship with the need of safety.

Participant 009 spoke to the challenge of being fearful toward her clients’ lethality:

There have been nights or weekends where I have gone home and, you know, and had
thoughts or dreams, or thought about someone all weekend, Am I going to see them on
Monday? Fear comes because, God forbid, something happens and they die.

A second important experience associated with the challenges of working with

individuals diagnosed with borderline personality disorder was the therapists’ feelings of

helplessness with regard to their inability to be or do enough for their clients. Participant 007

described an experience of “acute helplessness” for which she recalled, “No matter what I’m

offering, no matter how I do it, it’s going to get flung back in my face as not how I meant it.”

Similarly, Participant 006 described the challenges he faced when attempting to work on a

solution-focused level with his client. He stated, “Nothing is good enough if I go into solution

mode . . . the validation of the client is met with increased dysregulation.” Participant 005 also

described her experience with a client for which nothing is good enough: “The skills aren’t

working, the groups aren’t working, individual therapy’s not working, I don't know what to say

. . . I’ve given you all that I know there is to give.” Finally, Participant 004 explained the

challenges and helplessness she felt when she had the desire to help her clients but was met with

resistance, stating what she tells such a client: “I do want to help you, I don’t know how to help

you when everything I am presenting for you, you are pushing away.”

A third way in which therapists experienced their work with individuals diagnosed with

borderline personality disorder as challenging was in the fear associated with their own personal

safety. Participant 001 described her work with a particularly threatening client, where she felt

her personal safety was at risk. “I feel endangered. She’s threatened me. She’s actually said at
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one point in time, her self-harm was she [wanted] to go to jail. And um . . . she would strangle

me if that meant she would go to jail.”

Participant 003 described her fears around being an ineffective therapist when working

with hostile clients, “When I have a hostile client. When that client is . . . really threatening

towards me or has a language that threatens or where I don’t feel safe . . . I get scared. I get

scared that I’m going to be an ineffective therapist.” Finally, Participant 005 described her

experience of feeling challenged to remain grounded when her clients are angry. “They scare me.

You never know when they are going to take it out on you. . . . I’ll always find myself to be,

especially the explosive anger, I’ll find myself to be very edgy around those people.”

Finally, with regard to the challenges therapists experience in working with their clients

diagnosed with borderline personality disorder, several therapists describe the negative emotions

associated with these challenges. Participant 007 described her experiences with her client,

stating, “I hate . . . just, get away, I can’t stand you . . . a feeling of disgust and feeling trapped,

like I’m victimized.” Further, she recalled that working with this client “would evoke venom and

hate in me.” Participant 002 discussed her feelings of anger towards her clients that verbally

attack her, stating, “I don’t like being attacked . . . I stop wanting to work with people who yell at

me repeatedly.” Finally, Participant 004 described the sensation of anger in the room even if a

client was not verbal about this anger, “in working with Katie [pseudonym], she couldn’t express

her anger, but I would feel it. And so figuring out how to navigate that . . . there was anger and

there was frustration.”

Although the majority of participants described their challenging experiences as negative,

one important theme that was also evident was that some therapists experienced this challenge as

enjoyable. For instance, Participant 007, who has been a practicing clinician for over twenty
 76

years, explained how working with this particular population allows her to exercise creativity

and intellect, stating:

I like to be challenged . . . I have to work with that and get to know myself in a slightly
different way . . . a patient like this who doesn’t let me rest on my laurels, and I have to
stay creative and thinking . . . that’s rewarding, it’s hard but it’s rewarding.

Overall, therapists experienced their work with individuals diagnosed with borderline

personality disorder as challenging, specifically with regard to their own personal safety and the

constant questioning of their clients safety, with regard to self-injurious behaviors. Further,

participants experienced negative emotions in this work, such as anger, frustration, and hate.

Theme 2: Therapists experience their work with individuals diagnosed with

borderline personality disorder as rewarding. A second salient theme that emerged from the

thematic analysis was that therapists experienced their work with individuals diagnosed with

borderline personality disorder as rewarding on multiple levels. Rewarding experiences included

gratitude, joy, pride towards self and client, hopefulness, optimism, accomplishment and

achievement, the importance of being recognized and the rewarding experiences of seeing

clients’ progress throughout therapy.

In particular, therapists experienced gratitude and joy in this work especially when clients

were engaged in therapy. Participant 010 explained, “I’m grateful to be able to help when it goes

well and I’m grateful to be able to see that and to know that I’m part of what is turning things

around for somebody, so that’s nice.” From the therapists’ perspective, this sense of gratitude

created a space of grounding and centering in the work. For example, Participant 006 explained,

“I feel great gratitude that I get to experience this in my job . . . I try to hold on to those feelings

for the next difficult call or situation that comes up.” Further, Participant 009 described the

joyful feelings of watching a client begin to use skills and develop insights in therapy: “When
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someone is able to utilize the skills coaching [and] . . . when the behavior that you are trying to

shape actually is shaped.”

Therapists described a deep sense of pride they felt for themselves and their clients in this

work. Specifically, pride developed when the therapists worked with a challenging client and

began to see progress. Participant 002 described her experience:

There is a sense of pride, of going, of moving, of taking someone who has so many
problems and dysregulation and getting them to a place where, or hoping, they will move
into a really fulfilling life.

Similarly, Participant 008 reflected, “Yes, they were alive and well and it’s like…there’s a

moment of . . . pride, that moment of saying, ‘and we were part of that, we helped get them

through that.’” Additionally, therapists felt a sense of pride in their work and in their ability to

work with a challenging population. Participant 001 stated, “I feel proud that I took on a

diagnosis that has been labeled so difficult.”

Therapists also reported a sense of pride towards their clients’ accomplishments in

therapy. Participant 008 explained,

I think it was really also pride, I mean I’m so proud of our guys . . . you know even little
tiny things when you see movement . . . where you see the minor little movement there is
like this pride . . . if you can get my guys to come with you and join with you and listen
to you and really work hard and you see the movement, that’s really meaningful (p. 16-
17).

Further, when clients were particularly challenging, recognizing the small moments of change

was an important part of treatment. Participant 009 recalled these moments with of one of her

clients:

She’s still extremely challenging, however has come light years from where she was. I
think just a lot of pride . . . pride in them that they are able to recognize that they are
doing well and just recognize their feelings or emotions.

A third element therapists experienced as rewarding in their work with clients diagnosed
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with borderline personality disorder was the therapists’ feelings of optimism, hope, and

encouragement, particularly with regard to their clients’ recovery and successful outcomes in

treatment. For instance, Participant 010 explained process of “instilling hope” in his work with

clients,

I’ve just seen enough people change, and there are these ideas that Oh borderlines don’t
change . . . that’s a hard set of traits to change, but I’ve seen people do enough good work
with it that I am optimistic . . . so, when I heard people talking about Oh god, not another
borderline, I, um, I don’t agree—I don’t relate to that.

Many therapists experienced a sense of hope in their work, understanding that clients

diagnosed with BPD do have the capacity to improve, and found this hopefulness to be

rewarding. Participant 001 described her experience of this sense of hopefulness, comparing two

of her clients diagnosed with BPD:

So to work with somebody who is at the other end of the diagnosis and being able to
work with somebody who has gotten through it and is better and wonderful to be around,
that’s good, helpful . . . the most rewarding part is to imagine that this is really hard right
now because the one I’m having trouble with . . . she’s kind of right at the height of the
diagnosis and it’s really difficult.

It was through this experience of watching clients’ progress unfold in therapy that

therapists found their work with this client population rewarding. For example, Participant 005

explained the rewarding feelings that came with seeing clients’ make progress in treatment:

To see people make progress and to see people . . . you know clients who have gone
through the program once or twice and you know either have outside therapists they have
returned to or for some reason or another we terminate and then years later I will get an
email from them or a phone call from them saying how much it’s made a difference in
their lives and they wanted to thank me for it.

Participant 001 described the experience of running a DBT group and seeing progress with her

clients, “To watch people learn new skills and practice them and then come back and tell you . . .

that part is so rewarding.” Finally, Participant 007 explained the rewarding and humbling quality

of this work and seeing her clients make significant life changes:
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Watching her get better and watching her life not fall apart in certain ways is also
extremely rewarding, to know that our work has shifted her capacities to keeping a job,
she’s beginning to imagine that she can find a partner.

Finally, therapists described the rewarding experiences they have had while being

recognized for the work they do with their clients diagnosed with BPD. Participant 001 described

the rewarding experience of being appreciated for her work as a therapist. She recalled, “Clients

can be really grateful and appreciative and that part is rewarding, too, you know, feeling

appreciated and feeling the work you are doing is appreciated.” Further, Participant 005 recalled,

I often get clients that in the little line, you know, the title [memo on a check] . . . they
write thank you or they write something really nice there, and I’m, like, Wow! that’s
amazing! I never got a thank you in the paychecks I got in the corporate world . . . it’s as
if I’m making a difference.

In general, therapists experienced their work with individuals diagnosed with BPD as rewarding.

Specifically, therapists described the sense of accomplishment, achievement, gratitude, and joy

they felt in providing therapy to this clinical population.

Theme 3: Therapists describe ways in which they manage their own internal process

while working with individuals diagnosed with borderline personality disorder. Nine of the

10 participants described personal ways in which they managed their own internal process while

working with individuals diagnosed with borderline personality disorder. Specifically, therapists

used a personal practice, consultation, spirituality, and awareness of therapist as instrument in

their work in session with this clinical population.

Therapists described personal practices used in order to ground and center themselves

prior to or after meeting with their clients diagnosed with BPD. Several therapists indicated that

they had a mindfulness practice that supported them in this work, specifically if they were

feeling challenged with their clients. As Participant 002 explained,

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I have to use a lot of mindfulness with those clients, of detaching myself from this feeling
of “I don’t like this client” to, “Ok that’s part of the problem, this is what they do to
people, you’re not the only one who feels this way, how are we going to work towards
this person being more effective.”

Similarly to this, Participant 006 described the uplifting feelings he felt when uniting his

clinical work with his contemplative practice: “Something that I have noticed . . . is the unison of

my own kind of contemplative practice with DBT work with clients and the validation of the

work that I’m doing . . . it all ties together, which is really awesome.”

Therapists also described the importance of a grounding practice in their work with

clients diagnosed with borderline personality disorder, especially when therapists’ felt their

clients were not grounded themselves. Participant 005 explained,

I rely a lot on being grounded myself and finding that part of what it is that I want and
what it is that I need. . . . I find that I often go back to that place. . . . That’s where I get
my strength from. That’s where I get my motivation from. That’s where I live from.

Similarly, Participant 004 described the grounding process she does prior to seeing a particularly

challenging client.

Part of what I’m doing 10 minutes before and after [a client] is letting the smoke clear
and reground. . . . I close my door and I close my eyes and just breathe and let a wave of
calm wash over me and ground myself . . . and just get connected to my deep core self,
and that reminds me of why I work, and my value and my awareness of the gift of other
people, and my awareness of letting all the stuff drip off me.

A second salient aspect of how therapists managed their experiences in working with this

population was through consultation.

I’m very fortunate I have a wonderful team to work on and with. . . . We meet as a
consultation team every week just to keep ourselves in check and talk about burn-out and
talk about things that are exactly what you’re asking, like what’s being brought up for
you in the situation? You know, we consult with each other multiple times a week and I
think that’s—I don’t think I could do it otherwise, to be quite honest (Participant 009).
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Similarly, Participant 008 described the importance of consultation to provide a form of self-care

and awareness of his limits as a clinician:

We have gotten to the point where we really know each other, where we really know our
tendencies and habits, you know, the things I’m saying about myself with regard to my
conflict. . . . I think consultation is the most important piece of it, where my own personal
journey that could get lost—so I can check it constantly with others. . . . We have gotten
really skillful at noticing limits within each other.

Participant 006 mirrored these experiences, specifically in speaking about his DBT team, “[W]e

have an amazingly supportive environment, a camaraderie that I don’t have in other consult

groups that I’m in . . . the vulnerabilities that we step into as therapists with this population . . .

we are totally in the trenches together.”

A third important component to the therapists’ personal practice in relationship to their

work with individuals diagnosed with BPD was their own awareness of their personal influence

on therapy. Specifically, an awareness of countertransference was important to effective work.

Participant 004 recalled:

My experience in working with folks with borderline personality is that they can give
[off] some narcissism and are more likely to hit on stuff in me or pull stuff out of me than
other clients I work with, and so I check in with, Ok, what is this hitting on me?

She explained further:

I think that when I’m working with borderline there is this element of tending to what is
my own stuff that takes more energy . . . it’s always there as a clinician, you’re
monitoring that and that’s part of my barometer for picking it up—I have to turn that up
more. I have to turn the awareness up more and it takes more energy and more awareness.

Participant 007 described a parallel process she felt with her client:

I definitely notice it . . . checking in with myself, what I might be attributing or projecting

onto her and . . . a self-reflection of where I’m at: What am I doing with this? What is it
triggering in me? So partly assessing it and paying attention to what my hot buttons [are]
and. . . . imagining a parallel process of the countertransference: Was she feeling dread?
Was she feeling anxiety?
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Participants described multiple personal practices they utilize while working with individuals

diagnosed with borderline personality disorder. Specifically, therapists discussed their use of

grounding practices, mindfulness, consultation, and awareness, to aid them in the process of

providing therapy, as important in their experiences of the work.

Theme 4: Therapists experience a strong dialectic component in their work with

individuals diagnosed with borderline personality disorder. Eight of the 10 participants in

this study alluded to a dialectic component in their experiences of working with clients

diagnosed with borderline personality disorder. The most salient dialectic in this work, according

to therapists’ experiences, was that of control vs. letting go. This control dialectic was described

through a delineation of power struggles and tension between therapist and client. Participant

002 explained:

The biggest problem . . . in working with her would be butting heads. That one of our
early target goals, target behaviors on both our parts was a therapy-interfering behavior of
getting into deadlocks. She would want it one way and I’d want it another and we would
just meet in learning to negotiate.

She went on to explain, “I noticed we were getting into power struggles. . . . There was a lot of

frustration that I was getting caught in the power struggle. . . . I was having trouble

maneuvering.” Participant 002 negotiated this power struggle by becoming mindful of her

experience and stated that, “if I let myself get locked into that kind of struggle, we weren’t going

to make any progress.”

Similarly, Participant 008 discussed how control might shift throughout session and how

he noticed this shift with his client:

[We’d] observe it together and just notice that control was really important, and one of
the things that I said to her in session was, “Sometimes you’ll control the session, and
sometimes I’ll control the session, and sometimes we will control the session together.”
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Participant 003 described tension created in session with her client:

She wanted to avoid, and I would not let her. So when those moments come up . . . we
were polarized, and so, when we get polarized, that tension does come in the room and,
you know, I get really anxious, you know, I . . . have more of a tendency to push for
change rather than acceptance.

A second dialectic component of this work, according to participants, was the balance

between feeling refreshed and exhausted. Participant 004 described the adrenaline she

experienced doing this work: “There’s almost a little bit of, um, adrenaline, because I can feel

like we are on the edge of her making an important move.” Participant 007 supported this

experience of feelings of stimulation: “I find them interesting, so stimulating emotionally [and]

intellectually stimulating.” Participant 003 was reminded of how this work kept her refreshed:

I feel refreshed. Like I can see myself doing this forever. . . . We treat very difficult
clients. . . . I just get reinforced by it. It makes my world go round. . . . It’s kind of like a
domino effect. Then her son has a better life [with her], then the son will have a better life
for his family, then the family has a better life. . . . It keeps me coming back every day.

In opposition, participants also described their experience of this work as overwhelming

and exhausting. Participant 010 described his experience of being overwhelmed by the constant

shifts that happened in session.

Overwhelmed is a good way to describe how I feel sometimes, especially when therapy is
going really well and they are working and I think I know where we are going next and
things begin to unravel and in borderline personality disorder that can happen fairly
quickly. . . . It feels a little overwhelming, like, What are we—? Where do we start?

Participant 001 discussed her experience of being overwhelmed with her clients diagnosed with

BPD, specifically with regard to their self-harming behaviors: “There’s just like so much going

on. . . . It’s overwhelming to work with somebody who always has suicide on the table.” She

went on to say, “I get overwhelmed when I see the big picture that’s sort of just this person in my

office, and how it affects their whole life.”

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Therapists also felt burned out when working with their clients diagnosed with borderline

personality disorder. Participant 009 explained:

I think burn-out almost happens more because you are interacting with them and I
definitely think it can affect how I react. . . . If I’m feeling frustrated or burned out and
you catch me again in the hallway, sometimes I will get a little snippy.

A third dialectic that therapists experienced was the movement between feeling idealized

and feeling devalued by their clients. Participant 010 explained the subtle degrading of the

therapist that can occur:

Idealization and devaluation are just symptomatic things that you really need to be aware
of. . . . Um, I guess they are a little bit, it’s a little bit easy sometimes [to see it coming]
because people will be like “Oh, this therapist was terrible, but you’re the best ever” and
then, you know, you’re ready for either the rise or fall.

Participant 004 further explained, “At times I would be fabulous and amazing and wonderful,

and I knew at other times I would be terrible and awful and like Satan.”

Finally, Participant 006 described the anxieties that came up for him when feeling as

though his clients were idealizing him in therapy:

The discomfort I feel with them putting me on a pedestal and kind of projecting
perfection. . . . that’s much more common with these clients I’m experiencing than with
other clients. . . . I go down that route and be really genuine and let it pass and work on
the relationships [or ask myself] When am I going to fall from grace? you know?

Therapists reported the necessity of balance (dialectic) in their experiences of working with

individuals diagnosed with borderline personality disorder. Specifically, therapists remained

aware of the balance required for effective treatment and learning how to be flexible throughout

sessions.
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Theme 5: Therapists question their own competency and clinical skills when

working with individuals diagnosed with borderline personality disorder. Of the 10

participants interviewed in this study, 8 indicated that their experiences working with individuals

diagnosed with borderline personality disorder caused them to question their own competency

and clinical skills as a therapist. Specifically, therapists struggled with issues of incompetency

and inadequacy, in addition to experiencing a lack of self-confidence, self-doubt, and negative

judgment. Therapists also reported feeling disappointment, shame, and guilt because of these

feeling of incompetency with their clients diagnosed with BPD.

In discussing a client she currently works with in individual therapy, Participant 009

recalled questioning her clinical intuition during particularly stressful sessions, asking, “Did I do

the right thing, should I have done this approach instead?” Therapists also experienced a sense of

incompetence when working with this clinical population. Participant 010 recalled, “I can feel

like I don’t have adequate training to work with somebody with borderline personality disorder.”

Participant 005 questioned her own sense of inadequacy and the challenges she faced helping

clients who were having difficulty. She recalled,

Well, you know, [I] question, What could I be doing differently—What am I not getting
here? What I am missing here? What is it that they really need from me? Because
whatever it is that I’m giving isn’t helping . . . feeling that I’m not the right therapist for
them.

Similarly, Participant 001 reflected on her early work with a client diagnosed with BPD:

Oh, it’s torture. Um, yeah, I feel like I can do a great job and be a great therapist, and
then, working with people who have borderline, all of a sudden feel like, I don’t know
what I’m doing! or, Why does this feel so hard?

Therapists spoke of their lack of confidence and their self-doubt in their clinical intuition

while working with individuals diagnosed with BPD. For example, Participant 005 felt
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disappointed in herself after having misjudged the therapeutic relationship between herself and

her client,

There is some sort of self-doubt that comes up with myself, like, How did I think we had
such a wonderful open honest relationship if this person has been sitting here bold-face
lying to me all this time? . . . Where is my judgment in all this if I sort of sense that we
have this great relationship and it’s clearly not there?

Finally, therapists reported feeling shame, disappointment, regret, and guilt based upon

feelings of self-doubt, inadequacy, and incompetency. For example, Participant 003 discussed

her feelings of shame when thinking that she had reinforced something in session that she should

not have reinforced. She explained:

Brief moments—very, very brief moments of shame. Like if I did something in session
. . . but I don’t think it’s justified shame . . . like if I did something wrong—for instance,
if I reinforced something, um, that I shouldn’t have, you know, or. . . . Like, I think there
is a lot of pressure on DBT therapists that you have to do something therapeutic, you
know, and I may have some sessions or sessions here and there where I don’t know that I
did anything therapeutic, you know, and then I’ll have this shame sensation where I’m,
like, Am I going to get fired?

In a similar sense, Participant 008 struggled with a comparable sensation of unjustified shame as

it pertained to discussing his clients’ progress with colleagues:

It’s very hard to separate ourselves from the sense of How they’re [clients] doing is how
I’m doing. . . . If I have to report to the integrated team this persona is not doing well I
struggle with that reflecting on my ego. . . . There is some shame attached to that. . . . I
don’t feel it’s justified shame.

Therapists’ described a sense of guilt for their feelings of incompetence and self-doubt in

their work with individuals diagnosed with borderline personality disorder. For example,

Participant 010 stated that, at times, he felt guilty:

That goes with the incompetence part, the idea that I should be doing more . . . feeling
guilty when you are the therapist and someone comes in and is doing really poorly for
another week, and so, personally, I think . . . sometimes I feel guilty.

And further, Participant 004 regretted not treating her client in the most appropriate way:
 87

I missed it with her initially and I don’t often miss it, and so I would say that was one of
my clinical mistakes because part of what I was going on with her, her presentation, if I
understood that the borderline was there, I would have treated the presenting issue
differently, and so I, I regret that.

Therapists reported that their experiences working with clients diagnosed with borderline

personality disorder caused them to question their clinical competency at times. Specifically,

therapists felt a lack of confidence, had self-doubt, and often negatively judged their clinical

intuition.

Theme 6: Therapists indicate that boundaries are an important part of the work

with clients diagnosed with borderline personality disorder. Eight of 10 participants in this

study experienced boundaries as being an important part of their work with their clients

diagnosed with borderline personality disorder. Specifically, therapists reflected that boundaries

were important to set treatment expectations, for the benefit of the client, for the benefit of the

therapist, and for clarity of treatment goals. Secondarily, therapists were explicit in identifying

the importance of keeping personal versus professional boundaries with their clients.

Regarding the importance of boundaries to set up for treatment expectations, Participant

005 stated, “It got to the point that I was ready to tell her that we probably couldn’t continue

working together if she was going to continue to be very disruptive.” Further, the therapist stated

that she “had to be very clear” and “I told her that it wasn’t my job to make her feel better and

that she needed to use the skills to make herself feel better.” Further, Participant 006 explained

the importance of boundaries in setting up structure for treatment. “I need to have an external

structure in the session that’s going to support us . . . because you get lost and are, like, Where

are we and what’s our plan?”

Therapists expressed the importance of setting up boundaries both for the benefit of the

client and for their own benefit in providing treatment. Participant 007 explained, “[I was]
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reminding myself that this is, this is someone in a very primitive state of mind that she’s needing

me to contain and not retaliate.” Participant 010 echoed this belief: “I think the therapist just

being steady and just being . . . sort of holding the relationship while the patient bounces around

emotionally is therapeutic.”

Participant 006 discussed his role as a male therapist working with female clients

diagnosed with BPD and the importance of boundaries around that work.

Well I think it’s an opportunity as a male therapist to model a trusting, validating, you
know, intimate relationship that’s not sexual. And this one client in particular didn’t,
couldn’t, distinguish between those . . . keeping that boundary . . . modeling the proper
boundaries for them, which is why they are here, so you know it’s a richer opportunity in
some ways.

Just as therapists felt boundaries were important for the benefit of their clients, they also

benefited from holding boundaries for themselves. Participant 005 explained:

I call it self-protection. What I say to them is “I can’t be there for all my clients at the
extent that you expect me to be there for you. If I had to do this, I couldn’t handle more
than five clients a week—so I have to preserve myself.” I’m not doing my clients a favor
if I let my clients suck up all my energy.

Participant 007 discussed her shifting in boundaries with her clients, “It’s different than how I

usually work, because I don’t disclose things about myself, and I don’t typically disclose

feelings, but, with her, I learned that I had to.” She explained further: “There is an accountability

. . . that paradox, she is consistently trying to get more from me and, you know, test boundaries.”

Participant 006 explained how this work has gotten easier because of having strong boundaries in

session: “I think it’s gotten a little easier. I think my natural tendency is to have pretty strong

boundaries, so that helps me out, compared to other therapists.”

Finally, Participant 005 explored her balance between personal and professional

boundaries in her clinical work with clients diagnosed with BPD.

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When I first started doing this work I was way too worried about clients and way too, you
know, wanting to call them when I know they were having a bad day, and I was like, you
know, I can’t do this if I plan on having a busy practice; I have to be able to separate and
turn it off.

Therapists reported the importance of maintaining boundaries in their experiences of working

with individuals diagnosed with borderline personality disorder. Specifically, therapists believed

that boundaries were important for treatment in that they helped the client and therapists have

clarity on treatment goals and expectations in addition to distinguishing for both between

professional and personal relationships.

Theme 7: Therapists experience the therapeutic relationship as an important part of

working with individuals diagnosed with borderline personality disorder. Eight of the 10

participants indicated that the therapeutic relationship was an important part of their experience

in working with clients diagnosed with borderline personality disorder. Specifically, validation,

building rapport, respect, and empathy towards the client, in addition to unconditional positive

regard and acceptance, were all important elements to the relationships. Participant 002

explained:

[T]he biggest thing is that validation is a super powerful tool with emotionally
dysregulated clients. . . . After rapport is established [they] will come in and say, “You
are the only person in my life that ever tells me I’m doing a good job.”

Participant 001 further discussed the importance of building rapport with these clients and how it

can influence treatment.

I’ve worked with her so long . . . it’s just been, now it’s fun, because even when she will
. . . when she struggles with relationships . . . I can call her on it . . . ust be able to be
playful and not worry as much about her strong reaction. That’s been fun, and to see her
start letting it in.

Therapists explained the importance of showing respect for their clients in their progress
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and process. “Well . . . it’s not rocket science what we do, you know. . . . I didn’t do the DBT

work; she did a year of DBT, which was phenomenal of her, and she’s the one who does the

work” (Participant 004). Participant 007 stated, “I admire and respect folks that fight, you know,

and fight for health and fight for growth.” Finally, Participant 005 explained, “I have an immense

amount of respect and admiration for most of my borderline clients, because life is really hard

for them. . . . there is a lot of admiration that they just keep going.”

Therapists also described the importance of experiencing empathy towards their client to

help facilitate effective treatment.

I also try to bring it back where to, you know, I’m having a real experience and this is a
real relationship and that, perhaps, she could use me kind of like this barometer of how
people interact with her outside of therapy. . . . then also start to think, perhaps this is
what her parents feel like, you know . . . a lot goes on in the moment and then I’ll have a
ton of compassion and empathy for her in that she simply does not know how to act
differently, and this is her opportunity to learn how (Participant 003).

Similarly, Participant 005 recalled:

[T]rying to find something about them that I can appreciate, that I value. Something
about that that I can say Well, you know, even though most of my experiences with them
is not something I look forward to, you know, there is a human being in here that has
shown up—even though they might seem hopeless, they are still showing up’.

Therapists discussed the importance of unconditional positive regard and acceptance

while working with clients diagnosed with borderline personality disorder. Participant 009

explained that, “if you don’t have that core belief that there is good in everybody, [therapy is] not

going to make a difference.” She further stated, “You’ve got to have that core belief that people

are good.”

Therapists also struggled with maintaining a therapeutic relationship with their clients.

For example, Participant 001 described her difficulties connecting with a particularly challenging

client, explaining, “I feel like I don’t connect with her the way I do with other people,” and this
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lack of connection causes her to be “detached so much” from her client. Further, Participant 001

stated, “I want to care, but I can’t,” a realization in part due to her client’s evasive behavior. “I

feel lost with her. I feel kind of like a puzzle, a mystery . . . everything seems like a game and I

don’t know what part is real.”

Participant 005 described the difficulties she experienced with a client with whom she did

not feel connected:

There’s no real connection there. . . . I try to be as honest as I can with my clients and I
expect the same back, so, sometimes, it’s really hard for me to be honest with them, but I
always try to put my best effort and, you know, if it’s not reciprocated, then I feel angry
that [the question becomes] What are we doing here? Why are you wasting our time
together?

Based upon this lack of connection with their clients that can occur, therapists describe

their additional struggle with compassion towards these individuals in therapy: “I’ve really got to

dig deep to look for compassion. . . . I find myself struggling to get to that place of finding

compassion for them” (Participant 005).

Participant 002 described her experience of having to actively detach from a client due to

that client’s destructive behaviors. The most challenging factor of the relationship is “not getting

sucked into the story line at times . . . watching the client do things as an individual I really

disagree with and think are destructive but staying detached.”

Finally, part of the reason therapists have trouble connecting and feel the desire to detach

from their clients diagnosed with BPD is due to a sense of mistrust in the therapeutic

relationship. Participant 008 explained, “I find myself moving away from that faith and not

believing that person when I’m with them, and moving toward a stance of doubting or a

pejorative stance of, of labeling, I know they lie. . . . it’s very difficult” (pp. 8-9).
 92

Therapists described the importance of the therapeutic relationship in working with

individuals diagnosed with borderline personality disorder. They discussed how the relationship

could be effective, through validation, respect, empathy, and rapport-building, in addition to how

the therapeutic relationship might, on the other hand, be ineffective, especially when they had

trouble connecting with their clients.

Theme 8: Therapists experience the importance of measuring improvement and

change in therapy based upon the context of the diagnosis and the clients’ capacity to

change. Seven of the 10 therapists interviewed discussed the importance of measuring

improvement and change in therapy as based upon the context of a borderline personality

disorder diagnosis, in conjunction with the clients’ ability and capacity to change. Specifically,

therapists believed that improvement requires perspective. In addition, therapists suggested that

it was important to be creative and flexible in this treatment.

With regard to having perspective on how much change can happen in treatment of BPD,

Participant 008 recalled, “The struggle is never truly over, it’s a constant and ongoing . . .

constant and ongoing journey.” He went on to say individuals diagnosed with BPD “tend to

really have a long journey of emotional regulation ahead of themselves. . . . it just doesn’t change

easily or quickly at all.” On the other hand, Participant 005 found hope in recognizing how far

her clients have come:

Reminding yourself, you know, myself, that they have made progress, they are doing
better, they are using their skills, even though it seems mostly that they are still
struggling. You know, but I look at the intake form and the comments I made there—it
really helps me reflect on where they started.
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Similarly, Participant 008 discussed the importance of keeping perspective on change. He said,

“You might be expecting too much. . . . this is going to take time, and this is going to take a lot

of moments of rewarding.”

Creativity and flexibility comprised an important part of the therapists’ experience of

working with this clinical population. Specifically, Participant 010 discussed making changes in

therapy, if necessary: “[If] I’m not getting the sense that they are benefiting from any of it, then I

need to make a change.” Similarly, Participant 007 explained, “I get to exercise some creativity

to my own intellect.”

Theme 8 explored the ways in which therapists’ measured change in their experiences of

working with individuals diagnosed with borderline personality disorder. Specifically, therapists

were familiar with their clients’ capacity to change and their own awareness of pushing for

change before their clients are ready. This measure of change required patience, flexibility, and

creativity on behalf of the therapist.

Theme 9: Therapists experience a somatic component to their work with individuals

diagnosed with borderline personality disorder. Six of the 10 participants reported having

somatic experiences in their work with their clients diagnosed with borderline personality

disorder. Somatic experiences ranged from noticing tense body sensations, a physical release,

energy in the chest, trouble breathing, and feeling hot and sweaty.

Participant 006 described his somatic sensation while working with a client diagnosed

with BPD: “My body often feels anxious and full of energy.” Additionally, this participant said,

“I felt a physical release inside my body when [noticing] her progress and an ability to meet her

where she is that day.”

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Participant 005 recalled, “I was very much on edge . . . tension in my shoulders . . . sitting

on the edge of my seat with her.” In order to center herself in this work, she described her

intention to “consciously remind myself to breathe, deep breathing, relax my shoulders,

purposefully relaxing my shoulders.” Participant 008 described his ability to notice his somatic

experience early on in session, “I feel my feelings in my stomach, so my stomach might tense or

tighten. . . . I notice my body language very early on in session.” He further recalls that “it’s

usually this sinking feeling—for me it’s all in my gut, just get a pit in my stomach . . . I might

also get . . . when someone is anxious, I don’t flush but like I feel warmer . . . I feel hot.”

Participant 001 described her somatic sensations to be centrally located around her core

and affecting her breathing. She stated, “I feel pressure in my chest. . . . I want to run away” and

“I feel like I have to stay on my toes. . . . it feels like a fear response, like start kind of tingling

. . . ready to react, to get out of the room if I need to.” She continues, “It’s still part of this core.

Kind of intense, like my stomach will tighten. . . . I will notice that I don’t breath well, I’ll hold

my breathe a lot.” Finally, she described the somatic sensation in her chest and in the pit in her

stomach: “the tightness in my chest. . . . I stop breathing . . . and then like the pit in my stomach,

there’s just like so much going on . . . and it’s overwhelming.” Participant 007 described a

similar somatic sensation: “I feel energy in my chest, and I notice myself pointing and my body

rearing up in this more aggressive state. . . . It’s very active.”

Theme 9 explored the somatic experiences therapists had while working with clients

diagnosed with borderline personality disorder. Therapists reported feeling tense body sensation,

physical releases, energetic feelings in the neck and chest, and an attunement to their breathing

while providing therapy to these clients.

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Theme 10: Therapists experience this work as providing meaning and purpose to

their lives. Six of the 10 participants interviewed discussed their experience of finding meaning

and purpose in the work they do with their clients diagnosed with borderline personality

disorder. Participant 003 explained, “I love what I do, so . . . I think that comes off. My clients,

like it’s very meaningful for me that my clients feel very well taken care of, like, uh, I like that

my clients feel like they are family to me.” Participant 005 discussed this meaning with regard to

seeing her clients make progress in therapy.

Well, knowing that you are not just spinning your wheels, that this stuff is actually
penetrating—the skills are penetrating—people are using them, it is making a difference
in their lives, and you know it creates meaning, it puts meaning to my work. . . . This
really does give me a sense of contributing and creating meaning in my life.

Similarly, Participant 007 explained the meaning she receives from working with clients who

begin to change their behavioral patterns, “I am an essential person, and that is meaningful . . .

especially when there is a feeling of movement and change where I can feel that we’ve got a

fighting chance. . . . It makes me feel that I have worth and value.”

With regard to purpose, Participant 003 explained,

I feel that they pay, top, a good amount of money to come here and I feel like they got
their dollars’ worth, and that’s very satisfying for me. . . . I want them to leave [with],
you know, take home something, [and] so it makes me feel validated; it makes me feel
like I have purpose. . . . It makes me feel like I chose the right profession.

Similarly, Participant 008 reflected, “To me . . . I’m helping to save a life, and. if I’m helping to

save a life, that’s what I’m here for. . . . If I can be there for somebody, then that’s why I’m here

. . . more or less for me it’s a sense of purpose, meaning . . . what I was born to do. . . . I love to

be there for them.”

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Theme 10 explored the therapists’ experiences working with clients diagnosed with

borderline personality disorder as providing meaning and purpose in their lives, specifically,

giving them value and believing they were truly called to do this work.

Theme 11: Therapists experience a development of mastery and competence when

working with individuals diagnosed with borderline personality disorder. Four of the 10

participants interviewed for this study discussed their sense of mastery and competence while

working with individuals diagnosed with borderline personality disorder. Participant 002

explained,

I feel very competent, I feel very in control of myself when I’m working with
emotionally dysregulated clients. . . . I like clients who are a challenge . . . you know,
when I’m working with borderline clients I feel very competent. . . . I feel competent that
I know what I’m doing and then I’m going to look for the best path and that I’ve got a
good description of what’s going on.

Further, she explained how she feels a sense of pride in her competency and her abilities to shape

behaviors at the beginning of treatment. “[There is] pride that I’m competent. . . . you are the

expert you know that . . . particularly in the beginning, there is a lot of behavior-shaping with

really distressed clients.”

Participant 003 described her sense of mastery and how it has evolved, as she has been a

practicing psychologist,

I’m not scared anymore. . . . I think that I, since I have mastery in knowing what to do
. . . . I think it helps the client feel comfortable with me that, not only am I not freaked
out, but that—I think that . . . most clients who come in here have been fired by several
therapists before and they experience therapists freaking out . . . and that I’m not freaking
out, I think, in a way, comforts them.

Similarly, Participant 009 discussed her competence and confidence in the work she does

with her clients diagnosed with borderline personality disorder:

I feel much more competent and confident. . . . I would rather have someone screaming
and yelling, slamming a door, or threatening to throw a chair because, um, they are
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voicing it. . . . They are voicing emotions, so, in my head, I can identify what it is I need
to . . . work with in that moment and what skills I need to pull out, as opposed to someone
who is just sitting there shut down.

Finally, Participant 010 described his feelings of competency when seeing progress in his

clients:

Honestly, I think it makes me feel like I’m a good therapist. . . . It probably makes me
feel effective and confident in treating the next person because I can see the contrast
between when they came in and when they left.

Theme 11 explored the therapists’ experiences of feeling a sense of mastery in their work

with individuals diagnosed with borderline personality disorder. Specifically, therapists reported

feeling confident, competent, and proud of their ability to work with this clinical population.

Theme 12: Therapists experience stigma connected to the diagnosis of borderline

personality disorder. Four of the 10 participants interviewed spoke to the effects stigma has on

their experiences working with individuals diagnosed with borderline personality disorder.

Participant 001 explained how she had preconceived notions about this work due, in part, to her

clinical training, that were eventually challenged when she began working clinically with this

population:

The diagnosis has so much stigma. . . . You just heard horror stories in school, and the
way society and doctors respond to it. . . . Oh, you better watch out! and after getting to
know people who have this diagnosis that’s not always the case. Extreme cases seem to
shadow . . . working with other people who have this diagnosis.

Participant 009 discussed ways in which stigma affects the individuals with the diagnosis of

BPD:

One of the words that I hate to use, or hate to hear is “They are being manipulative.” It
just drives me absolutely insane . . . because I think it has a negative connotation . . . You
know, people in general develop skills to [obtain] service, they develop ways to get their
needs met. And I think they are pretty skilled at getting their needs met. People with
borderline are seen as, you know, for lack of a better word, evil. Like they are doing it on
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purpose. . . . It’s hard because they are a difficult population; folks generally don’t want
to give them the time.

She went on to describe how the language professionals’ use does a disservice to the clients with

the diagnosis:

It’s the language and the way we view people with borderline. . . . A lot of times people
come in with a certain behavior or urge, and even before they meet the difficult patient,
you know they are already discharging them in their mind. . . . I get caught up in that too
. . . but, um, they are real people, and it’s just, it annoys me to no end when people see
their behaviors as purposeful.

Because of the stigma associated with BPD, there is a general misunderstanding of those

who carry the diagnosis. “My experience of them generally is very misunderstood individuals.

. . . their experiences is being very much outsiders” (Participant 008). Further, because of this

misunderstanding, therapists expressed their fear around being judged or misunderstood. “You

are being judged by your peers—especially for people who may not understand why you’re

doing something. . . . It’s hard because you feel like you have to defend why you’re doing

something to people who just don’t get it” (Participant 009).

Finally, therapists experienced frustration with the system and community when dealing

with the stigma associated with BPD.

Whenever someone asks me what is the most difficult part of your job, it’s never the
client, it’s the people I work with—it’s with the other professionals . . . you know when
you’re trying to work on a behavior, shaping a behavior, and it doesn’t always get
reinforced in the way you want . . . a lot of frustration, annoyance, you get that like
feeling in the pit of your stomach because a lot of that is push against the doctors, and
good luck with that. (Participant 009)

Theme 12 explored the stigma therapists felt is associated with a diagnosis of borderline

personality disorder. Therapists experienced this stigma as influential in their early training and

careers as clinicians, but found, in practice, that the extreme cases tended to overshadow the
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typical client presentations. Further, therapists believed that stigma does a disservice to the

treatment of BPD clients and that there is an overall misunderstanding of the diagnosis.

Qualitative data, as presented in the previous twelve themes, was then separated into two

categories (a) positive experiences/descriptions and (b) negative experiences/descriptions (Table

3), in order to quantify therapists’ experiences. As was mentioned in chapter 3, this was done so

that qualitative and quantitative data might be mixed in support of the original hypothesis of this

study—a procedure whose outcome will be discussed in the mixed-methods results of this

chapter.

Table 3

Quantified Data from Qualitative Thematic Analysis

Negative Codes Positive Codes Negative Themes Positive Themes

Anger Acceptance Challenging Rewarding

Anxiety Admiration Burn-out Mindfulness

Burn-out Appreciation Overwhelmed Spiritual Practice

Challenging Awareness More Effort Contemplative

Practice

Detached Building Rapport Questioning Contemplative

Competency Practice

Devalued Calling Challenge Grounding Practice

Connecting

Difficult Centered Meaning/Purpose

Disappointed Competency Therapeutic

Relationship

Disgust Confidence

(Table 3 continues)
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(Table 3 continued)

Negative Codes Positive Codes Negative Themes Positive Themes

Energy Creating Space

Fear Empathy

Frustration Encouraged

Fury Flexibility

Guilty Fulfillment

Hate God

Helplessness Grace

Helpless Grateful, Gratitude

Hopeless Grounding

Hopelessness Holding Hope

Inadequacy Hope, Hopeful

Incompetent Inspiring

Ineffective Introspection

Irritated Joy

Judgmental Letting Go

Lack of Confidence Meaning, Meaningful

Mistrust Measuring
Improvement

Misunderstanding Mindful, Mindfulness

More Effort Misunderstood

(Table 3 continues)
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(Table 3 continued)

Negative Codes Positive Codes Negative Themes Positive Themes

Negative Feelings Optimistic

Never Enough Personal Journey

Overwhelming Personal Practice

Power Struggle Personal Process

Question Competency Positive Feelings

Regret Potential

Self-Doubt Pride

Shame Refreshed

Struggle with Relief

Competency

Tension Respect

Trouble Connecting Reverence

Victimized Rewarding

Sacred

Satisfying

Spiritual Path

Spirituality

Trust

Unconditional Positive
Regard

(Table 3 continues)
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(Table 3 continued)

Negative Codes Positive Codes Negative Themes Positive Themes

Understanding

Validation

Witness

Quantitative Results

Data from the Assessment of Spirituality and Religious Sentiments (ASPIRES; Appendix

B), Spiritual Orientation Inventory (SOI; Appendix A), and quantified themes and codes (Table

3) were merged. SPSS (Version 17) was used to analyze data for correlations, using Pearson’s r,

and descriptions.

Descriptive analysis of the Assessment of Spirituality and Religious Sentiments showed

that participants in this study scored above the general, normative average. The ASPIRES scale

was normed on two age groups (26-45 and 46-94) and by gender. For this study, gender was

collapsed, due to the small male participant size (n = 3) and that, therefore, any statistical results

would not be significant or substantial. Table 4.0 shows results indicating that these therapists

had mean ASPIRES scores higher than normative scores in all but one area. Specifically,

therapists scored lower than average on the Connectedness measure in both age groups. These

results are significant, but must still be taken with caution and cannot be generalized, given the

small sample size of the current study.

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Table 4

ASPIRES Normative Sample Versus Current Study Sample

Total Score Prayer Universality Connectedness

Sample Age M (SD) M (SD) M (SD) M (SD)

Normative 26-45 78.25 (21.04) 34.08 (11.71) 24.40 (7.56) 19.99 (4.50)

Normative 46-94 79.74 (21.26) 34.64 (12.02) 24.86 (7.32) 20.31 (4.40)

Current Study 26-45 96.33 (11.075) 42.83 (4.708) 27.33 (2.16) 17.83 (4.875)

Current Study 46-94 92.50 (7.047) 40.75 (4.924) 25.50 (2.082) 17.75 (0.957)

Note. Normative Sample n = 2989 Current Study sample n = 10

Current Study (Ages 26-45) n = 6 Current Study (Ages 46-94) n = 4

Correlational and descriptive analysis results indicated strong correlations between SOI total

scores and SOI subscale scores (see Table 5).

Table 5

Correlations Between SOI Total Score and Subscale Scores

SOI Transcendence Subscale r = .833, p = .003*

SOI Meaning & Purpose in Life Subscale r = .794, p = .006*

SOI Mission in Life Subscale r = .916, p < .001**

SOI Sacredness of Life Subscale r = .820, p < .005*

SOI Material Values Subscale r = .451, p = .150

SOI Altruism Subscale r = .830, p < .005*

SOI Idealism Subscale r = .640, p < .05*

(Table 5 continues)
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(Table 5 continued)

SOI Awareness of Tragic Subscale r = .828, p < .005*

SOI Fruits of Spirituality Subscale r = .893, p < .001**

SOI Mean = 496.90, Standard Deviation = 43.046

* significant at .05, ** significant at .001

Based upon correlational and descriptive analysis, results indicated a significant

relationship between ASPIRES Total Scores and SOI Total Scores (r = 0.762, p = 0.010), when

age was not a factor. As Table 6 below shows, results further indicated strong correlations

between ASPIRES Total Score and SOI Altruism and Fruits of Spirituality. There was a

significant correlation between ASPIRES Prayer Fulfillment (i.e., joy from personal encounters

with the transcendent; Piedmont, 2007), SOI Altruism, Fruits of Spirituality, and Meaning and

Purpose. In addition, significant correlations between ASPIRES Universality (i.e., unitive nature

of life; Piedmont, 2007) and SOI Altruism, Idealism, and Fruits of Spirituality were found.

Finally, results supported a correlation between ASPIRES Connectedness (i.e., belief of being

part of a larger human reality; Piedmont, 2007) and SOI Altruism.

Table 6

Significant Correlations Between ASPIRES and SOI Measures

SOI Scores ASPIRES Scores

ASPIRES Total Score

SOI Total Score r = 0.762, p = 0.010

SOI Altruism Score r = 0.913, p = 0.000

SOI Fruits of Spirituality Score r = 0.791, p = 0.006

(Table 6 continues)
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(Table 6 continued)

SOI Scores ASPIRES Scores

ASPIRES Prayer Fulfillment Score

SOI Altruism Score r = 0.821, p = 0.004

SOI Fruits of Spirituality Score r = 0.883, p = 0.001

SOI Meaning and Purpose r = 0.690, p = 0.027

ASPIRES Universality Score

SOI Altruism Score r = 0.847, p = 0.002

SOI Idealism Score r = 0.689, p = 0.027

SOI Fruits of Spirituality Score r = 0.724, p = 0.018

ASPIRES Connectedness Score

r = 0.678, p = 0.031
SOI Altruism Score

n = 10

Further within-subject analysis was done to incorporate age as a factor in the relationship

between ASPIRES and SOI scores, based upon Piedmont’s (2010) normative data (Table 5).

Correlations were not as strong in the 26 to 45-year-old age group (see Table 7). However, there

was still a significant relationship between ASPIRES total scores and SOI Altruism, ASPIRES

Prayer Fulfillment and SOI Altruism and Fruits of Spirituality, ASPIRES Universality and SOI

Altruism and Idealism, and ASPIRES Connectedness and SOI Altruism.

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Table 7

Significant Correlations Between ASPIRES (Ages 26-45) and SOI Measures

SOI Scores ASPIRES Scores

ASPIRES Total Score

SOI Total Score r = 0.687, p = 0.132

SOI Altruism Score r = 0.957, p = 0.003

ASPIRES Prayer Fulfillment Score

SOI Altruism Score r = 0.827, p = 0.042

SOI Fruits of Spirituality Score r = 0.878, p = 0.021

ASPIRES Universality Score

SOI Altruism Score r = 0.883, p = 0.020

SOI Idealism Score r = 0.820, p = 0.046

ASPIRES Connectedness Score

SOI Altruism Score r = 0.888, p = 0.018

n=6
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Finally, correlations between ASPIRES and SOI in the 46-94 age group revealed only

two significant findings, as are shown in Table 8.

Table 8

Significant Correlations Between ASPIRES (Ages 46-94) and SOI Measures

SOI Scores ASPIRES Scores

ASPIRES Total Score

SOI Total Score r = 0.984, p = 0.016

SOI Fruits of Spirituality Score r = 0.991, p = 0.009

ASPIRES Prayer Fulfillment Score

SOI Fruits of Spirituality Score r = 0.974, p = 0.025

ASPIRES Universality Score

n/a

ASPIRES Connectedness Score

n/a

n=4
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Mixed-Method Results

Quantified codes and themes, taken from qualitative thematic analysis, were assigned +1

for positive themes/codes and -1 for negative themes/codes (see Table 2). Positive themes and

codes and negative themes and codes were added to establish a total positive and a total negative

score for each participant. Data were analyzed for descriptors and correlates. Descriptive results

indicated that, overall, therapists described their experiences with their clients diagnosed with

BPD as positive (Table 9).

Table 9

Quantified Qualitative Themes

Minimum (negative) -21

Maximum (positive) 74

Mean 16.20

Standard Deviation 26.410

Results indicated no statistically significant correlation between quantified themes, due to

a high standard deviation (SD = 26.410). Due to such a wide variance, generalizing these results

to a larger population is not possible. Table 10 shows the correlations between quantified

qualitative themes and SOI/APIRES scores. Of interest to note is the relationship between

qualitative data and SOI Awareness of the Tragic (r = 0.607, p = 0.063). Although not highly

statistically significant, it is the most significant within the data set.

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Table 10

Correlations Between Quantitative Data and Quantified Themes

ASPIRES & SOI Scores Quantified Themes

ASPIRE Total Score r = 0.101, p = 0.782

Prayer Fulfillment r = 0.227, p = 0.529

Universality r = -0.184, p = 0.611

Connectedness r = -0.014, p = 0.986

SOI Total Score r = 0.386, p = 0.270

Transcendent Dimension r = 0.505, p = 0.136

Meaning & Purpose r = 0.250, p = 0.486

Sacredness of Life r = 0.238, p = 0.509

Mission in Life r = 0.270, p = 0.451

Material Values r = 0.571, p = 0.085

Altruism r = 0.173, p = 0.632

Idealism r = -0.090, p = 0.804

Awareness of the Tragic r = 0.607, p = 0.063

Fruits of Spirituality r = 0.222, p = 0.537

n = 10
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Chapter 5: Discussion

This study explored two central research questions: 1) What are therapists’ experiences of

working with individuals diagnosed with borderline personality disorder? And 2) How might

spirituality affect his/her experience of working with these individuals? It was hypothesized that

therapists who score higher on spirituality measures would describe more positive experiences in

their work with clients diagnosed with BPD than will those with lower scores. The primary goal

of this research was to gain a qualitative sense of what therapists experienced while working

with this clinical population. Secondary to this aim was the intent to explore the hypothesis that

spirituality had an effect on these experiences. Given this aim, the qualitative results, which

focused on main themes that emerged from the data, will be discussed first, and, subsequently,

quantitative results will be interwoven into this discussion. Further, suggestions for future

research will be explored, in addition to implications this study might have in both the clinical

and transpersonal psychology fields.

Discussion of Salient Themes

Historically, empirical research and literature exploring the experiences of therapists

working with any clinically diagnostic population is scarce. The main intent of this research was

to explore therapists’ experiences of working with individuals diagnosed with borderline

personality disorder. Qualitative results indicated that therapists experience this work as

dynamic, multidimensional, and, at times, contradictory.

Not unlike previous literature and research (Fallon, 2003; Gunderson, 2009; Koekkoek et

al., 2009), therapists in this study described their experiences of working with individuals

diagnosed with borderline personality disorder as challenging. Therapists found it challenging to

work with clients who were aggressive, had high incidents of self-injury, and created a sense of
 111

hopelessness and helplessness for the therapist. Although these challenges in the clinical

relationship had the tendency to bring up intense, negative emotions for the therapists, some

therapists found these challenges rewarding, requiring them to stay connected to their own

intrapersonal, countertransference process while in the counseling room.

This finding is supported by psychodynamic research in the field, exploring the role of

countertransference in the treatment of individuals diagnosed with borderline personality

disorder. Specifically, Chatziandreou, Tsani, Lamnidis, Synodinou, and Vaslamatzis (2005)

discussed the importance of adhering to one’s own countertransference and personal process in

therapy, in line with the caution that the “therapist must be in a position to tolerate the initial

confusion in order to gradually start categorizing his or her own feelings” (p. 138). Mindfulness

practices, such as grounding, meditation, and awareness were ways in which some therapists

learned to manage and tolerate the countertransference that came up in session. Therapists also

valued consultation with colleagues as a way to manage their own reactions to their clients.

A second salient theme, which emerged from the data, comprised the rewarding aspects

of working with clients diagnosed with BPD. These rewarding experiences, defined by therapists

as joy, gratitude, pride, optimism, hopefulness, accomplishment, and achievement, are reflected

in no known published research in the field. Perhaps it is the case that current literature is

saturated with negative associations to the term borderline personality disorder (Gunderson,

2009; Lieb et al., 2004). Emergence of this theme of positivity by therapists regarding this work

provides hope, in that, perhaps, clinicians are beginning to experience the multidimensional,

nuanced complexity of their clients diagnosed with BPD.

Therapists described several dialectic components to their work with individuals

diagnosed with borderline personality disorder, from feeling refreshed versus exhausted, wanting
 112

to be in control versus allowing themselves to let go, and feelings of idealization versus

devaluation. Therapists reported having to balance this tension with constant flexibility and

creativity in session with their clients. Schwartz-Salant (1989) speaks beautifully to the

idealization of the therapist by the BPD client:

The borderline patient’s unconscious structures of idealization may induce massive

insecurity in the therapist. He or she may then become inflated as an unconscious
maneuver to get rid of the patient and undo the induced sense of impotence. Prior to this
experience with the patient, the therapist may have been duped by a seemingly positive
relationship and may have entertained thoughts of the inadequacy of diagnostics. The
therapist may have determined that the patient had qualities of spirit and courage
transcending the scientific reductionism of psychiatry. But, under the pressure of massive
feelings of insecurity, such optimism quickly gives way to the harsh terms of diagnosis
and prognosis and to sober questioning of whether or not the patient is suitable for
therapy (p. 58).

This theme is further supported by literature emphasizing the importance of holding the dialectic

in the treatment of individuals diagnosed with BPD (Linehan, 1993). Specifically, dialectics is

the “complex interplay of opposing forces” (Linehan & Schmidt, 1995, p. 557). Holding this

complex interplay has been an essential part of the therapists’ experiences, as has been reflected

both in the historical literature and in this current study.

Therapists reported a strong experience of questioning their own clinical competency in

their work with clients diagnosed with BPD. Specifically, they felt they lacked confidence, had

self-doubt, self-judgment, shame, and guilt. Many therapists questioned whether there was for

them a need for more integrated dynamic training in BPD diagnosis and treatment. This theme is

not unlike that in published research exploring the importance and positive correlations between

feelings of clinical competency and participation in clinical training and education (Hauk et al.,

2008). It is recommended that clinicians receive integrated training with regard to working with

challenging clients such as those diagnosed with BPD. This training would support and prepare
 113

clinicians for possible feelings of guilt, shame, and self-consciousness when addressing severe

personality pathology in such clients. It is further suggested that therapists become familiar with

their own personal triggers and process while in session with their clients, so that they might best

manage their countertransference in support of the client’s treatment.

Traditionally, there has been a pejorative narrative in the fields of psychology and

psychiatry regarding research on borderline personality disorder. This narrative continues to

marginalize this clinical population as incurable, or as having the “kiss of death” (Lander, 2003).

Stigma associated with BPD have been extensive (Lequesne & Hersh, 2004; Nehls, 2000;

Servais & Saunders, 2007). Such stigma invades the therapeutic relationship, creating fear in

therapists who provide therapy to this clinical population that they, too, will be marginalized and

misunderstood, themselves (Aviram et al., 2006). Participants in this study agreed. There was a

significant theme that emerged regarding the role stigma plays in both the term for and diagnosis

of borderline personality disorder. Therapists also found themselves worried about being

marginalized and judged by others, fearing they would be misunderstood or seen as not doing

enough to support their clients. This theme is of particular interest in that, not only does

published literature explore the stigma associated with a diagnosis of BPD, but the current study

showed evidence of the stigma therapists’ experience as held by other mental health providers. It

is suggested that this stigma exists because a lack of comprehensive understanding and

willingness to learn about the etiology and complexities of the BPD client and the specific role

therapists have in such clients’ treatment.

Therapists reported that a strong therapeutic relationship was very important in their

experiences of working with their clients diagnosed with borderline personality disorder.

Specifically, therapists discussed the importance of validation, rapport-building, respect,

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empathy, and unconditional positive regard as being essential to effective treatment of their

clients diagnosed with borderline personality disorder. Previous research in the field of

therapeutic alliance has supported this finding (Eskedal, 1998). Specifically, Halperin,

Weitzman, and Otto (2010) supported the importance of a strong therapeutic relationship,

identifying the therapeutic alliance as the “emotional and collaborative bond between the

therapist and the patient” (p. 52). For therapists in this study, the strong therapeutic relationship

created a sense of appreciation, respect, and empathy for their clients’ processes. Results suggest

that therapists who are invested in creating a relationship with their clients might better manage

the challenges that come up in therapy. Perhaps the alliance that is created allows the therapist to

see their clients diagnosed with BPD as more than just a set of symptoms and challenges, but

also, and more properly, as a complex individual struggling to maintain relationships and

emotional equilibrium.

Therapists also described the importance of consultation in their experiences of working

with individuals diagnosed with borderline personality disorder. This consultation with

colleagues provided a space for therapists to explore their own personal triggers and

countertransference in session. Further, it allowed therapists to feel as though they were part of a

larger community that further understood the challenges that clinicians’ face when working with

this population. Current research has begun to explore the importance of therapists’ self-care as it

pertains to their effectiveness in providing therapy to clients (Webb, 2011). This is especially

important when therapists’ emotional and physical exhaustion can influence the process of

psychotherapy. Consultation appears from this study’s participant report to be one way in which

therapists provide self-care and, in return, offer support to their colleagues.

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Original Findings in this Study

To the best of this researcher’s knowledge, no literature has explored two significant

qualitative findings of this study: measuring therapeutic progress as it pertains to the client’s

capacity to change and the somatic experience of therapists who work with clients diagnosed

with BPD. Therapists in this study were aware of the challenges their clients diagnosed with

BPD faced in relationship to healing and recovery. Therefore, it was important for therapists to

remind themselves of the small, yet significant, progress their clients made in treatment. This

finding might have implications for future research as it pertains to outcome assessment in

therapy. For example, the Outcome Rating Scale (Miller & Duncan, 2004), which assesses

clients’ weekly progress, would be a valuable tool to use with clients diagnosed with BPD, as it

provides clients the sense of agency to report on their own progress in therapy, as separate from

the therapists’ perception of progress. This tool might be a valuable guide for therapists and

clients to use to come together to evaluate treatment goals and expectations, and to provide the

client with a sense of personal responsibility regarding their treatment (Miller, Duncan, Sorrell,

Brown, & Chalk, 2006).

Additionally, unique to this study, therapists’ explored the somatic sensations they

experienced in this work. From a somatic perspective, therapists described their bodies as being

full of energy, with tension in their shoulders, sitting on the edge of their seat, feeling tense or

tight in their stomachs, or experiencing pressure in their chest. They also described the positive

somatic sensation of a release when a client made progress in therapy.

Somatic psychology offers a great deal in support of identifying experiences, in that it

provides individuals with the capacity for recognizing subtle shifts in and awareness of the

therapeutic process that might otherwise be missed (Cohen, 2011). In support of this finding, it is
 116

suggested that therapists-in-training and licensed therapists, alike, participate in somatic training

programs, learning to identify their own personal physical experiences while working with this

clinical population. This would be of value so as to add an additional element of awareness of

and attunement with the client, in addition to supporting therapists in their own internal

processes while providing therapy. Future research on the connection between somatic

awareness and therapist experiences is recommended.

Relationship Between Therapists’ Experience and Therapists’ Spirituality

Results did not support the original hypothesis that therapists who scored higher on

spirituality measures would describe more positive experiences in their work with clients

diagnosed with BPD than would those with lower scores. This was, in part, reflected in a

significant standard deviation and low mean. Given the quantification of themes, however,

participants described their experiences working with clients diagnosed with borderline

personality disorder as generally positive. However, given the wide variance and small sample

size, it is not possible to generalize their experiences to a broad therapist population or, further,

to make any significant correlations between these experiences and spirituality.

In this study, therapists’ scores on the ASPIRES scale were higher than were the

normative average scores, a finding that runs counter to research indicating that therapists are

less spiritually and religiously oriented as compared to the general population (Neeleman &

Persaud, 1995; Shafranske & Malony, 1990; Worthington, Kurusu, McCullough, & Sandage,

1996). However, the ASPIRES measure does not have normative data for therapists, so it is

uncertain how this study sample compares to a broader sample specifically of licensed therapists.

Given this limitation for generalizability, these results might suggest merely that this particular

sample of therapists who provide individual therapy to clients diagnosed with borderline
 117

personality disorder might consider themselves, generally, more spiritual than therapists who do

not. This is of interest to the researcher in that perhaps it I, in fact, the case that therapists who

work with individuals diagnosed with BPD are naturally more spiritual than therapists who do

not treat this clinical population. Results for validation of that possibility that appears to be

reflected in this group of participants are preliminary, due to this present study’s having such a

small sample size, and future research is required to further explore this finding.

An important finding from this study is the positive correlation between the ASPIRES

and SOI scales. As was mentioned in the methodology review of the Spiritual Orientation

Inventory, the scale does not have much published literature to support validity or normative data

with which to compare sample groups to whom it has been administered. This study offers an

initial exploration of the parameters regarding the validity of the SOI. Given the positive

correlation between the ASPIRES and SOI scales, there is preliminary evidence to support the

claim that the SOI measures constructs of spirituality similar to that of the ASPIRES scale. More

in-depth analysis and norming of the Spiritual Orientation Inventory is, of course, recommended

to fully validate this scale, but this study points to the possibility that the SOI is a valid measure

of spirituality.

With the understanding that there was a significant variance within quantified qualitative

data, it is of interest to note that the most significant finding was the positive correlation between

therapists’ positive experiences and the SOI measure of Awareness of the Tragic. As mentioned

in the literature review, individuals who take part in challenging work require a capacity to sit

with suffering and pain without feeling overwhelmed by these emotions (Dreschner & Foy,

2010). These results might demonstrate that a capacity to sit with the pain and suffering of

individuals diagnosed with BPD is a strength therapists might have and that their ability to
 118

transform this pain into compassion and empathy will create a more positive, meaningful

experience in their work.

Literature speaks directly to this awareness of the tragic, particularly in the form of

working with the shadow in psychotherapy. Carl Jung described the shadow as “aspects of the

self outside awareness . . . usually used to describe negative and even evil aspects of the self” (in

Scotton, Chinen, & Battista, 1996, p. 46). In bringing a conscious awareness to these negative or

unworthy aspects, there is a risk of experiencing intense and difficult emotions. Therapists in this

pilot study indicated their ability to sit in this difficult, often unconscious, space without losing

sight of spiritual joy (Elkins et al., 1988). More research into this key finding is strongly

recommended, in that it might offer significant findings in support of therapists’ ability to deeply

connect with their clients diagnosed with BPD, as well as for their capacity to honor their own

and their clients’ shadow that contains the tragedy of life’s suffering.

Although the hypothesis connecting therapists’ experiences to their spirituality provided

statistically insignificant results, therapists spoke directly and indirectly of spiritual themes

recognized in the literature, (i.e., meaning and purpose (Baker, 2003); meaning-making

(Delgado, 2005); and mindfulness (Palmer & Muse-Burke, 2012). One therapist spoke,

specifically, of the importance of spirituality and faith in her work with her clients diagnosed

with borderline personality disorder. She described her spirituality and faith as providing a sense

of awe and reverence, which made the work meaningful. Further, within the spiritual construct of

Meaning and Purpose in Life, as identified by the Spiritual Orientation Inventory (SOI; Elkins et

al., 1988) many therapists described their experience of working with individuals diagnosed with

borderline personality disorder as contributing to the collective community, providing meaning

in their lives, and further that it had made a difference in their clients’ lives.
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Limitations and Delimitations

Significant limitations of this study can be attributed to this study’s sample and their

present role as therapists to BPD clients. Research has shown that individuals diagnosed with

BPD can be a challenging population with which to work. Requiring that therapists participating

in this study currently provide therapy to at least two clients diagnosed with BPD might bias the

research in that this sample of participants willing to take such clients might already find this

clinical population less challenging, with or without spirituality playing a role in their work. In

connection with possible sampling limitations, this researcher primarily recruited therapists in

the Seattle area, which is well known for Dialectical Behavior Therapy-oriented therapists. This

may have also influenced the research in that therapists who specialize in DBT might be more

patient, compassionate, and less triggered while working with individuals diagnosed with BPD.

The reader is reminded that this research served as a preliminary study, with the intention

of engaging in a dialogue and promoting future research based upon interesting findings. As with

any study of this size, generalizability of results is not possible, due to the small sample size and

its lack of diversity. Six months of participant recruitment resulted in the recruitment of 10

interested and qualified participants. Many therapists who were contacted explained that they

“did not work with borderlines” or have “steered clear of borderlines” for years. This is, in and

of itself, an interesting anecdotal result of this attempted research. It is assumed that, based upon

the lack of response/interest in this research, there is still a great deal of education, information,

and understanding that needs to be promulgated in the field of psychology regarding how

clinicians understand and work with individuals diagnosed with borderline personality disorder.

The smallness of this sample may be one reason that there was a statistically insignificant

relationship between therapists’ positive experiences and their spirituality. The smallness of this
 120

sample size might also have contributed to such a low mean and high standard deviation within

the quantified themes. This high standard deviation could be attributed to how qualitative themes

were quantified. For instance, themes were simply broken into positive and negative experiences.

If themes had been quantified further (e.g., giving weights to spiritual words, positive or negative

emotions, feelings versus thoughts) correlations might have been more significant.

A further limitation is the researcher’s use of the Spiritual Orientation Inventory.

Although a phonomenologically matched instrument, aimed specifically to gain insight into

measuring spirituality, the measure has not been widely used and lacks validation and normative

data in the field. It is with this limitation in mind that the research selected the ASPIRES scale, a

wider known, normed and validated measure, to be used in conjunction with the SOI. Results

indicated that the SOI and ASPIRES measures were positively correlated. This offers

encouragement to the field to further research and test the SOI, since phenomenologically based

spirituality measures are lacking in the field.

This study was delimited to the experience of licensed clinicians in the Seattle, the San

Francisco Bay and Rochester, New York areas. Further, since other mental health professionals,

such as psychiatrists and nurses, work with this population, excluding such practitioners might

limit a wide range of results and experiences. However, the primary interest of this research is

the role that spirituality might play in therapists’ experience. It is likely that these selected

participants are at the “front line” of duty when it comes to working with this population, and it

is the hope that this research will, in some limited manner, even provide insight into the potential

benefits that spirituality might have on working with this clinical population.

A further delimitation is the lack of empirical evidence in the field that explores how

therapists might be influenced in their work with individuals diagnosed with borderline
 121

personality disorder. It is because of this lack of literature and research that this researcher

selected a heuristic model. This model assumes that the researcher is deeply aware of and

compassionate towards the central research question, as based upon personal experience. It was

from this personal experience that the researcher crafted the central research question, wishing to

further explore therapists’ experience of working with individuals diagnosed with borderline

personality disorder and how spirituality might influence this work.

In using a heuristic model, the researcher was aware of the potential bias brought into this

study, which was mentioned as an initial limitation and is further explored in Appendix G:

Personal and Anecdotal Evidence. The researcher attempted to contain this bias by opening up to

explore the experience of the individual, as separate from the researcher’s personal experience.

Braud and Anderson (1998) explained that, in order to honor the individual human experience, it

is essential to include “appreciation, humility, and wonder as intrinsic values fundamental to

scientific inquiry” (p. xxvii). Although the researcher’s personal experience with regard to this

topic is evident, there is recognition that all participants likely had different but equally

fascinating and powerful experiences in their own right. The researcher welcomes this

opportunity and challenge to better understand both the collective and individual experience of

these individuals in their work. Bias was also contained by using two unaffiliated coders, who

reviewed randomly sampled transcripts and coded for meaning units and themes (see

Appendixes H & I).

Implications for Future Research

There could be multiple reasons and explanations as to why and how therapists reported

their experiences working with individuals diagnosed with BPD as more positive, as compared to

the trend in current published literature. Several confounding variables might begin to explain
 122

the subtle nuances between experience, theoretical orientation, and education/training specific to

BPD. It is suggested that one of these reasons might be due to the amount of time therapists were

required to be working with their clients diagnosed with BPD. For instance, might it be that

therapists who work with clients diagnosed with BPD for only 3 or 6 months describe their

experiences differently? Therefore, a more thorough exploratory model is needed to learn more

about the possible relationships between these factors and how they might influence therapists’

experiences working with individuals diagnosed with borderline personality disorder.

In addition to exploring the confounding variables found in this study, it would be of

interest for future researchers to explore how forgiveness might influence therapists’ work with

this clinical population. Therapists in this study spoke of the gratitude they felt working with

their clients. Previous research has found a connection between gratitude, forgiveness, and well-

being (Toussaint & Friedman, 2009). Further, there is a great deal of literature that explores

forgiveness as a construct of spirituality (DiBlasiom 1992; Davis, Hook, Van Tongeren, &

Worthington, 2012)—how it might influence well-being (Toussaint & Friedman, 2009; Lawler-

Row, 2010) and how it might be used in clinical practice (DiBlasio & Proctor, 1993).

Forgiveness has been shown to heal emotional wounding and support psychological well-being

towards both the self and the other and that, therefore, might be an important construct to

consider when looking at the experiences of therapists who work with individuals diagnosed

with BPD.

An additional study, which might be prompted by this original research would be a

secondary exploration of how spirituality might affect therapists’ experience working with

individuals diagnosed with BPD. Specifically, comparing a control sample of therapists who do

not self-identify as spiritual to self-identified spiritual psychotherapists and studying both groups
 123

in their experiences of working with this clinical population. This study would be of value

because it would specifically look at spirituality as the dependent variable. Further, in order to

quantitatively assess for affect in therapists’ experiences, it is suggested that, in addition to

qualitative interviews, a measure such as the Positive and Negative Affect Schedule (PANAS;

Watson et al., 1988) be given to participants to compare positive and negative affective measured

outcomes related to how therapists qualitatively report their experiences of their work with BPD

clients.

Clinical Implications

This research has several clinical implications. Currently, it is the first research study to

explore the qualitative experiences of therapists who provide individual therapy to individuals

diagnosed with borderline personality disorder. To add to this, is it also the first study to

investigate how therapists’ spirituality might influence the experience of the therapist treating

those diagnosed with BPD. As for the qualitative portion of this study, it serves as a guidepost

and tool for therapists who provide therapy to individuals diagnosed with BPD. It provides

insight into the process, touching significantly on countertransference and personal processes

experienced by the therapist. It introduces ways in which therapists manage these interpersonal

relationships and reactions. Most importantly, it sits among the research as a hopeful suggestion

that the stigma associated with BPD will eventually be overcome by the rewards and

accomplishments of successful treatment provided by therapists who value their work.

From a transpersonal perspective this researcher is inclined to suggest the importance of

implementing spiritual and religious clinical competency training and measures into graduate

programs that prepare students to become licensed clinicians. Previous research has just begun to

explore the influence of implementing spiritual/religious education and training in graduate

 124

programs (Schaefer, Handal, & Brawer, 2011; Cook-Lyon, O’Grady, Smith, Jenson, Golightly,

& Potkar, 2012). Research has also supported the delicate balance between therapists’ personal

religious and spiritual beliefs and the ethical standards to which therapists must adhere when

working with spiritually and religiously diverse clients (Shaw, Bayne, & Lorelle, 2012). If

training therapists are exposed to multiple religious and spiritual beliefs in their formative

graduate years, might they find their own, personal, spiritual belief system or practice to help

them best manage the difficult therapeutic work they are inclined to encounter during their

career? Might this spiritual belief system and/or practice help provide more meaning, purpose,

and respect for their clinical work?

Conclusion

This original research attempted to explore four specific aspects of therapeutic service as

they pertained to the central research questions: (a) What are therapists’ experiences of working

with individuals diagnosed with borderline personality disorder? and (b) How might spirituality

affect their experience of working with these individuals?

First, this research attempted to serve as a guidepost for both in-training and practicing

clinicians, with an attempt at normalizing possible parallel experiences of working with clients

diagnosed with BPD. Results suggested that therapists feel challenged working with these clients

and, yet, that positive experiences outweigh negative experiences, with a main focus on the

rewarding, joyful, hopeful, and optimistic experiences encountered while providing treatment to

this population of clients. The second purpose of the research was to engage in a dialogue and

exploration of how therapists manage their own challenges and struggles in this work. Results

provided evidence that therapists use personal practices such as mindfulness, grounding
 125

exercises, and consultation to support their work. Specifically, therapists focus on their own

personal process in therapy, attending particularly to experiences of countertransference.

The third aim of this study was to provide a shift in the way clinicians and mental health

professionals engage with each other and talk about their work with individuals diagnosed with

borderline personality disorder. In alignment with reviewed literature, results indicated that

stigma is a salient experience for both clients diagnosed with BPD and their treating therapists. It

is the hope that qualitative results will provide a new narrative supporting education, awareness,

and humility in the understanding of BPD etiology and symptomatology. The final aim of this

study was to investigate the assumed connection between therapists’ experiences treating those

diagnosed with BPD and their spirituality. Although descriptive and correlational analysis did

not provide statistically significant results, a few participant therapists discussed the importance

of spirituality, faith, and spiritual practices in their work with their clients diagnosed with BPD.

It is the hope that this research will be used as a starting point to further investigate the important

and dynamic role spirituality has in the lives of therapists.

 126

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Appendix A: Spiritual Orientation Inventory (SOI)

Spiritual Orientation Inventory David N. Elkins, Ph.D.

Instructions:

This booklet contains statements related to spirituality.

Read each statement and decide how intensely you agree or disagree with the statement.

Then circle ONLY ONE NUMBER on the seven-point answer scale to indicate how intensely
you agree or disagree with the statement.

Answer as honestly as possible and give only your own opinion in regard to each statement.
Please try to answer EVERY ITEM

Sample Item for Practice: Please read the following statement and circle the number which
best represents how intensely you agree or disagree with the statement. Remember to circle
ONLY ONE NUMBER.

Intensely Intensely
Disagree Agree

1. Humans are basically good 1 2 3 4 5 6 7

On the answer scale above you should have circled ONLY ONE NUMBER – the number which
most accurately reflects how intensely you agree or disagree with the statement.

Before you Begin:

Have you read and do you understand the instructions? Yes No
(If “No,” please read the instructions and do sample item again)

NOW OPEN THE BOOKLET AND START WITH ITEM 1

__________
Unpublished work 1986 by David N. Elkins, Ph.D. Direct all orders and inquiries in writing to Sara Elkins
37827 N. 9th Place Phoenix, AZ 85086
 141

Intensely Intensely
Disagree Agree

1. There is a transcendent, spiritual dimension 1 2 3 4 5 6 7

to life.

2. Whether or not it is clear to use, the universe 1 2 3 4 5 6 7

is unfolding in a meaningful, purposeful
manner

3. When I am old and look back at my life I 1 2 3 4 5 6 7

want to feel that the world is a little better
place because I lived.

4. Even such activities as eating, work, and sex 1 2 3 4 5 6 7

have a sacred dimension to them.

5. My primary goal in life is to become 1 2 3 4 5 6 7

financially secure.

6. I feel a strong identification with all 1 2 3 4 5 6 7

humanity

7. When I see “what is,” I have visions of 1 2 3 4 5 6 7

“what can be.”

8. While one should not overdo it or become 1 2 3 4 5 6 7

morbid, I think it is good for us to be aware of
pain, suffering and death.

9. Our highest good lies in harmoniously 1 2 3 4 5 6 7

adjusting ourselves to the transcendent
spiritual dimension.

10. I know how to contact the transcendent 1 2 3 4 5 6 7

spiritual dimension.

11. The universe is not yet done but is 1 2 3 4 5 6 7

unfolding in a meaningful way.

12. It is important to search for one’s purpose 1 2 3 4 5 6 7

or mission in life.
 142

Intensely Intensely
Disagree Agree

13. I do not divide life into sacred and secular; 1 2 3 4 5 6 7

I believe all of life is infused with sacredness.

14. It is much more important to pursue 1 2 3 4 5 6 7

spiritual goals than to pursue money and
possessions.

15. I seldom show my love for humanity 1 2 3 4 5 6 7

through action.

16. In spite of all, I continue to have deep 1 2 3 4 5 6 7

positive belief in humanity.

17. I have grown spiritually as a result of pain 1 2 3 4 5 6 7

and suffering.

18. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension has given me a sense of personal
power and confidence.

19. I have had experiences which I have felt 1 2 3 4 5 6 7

very close to the transcendent, spiritual
dimension.

20. The search for meaning and purpose is a 1 2 3 4 5 6 7

worth quest.

21. I believe life presents one with a mission to 1 2 3 4 5 6 7

fulfill.

22. I have experienced a sense of awe that love 1 2 3 4 5 6 7

between family members can be so deep and
special.

23. While money and possessions are 1 2 3 4 5 6 7

important to me, I gain my deepest satisfaction
from spiritual factors.

24. I do not feel any sense of responsibility to 1 2 3 4 5 6 7

humanity.
 143

Intensely Intensely
Disagree Agree
25. I believe the human spirit is powerful and 1 2 3 4 5 6 7
will win in the end.
26. I am a better person today because of life 1 2 3 4 5 6 7
experiences which at the time were very
painful.
27. I believe that alcoholics, drug addicts, and 1 2 3 4 5 6 7
others whose lives are out of control can be
helped through contact with the transcendent,
spiritual dimensions.

28. I have had transcendent, spiritual 1 2 3 4 5 6 7

experiences in which I felt almost unbearable
delight and joy

29. Answers can be found when one truly 1 2 3 4 5 6 7

searches for the meaning and purpose of one’s
life.

30. It is more important to me that I be true to 1 2 3 4 5 6 7

my mission than that I succeed in the eyes of
the world.

31. I often experience a sense of awe about the 1 2 3 4 5 6 7

specialness of human beings.

32. Ultimately, the sole pursuit of money and 1 2 3 4 5 6 7

possessions will leave one empty and
unfulfilled.

33. I feel a deep love for all humanity 1 2 3 4 5 6 7

34. I truly believe that one person can make a 1 2 3 4 5 6 7

difference.

35. While we all must die, I believe it is better 1 2 3 4 5 6 7

not to think much about this fact.

36. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension has helped reduce my personal
stress level.

37. I have had transcendent, spiritual 1 2 3 4 5 6 7

experiences which seem almost impossible to
put to words.
 144

Intensely Intensely
Disagree Agree

38. If someone has a reason or purpose for 1 2 3 4 5 6 7

which to live, one can bear almost any
circumstances.

39. I have a sense of personal mission in life; I 1 2 3 4 5 6 7

feel I have a calling to fulfill.
40. I have never felt a sense of sacredness. 1 2 3 4 5 6 7

41. I have a spiritual hunger which money and 1 2 3 4 5 6 7

possessions do not satisfy.

42. I am often overcome with feelings of 1 2 3 4 5 6 7

compassion for human beings.

43. Idealists are usually just romantic 1 2 3 4 5 6 7

neurotics.

44. It seems pain and suffering are often 1 2 3 4 5 6 7

necessary to make us examine and reorient our
lives.

45. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension has enhanced my physical health.

46. I have had transcendent, spiritual 1 2 3 4 5 6 7

experiences in which I felt deeply and
intimately loved by something greater than I.

47. My belief that there is a transcendent, 1 2 3 4 5 6 7

spiritual dimension gives meaning to my life.

48. I am personally devoted to what I consider 1 2 3 4 5 6 7

to be a meaningful cause.

49. Nature often inspires me a solemn sense of 1 2 3 4 5 6 7

awe and reverences.

50. If I had to chose between being rich or 1 2 3 4 5 6 7

being spiritual, I would chose to be rich.

51. People who know me would say I am very 1 2 3 4 5 6 7

loving and reach out to help others.
 145

Intensely Intensely
Disagree Agree

52. While there is much evil in the world, I 1 2 3 4 5 6 7

believe goodness, integrity, and love also
abound.

53. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension has enhanced my emotional health.

54. I have had transcendent, spiritual 1 2 3 4 5 6 7

experiences in which I “let go” and surrender
my life to something higher.

55. The fact that we ultimately have to die 1 2 3 4 5 6 7

shows that life is meaningless.

56. Humans are sometimes “called” to fulfill a 1 2 3 4 5 6 7

certain spiritual destiny.

57. I believe it is a mistake to attach sacredness 1 2 3 4 5 6 7

only to religious places, objects, and activities.

58. Generally, I value love and cooperation 1 2 3 4 5 6 7

more than competitiveness.

59. I believe humans have great potential for 1 2 3 4 5 6 7

goodness and love.

60. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension has deepened my relationship with
others.

61. I have had transcendent, spiritual 1 2 3 4 5 6 7

experiences in which I have felt an unusual
oneness with, and acceptance of, the universe.

62. Even though I may not always understand 1 2 3 4 5 6 7

it, I believe life is deeply meaningful.

63. I have either found or am searching for my 1 2 3 4 5 6 7

mission in life.

64. To be honest, I almost never experience a 1 2 3 4 5 6 7

sense of sacredness about anything.
 146

Intensely Intensely
Disagree Agree

65. There is no hope for the human race. 1 2 3 4 5 6 7

66. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension has helped me to feel closer to my
“Higher Power.”

67. I have had transcendent, spiritual 1 2 3 4 5 6 7

experiences in which deeper aspects of truth
seem to have been revealed.
68. I believe people should just enjoy 1 2 3 4 5 6 7
themselves and not worry so much about such
philosophical issues as the meaning of life.

69. All I really want from a job is an excellent 1 2 3 4 5 6 7

income so I can live well and enjoy what
money can buy.

70. In our modern, scientific world we should 1 2 3 4 5 6 7

stop believing in such unscientific ideas such
as “sacredness.”

71. I am very cynical about the human race. 1 2 3 4 5 6 7

72. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension has helped me to sort out what is
really valuable in life from what is not.

73. I have had a transcendent, spiritual 1 2 3 4 5 6 7

experience in which I felt transformed and
“reborn” into new life.

74. One can find meaning in suffering, pain, 1 2 3 4 5 6 7

and death.

75. Nonreligious people who think of 1 2 3 4 5 6 7

themselves as being spiritual are deceiving
themselves.

76. It is good to dream of what can be and to 1 2 3 4 5 6 7

“build castles in the air.”
 147

Intensely Intensely
Disagree Agree

77. Contact with the transcendent, spiritual 1 2 3 4 5 6 7

dimension gives me optimism and energy to
live life wholeheartedly.

78. I have had transcendent, spiritual 1 2 3 4 5 6 7

experiences in which I was overcome with a
sense of awe, wonder, and reverence.

79. Religious people are more spiritual than 1 2 3 4 5 6 7

nonreligious people.

80. I have never had a transcendent, spiritual 1 2 3 4 5 6 7

experience.

81. Spirituality means being part of a church or 1 2 3 4 5 6 7

temple and actively participating in religious
activities.

82. Emotionally healthy people do not have 1 2 3 4 5 6 7

transcendent, spiritual experiences.

83. I often experiences feelings of awe, 1 2 3 4 5 6 7

reverence, and gratitude in nonreligious
settings.

84. I often experiences feelings of awe and 1 2 3 4 5 6 7

gratitude in regard to my close friendships.

85. Person’s who talk of being “scared” seem a 1 2 3 4 5 6 7

little strange to me; I simply do not experience
life in that way.
 148

Appendix B: Assessment of Spirituality and Religious Sentiments (ASPIRES)

ASPIRES™: Assessment of Spirituality and Religious Sentiments Self-Report Form

Ralph L. Piedmont, Ph.D.

Instructions: this questionnaire will ask you about various perceptions you hold about your view
of the world and your place in it. Answer each question on the scale provide by checking the box
that best describes your feelings (e.g.  or ). If you are not sure of your answer or believe that
the question is not relevant to you, then mark the “Neutral” category.

Please work quickly, do not spend too much time thinking about your responses to any single
item. Usually, your first answer is your best response, so go with your first reaction to the item.
 149

Section I.

1. How often do you read the Bible/Torah/Koran/Geeta?

☐ Never ☐ About once a month ☐ Several times a week
☐About once or twice a year ☐ 2 or 3 times a month
☐Several times a year ☐ Nearly every week

2. How often do you read religious literature other than the Bible/Torah/Koran/Geeta
☐ Never ☐ About once a month ☐ Several times a week
☐About once or twice a year ☐ 2 or 3 times a month
☐Several times a year ☐ Nearly every week

3. How often do you pray?

☐ Never ☐ About once a month ☐ Several times a week
☐About once or twice a year ☐ 2 or 3 times a month
☐Several times a year ☐ Nearly every week

4. How frequently do you attend religious services?

☐ Never ☐ Rarely ☐ Occasionally ☐ Often ☐ Quite Often

5. To what extent do you have a personal, unique, close relationship with God?
☐ Not at all ☐ Slight ☐ Moderate ☐ Strong ☐ Very Strong

6. Do you have experiences where you feel a union with God and gain spiritual truth?
☐ Never ☐ Rarely ☐ Occasionally ☐ Often ☐ Quite Often

7. How important to you are your religious beliefs?

☐ Extremely Important ☐ Very Important ☐Fairly Important
☐Somewhat unimportant ☐ Fairly unimportant ☐Not at all important

8. Over the past 12 months, have your religious interests and involvements…

1- - - - - 2 - - - - - 3 - - - - - 4 - - - - - 5 - - - - - 6 - - - -- 7
Increased Stayed the Same Decreased

9. I feel that God is punishing me

☐ Strongly disagree ☐ Disagree ☐Neutral ☐Agree ☐ Strongly Agree

10. I feel abandoned by God

☐ Strongly disagree ☐ Disagree ☐Neutral ☐Agree ☐ Strongly Agree

11. I feel isolated from others in my faith group.

☐ Strongly disagree ☐ Disagree ☐Neutral ☐Agree ☐ Strongly Agree
 150

12. I find myself unable, or unwilling, to involve God in the decisions I make about my life.
☐ Strongly disagree ☐ Disagree ☐Neutral ☐Agree ☐ Strongly Agree

Section II.

Strongly Agree Neutral Disagree Strongly

Agree Disagree
1. I have not experienced deep ☐ ☐ ☐ ☐ ☐
fulfillment and bliss through my
prayers and/or meditation
2. I do not feel a connection to some ☐ ☐ ☐ ☐ ☐
larger Being or Reality.
3. I do not believe that on some level ☐ ☐ ☐ ☐ ☐
my life is intimately tied to all
humankind.
4. I mediate and/or pray so that I can ☐ ☐ ☐ ☐ ☐
reach a higher spiritual level.
5. All life is interconnected ☐ ☐ ☐ ☐ ☐

6. There is an order to the universe ☐ ☐ ☐ ☐ ☐

that transcends human thinking.
7. Death does stop one’s feelings of ☐ ☐ ☐ ☐ ☐
emotional closeness to another.
8. In the quiet of my prayers and/or ☐ ☐ ☐ ☐ ☐
meditations, I find a sense of
wholeness.
9. I have done things in my life ☐ ☐ ☐ ☐ ☐
because I believed it would please a
parent, relative, or friend that had
died.
10. Although dead, memories and ☐ ☐ ☐ ☐ ☐
thoughts of some of my relatives
continue to influence my current life.
11. Spirituality is not a central part of ☐ ☐ ☐ ☐ ☐
my life.
12. I find inner strength and/or peace ☐ ☐ ☐ ☐ ☐
from my prayers and/or meditations.
13. Although there is good and bad in ☐ ☐ ☐ ☐ ☐
people, I believe that humanity as a
whole is basically bad.
14. I do not have any strong emotional ☐ ☐ ☐ ☐ ☐
ties to someone who had died.
 151

15. There is no higher plane of ☐ ☐ ☐ ☐ ☐

consciousness or spirituality that
binds all people.

Strongly Agree Neutral Disagree Strongly

Agree Disagree
16. Although individual people may ☐ ☐ ☐ ☐ ☐
be difficult, I feel an emotional bond
with all humanity.
17. I mediate and/or pray so that I can ☐ ☐ ☐ ☐ ☐
grow as a person.
18. Prayer and/or meditation does not ☐ ☐ ☐ ☐ ☐
hold much appeal to me.
19. My prayers and/or meditations ☐ ☐ ☐ ☐ ☐
provide me with a sense of emotional
support.
20. I feel that on a higher level all of ☐ ☐ ☐ ☐ ☐
us share a common bond.
21. I want to grow closer to the God ☐ ☐ ☐ ☐ ☐
of my understanding.
22, The praise of others gives deep ☐ ☐ ☐ ☐ ☐
satisfaction to my accomplishments.
23. I am not concerned about the ☐ ☐ ☐ ☐ ☐
expectations that loved ones have for
me.
 152

Appendix C: Demographic Information

Thank you for your interest in participating in this research study. Please fill out each answer to
the best of your ability and knowledge.

Name/Alias _________________________________________

Date of Birth ________________________________________

License Type Ph.D. Psy.D. LMFT LCSW

Are you currently treating at least two individuals diagnosed with borderline personality

disorder? YES NO

What clinical assessment tool was used to support your clients’ diagnosis of BPD? (please list)

_______________________________________________________________________

How many clients are you currently treating with BPD? ________________________

How long have you been treating each of these clients (listed from above):

Client 1: __________ Client 2: ____________ Client 3: ____________

Client 4: ___________ Client 5: ____________ Client 6: ____________

Additional Clients __________________________________________________

What is your average weekly case load of ALL clients?

____________________________________________________________________
 153

What is your theoretical orientation?

____________________________________________________

Gender _______________________________

Race/Ethnicity ___________________________

Length of time as practicing clinician _______________________________________

Type of practice (community mental health, private practice, etc.)

________________________________________________________________________

Do you consider yourself to be spiritual and/or religious?

YES NO MAYBE NOT SURE

Do you follow any type of spiritual/religious practice? If Yes, please elaborate.

YES NO MAYBE NOT SURE

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
 154

Have you, yourself, received therapy at some point in your life (as clinical training, personal

reasons, etc). YES NO

If yes, how long did you receive/have you been receiving therapy?

________________________________________________________________________

If yes, what theoretical orientation does your therapist practice?

________________________________________________________________________

How did you hear about this research? ________________________________________

Thank you for your time!

 155

Appendix D: Recruitment Flier

 156

Appendix E: Informed Participant Consent Form

To the Participant in this Research:

You are invited to participate in a study investigating the experience of therapists who
work with individuals diagnosed with borderline personality disorder. This study is being
conducted in order for me to meet the requirements of the doctoral psychology program at the
Institute of Transpersonal Psychology in Palo Alto, California. Your participation will support
scientific research in better understanding experiences of licensed clinicians who work with
people who are diagnosed with borderline personality disorder. It is the hope that this research
will advance understanding of the therapist’s experience and support further research in this area.
For you, benefits of participation might include a better understanding of your process as a
therapist, effective self-care practices, and reflections on your work as a practicing clinician.
Your participation will entail a single, private, confidential, in-person interview located in
a neutral setting, lasting a maximum of 2 hours, in addition to filling out 3 multiple-choice
surveys at the interview session, which should not take more than 45 minutes. Your total time
commitment to this research study will not exceed 3 hours. For research purposes, the interview
will be audio and video recorded. If you are not comfortable with video recording, please inform
the researcher of this prior to your initial in person interview. Your decision not to be video
recorded will not effect your participation in this research. If you chose to be video recorded, you
will receive an additional consent form. Additionally, all data will be used for future research
and further analysis.
All the information gleaned from this research will be protected for your privacy. All
information will be kept confidential and you identity will be protected. Electronic records (such
as interview recordings, notes on the computer, etc) will be stored in a password-protected, non-
internet, and non-network connected external computer hard drive so no one besides the
researcher can access it. Hard copy data will be kept in a locked file cabinet to which only the
researcher will have access. Your identity will also be protected through the use of a fictitious
name or code number. In the reporting or publication of this study or the information it contains,
any information that might identify you will be altered to conceal your identity. Your privacy is
essential to this research, so please feel comfortable asking any questions that might come up
before, during, or after your participation in this study.
This study is designed to reduce potential risks to you. However, discussion of treatment
process and experiences with individuals diagnosed with borderline personality disorder, in
addition to discussion of your own personal process may bring up potentially difficult and
negative emotions. If distress arises as a result of the interview, the researcher will provide you
with the appropriate resources for counseling or spiritual guidance that you may pursue at your
own expense. If at any time you have any concerns or questions, the researcher will make every
effort to discuss them with you and inform you of options for resolving your concerns. If you
have any questions or concerns, you may email me at [email protected], call me
collect at XXX-XXX-XXXX, contact my dissertation chairperson, Ron Pilato, Psy.D. at (XXX)
XXX-XXXX ext. XXX or [email protected] or contact the head of Research Ethics Committee
of the Institute of Transpersonal Psychology, Fred Luskin, Ph.D., at (XXX) XXX-XXXX, ext.
XXX or [email protected].
If you decide to be part of this research, you may withdraw your consent and cease your
involvement at any point, for any reason during the study, and you may do so without prejudice
 157

or penalty. You may request a summary of the research findings by providing your mailing
address with your signature.

I verify that I have read and understood this form, that the researcher has explained the
study to me, and that she has answered any questions about this research to my satisfaction. My
participation in this research is entirely voluntary and no pressure has been applied to encourage
participation. My signature indicates my willingness to be a participant in this research.

________________________________________________
Participants Name (please print)

________________________________________________
Participants Signature and Date

________________________________________________
Researcher’s Name

________________________________________________
Researcher’s Signature and Date

Kaelyn Langer
XXX XXXX XXXX
Seattle, WA XXXXX

If you have any questions or concerns, or would like additional information, you may contact
Kaelyn Langer [email protected] or XXX-XXX-XXXX
 158

Appendix F: Semistructured Interview Script

Thank you so much for taking the time to participate in my dissertation research study. I
just want to confirm that you have received all your consent information, have filled out the
initial demographic form and have chosen an alias to protect your identity.

Study Inclusion Criteria

1. Are you currently a licensed therapist?

Yes – in what field do you hold your license?

2. Are you currently treating at least two individuals diagnosed with borderline personality
disorder?
Yes – how many clients are you treating with borderline personality disorder?

3. What clinically diagnostic tool was used to diagnose your client with BPD?

4. Have you worked with these clients for at least one year?
Yes - How long have you worked with these clients?

5. How many clients are currently on your caseload?

6. How many clients on your caseload have a diagnosis of borderline personality disorder?

7. How long have you been a practicing clinician?

8. What is your theoretical orientation?

We are now going to spend some time talking about your clients who have a diagnosis of
borderline personality disorder. You mentioned you are currently treating [number of clients
w/BPD diagnosis] clients at this time. I would like you to spend some time and think about
one of these clients that you are currently treating. Allow yourself to think about this client,
their presentation, your feelings and thoughts when then client is sitting in session with you,
this could be the last time you saw the client, or several sessions ago. Let yourself remember
what it was like sitting in session with this client.

9. Please tell me your experience of working with this client…

 159

a. Possible cues could include:

i. How do you view this client?
ii. What does your body feel like when you are in session with this client

10. What has been the most challenging part of working with this client?
a. Possible cues could include:
i. Why did you find this particularly challenging?
ii. What did you notice in this client during this time?
iii. What did you notice in yourself during this time?
iv. Were you able to voice this in some way to your client?

11. How have you handled these challenges?

12. What has been the most rewarding part of working with this client?
a. Possible cues could include:
i. Why was this rewarding to you?
ii. Were you able to voice this in some way to your client?

13. How does working with your client’s diagnosed with BPD differ from your work with
your clients who do not hold this diagnosis?

14. What different experiences, if any, do you have working with this population compared
to your other clients?

15. Do you work with other members of your client’s family and/or individuals who are in
close relationship with your client?
If yes…How have you found this has influenced your work with your client?

16. Name 4 difficult feeling/expressions you notice in yourself when working with a client
diagnosed with BPD (break each of these down)

17. Name 4 uplifting feelings/experiences you notice in yourself when working with a client
diagnosed with BPD (break each of these down)
 160

18. Do you perform some type of practice or ritual prior to, or after, meeting with your
clients? (grounding practice).
 161

Appendix G: Personal and Anecdotal Evidence

As the researcher, I am aware of the potential biases and belief systems I bring into this

dissertation. First, this topic is of great interest to me, personally. While working as a psychiatric

technician with adolescents in an inpatient facility I had many experiences with young women

diagnosed with BPD. At the time, I was a novice to both the mental health field and the DSM. I

had little experience with personality disorders and found myself incredibly triggered by these

individuals consistently referred to as “borderline.” On a particularly stressful night, I turned to

one of the nurses and asked, “What is this?!” Her reply was simple, “It’s borderline, and you

don’t have to ever work with it if you don’t want.” I was stunned. Here I was, working in a

hospital, working with individuals who were in a tremendous amount of physical, emotional, and

mental pain, and I was being told that some clinicians simply refuse to work with individuals

who have been diagnosed with BPD. This did not seem right – how could a clinician who is

ethically responsible to provide help for all people refuse to treat a group that seemed so

desperately in need of attention? It was at this point that I turned towards this fear of being

angered and triggered by this population and began to seek deeply the truths and fears within

myself.

I have come to this research through my own intense interpersonal work, because I

believe clinicians must be clear on their own fears, insecurities, and triggers. Therefore, my bias

rests within my own experience of having been so triggered and angered by this population and

then finding my own inner strength, my Spirit, through my practices of meditation, yoga, and

personal psychotherapy, that a sustainable creation of relationship with Spirit allows for a deep,

authentic capacity to sit in the challenging, uncertain, disruptive, chaotic moments that often

transpire during treatment with people diagnosed with BPD.

 162

Appendix H: Transcriber and/or Coder Confidentiality Form

As a transcriptionist or coder I agree to maintain confidentiality with regard to all participants’

information, specifically the audio recordings from the interviews, the transcriptions of the
recordings, the assessments, and any other related written material. I will also help to aid the
researcher in protecting the identity of participants to ensure anonymity.

________________________________ ________________
Transcriber and/or Coder’s Signature Date

________________________________ _________________
Researcher’s Signature Date
 163

Appendix I: Second Coder’s Qualitative Analysis for Inter-Rater Reliability

Consultation with other providers Relationship based

Calling Duality of experience
Sacred Work Intimacy vs. thrown in trash
Integrated approach Not a person
Exhilarating Duality
Frustrating Boundaries
Ritual Transference/Countertransference
Awareness of what is necessary to work with Disclosure
BPD Change in client over time
Dialectic Gaining experience
Importance of relationship with client Changing strategy
Rewards for therapists Physical effects
Rewards and difficulties Becomes the abuser
Reward Rewards
Gratitude Intelligence
Difficulties Reward
Misdiagnosed Astute
Self-Reflection Requires change in therapists way of doing
Self-Awareness therapy and way of being
Reward is client growth Reward
Modeling tolerance for difficult feelings Never boring
Safe relationship Duality
Big picture required to treat BPD Opportunity for growth
Countertransference Opportunity for self-reflection
Self-reflection about experience Gratitude
Self-doubt Meaning and purpose
Awareness Difficult emotions
Consultation with peers Difficulties
Shift into relationship based therapy Willing to work and interpret
Have to be worked in layers Model responses
Therapists holds the dialectic for the client Therapist as tool
Therapist aware of boundaries between herself Rewards
and client Experience helps
Difficulty Ritual
Difficult for therapist to hold negative Consultation
emotions Support
Therapist self-doubt Stressful
Therapist trusting client Hard to trust client
Difficulty Ambiguity
Abuse from client Relationship
Swing in relationship Control vs. trust on both sides of relationship
Difficult Importance of consultation
Process awareness Prayer as helpful practice
Confusing signals from client Self-awareness
 164

Therapist as instrument Boundaries

Therapist difficulty Therapist as instrument
Difficulties – anxiety producing Understanding fixing vs. allowing
Anxiety and tension Transparency of internal process
Adrenaline Heightened awareness
Self-awareness Inexperience was difficult
Discloses process Supervision
Being centered Self-awareness
Peer support and consultations Difficult feelings
Therapist self-awareness Helper who can’t help
Therapy as a sacred calling Self-doubt
Detachment from diagnosis Judged by others
Rewards Team approach
Awareness of sacred connection Consultation
Deep appreciation Spirituality
Attachment Challenges of working with borderline client
Reward Spiritual awareness
Ritual
Self-Reflection

Codes and Themes

- Therapist theoretical orientation doesn’t seem to be of primary importance

- Relationship is the tool
- Length of time as a practicing therapist can matter–increase in ease and ability
proportionate to experience; change in experiences over time in working with Borderline
clients it gets easier over time
Client characteristics
- Clients have some symptoms in common, but also tend to present differently;
comorbidity common; need to treat symptoms of both Axis I and Axis II; each client is
unique
- Client behaviors in therapy –listed in the documents
Effects on the therapist
- Difficult feelings – hatred, fury, trapped, victimized, disgust, acute helplessness; self-
questioning, nervous, anxious, aggressive
- Rewards – challenging, admiration for client’s courage/fighting for health, humbling,
keep learning/intellectually stimulating, not boring, I can help, feeling of meaning and
purpose, affirming spiritual beliefs
- Hallmarks of working with borderline diagnosis – the duality in the relationship;
“intimacy versus thrown in the trash”
Keys to success for therapist
- Working with transference; countertransference
- Consultation with peers, supervisor
- Rituals – breathing, meditation, prayer
 165

- Detachment and boundaries- ability to tolerate ambiguity

- Willingness to disclose process to the client
- Ability to tolerate difficult emotions; self-awareness
- Spiritual center and stance about sacredness of therapeutic relationship
- Long term approach to the therapy
 166

Appendix J: Third Coder’s Qualitative Analysis for Inter-Rater Reliability

Alphabetical List of Codes:

Ability to trust?
Able to get to heart of the matter
Able to tolerate silence longest with BPD clt
Acceptance
Adept at feeling current in the room
Admire Clt courage
Admire Clt persistence
Adrenaline
All things are covered in grace
Allow both to be
Allowing Clt to have own process
Ambiguity in early tx
Ambiguity
An ear for spiritual stuff
Anger
Anger
Anger with competency issues being stoked
Anxiousness about/ safety
Anxiousness about/figuring out boundaries
Anxiousness about/how to hold Tx relationship
Appreciate her story
Appreciate/risk clt takes by coming to tx
Appreciation
Appreciation
Appreciation and awe for person
Attachment to long-term clts
Authentic response
Aware of excitement
Awareness of how spirituality is organized in my Clts
Awareness of relational factors
Awe
Axis II stuff
Be in that space
Been in the trenches together
Believe in using interpersonal process
Blown up in public ways
Body shut down
BORED
 167

BPD clts require more effort

Buffeted by obnoxious bx
Burden of Clts who aren’t going to be fine
Can you just fix them?
Can’t vent with spouse
Case load
Caught me off guard
CBT
Centered
Centered
Centeredness helps me create containing
Centering and grounding
Challenging to work with non mental health professionals
Changed over course of tx
Checking in with self
Clear
Click
Clinical mistakes
Clouded my vision
Clt bx called Thx competence into question
Clt did a year of DBT work
Clt fears that Thx would harm or abuse her
Clt hospitalized
Clt hx
Clt in control
Clt learned body awareness
Clt learning skills
Clt makes own choices
Clt not able to acknowledge needs
Clt not about to ask for what she needed
Clt presentation activated higher that usual desire to help
Clt presentation/I have big issues but don’t want to talk about it
Clt provokes response
Clt pulls out of it
Clt report unreliable
Clt responsibility
Clt sense of protective space
Clt setting up control
Clt shut down
Clt stoking the fire
Clt successes rewarding
 168

Clt taught me a lot

Clt tenacity
Clt testing Thx
Clt tries to anger Thx
Clt vs Thx need
Clt will disclose own responses
Clt will have skills for navigating vulnerability
Clt will have skills for stress
Clt/fabulous, amazing, wonderful
Clt/like Satan
Clt’s come far in trust issues
Clt’s worked hard
Clts do the work
Clueless after grad school
Collaboration
Collaboration
Colleagues
Colleagues
Comfortable holding uncertainty about clt well being
Commitment Tx
Common aspects of working with BPD
Companion
Compared to other clts
Competency being called into question
Competency called into question
Completely missed it
Connected with myself
Connection
Consulting with colleagues
Consulting with psychiatrists
Control
Coping/ talking about what was coming up with Clts
Coping/A lot of consultation
Coping/consulting with colleagues
Coping/extra space between sessions
Coping/Prayer
Coping/Space to process Thx reactions
Coping/spirituality as resource
Coping/time to sort through what’s really going on
Coping/used own thx as supervision
Could feel something but didn’t know what it was
 169

Could feel what clt couldn’t express

Couldn’t have been aware of BPD early
Create a different experience for Clt
Crisis Tx
Dangerous to lump sx and bx
DBT
Deep sense of contentment
Deep sense of satisfaction
Deeper listening
Derive pleasure from clt good time
Desire to be helpful vs How to be helpful in the circumstance
Developmental stage clt population
Diagnosis
Dialectic
Dialectic
Dialectic/do and don’t want to talk about it
Dialectic/Get away vs Don’t leave me!
Dialectic/Your best and your worst
Didn’t have the language
Didn’t have the training
Disclosure
Disclosure/with SOs
Discussing boundaries
Discussing levels of concern
Doing the best that she could
Don’t necessarily show spirituality to clients
Don’t put my religion out there
Don’t think I was aware of it yet
Drama
Duration of Tx
Each clt unique
Element of risk
Enjoy working with Clt
Enough rapport now
Establishing scope of Tx with Clt
Excited by Clt progress
Excited clt building some trust
Exhilarating
Experience of being loved and lovable
Extremely challenging
Fear for Clt safety
 170

Feeling between shame and embarrassment

Feels different
Felt disappointment in own clinical judgment
Figure out the truth
Figuring out how to navigate
Filed it away
First client narcissistic
Fix this!
Focused on what I knew best
Following Clt can lead to stalled process
Frequency of Tx
Frustrating
Frustration
Frustration
Frustration rooted in helplessness
Fullness of the good and not good in me
Fully appreciate scariness
Fully appreciate vulnerability
Fun because they are challenging
Genuine concern for clt
Getting frustrated
Getting myself together would be counter productive
Getting over being the thx that wants to help
Getting really grounded
Getting to see her beneath everything
God/as coping resource
God/is in control
Good and bad
Good at sitting in light and dark
Good question
Great listener
Greatly enjoyable
Grounded
Hang in there together
Hard for Thx to see aggression
Hard to articulate
Hard to trust accuracy of what clt said
Have to turn up awareness
Help clt contain
Help me vs Get away
Helplessness vs Would you just try to help yourself
 171

Her being really angry at me for a while

Hesitate to take credit
Hold Clt in check
Hold that with team
Hold the messiness
Holding on to in midst of anger and frustration
Holding space for ambivalence
Honor clt need to control own boundaries
Honor her unfolding
Honoring the person I’m sitting with
Hospitalization pissed her off so much
How did I miss this?
How far to push?
How much space?
How to managing conflicting needs
I can call her on that
I could tell something was off sitting with him
I do my part
I don’t know how to help you
I don’t often miss Axis II
I end up liking BPD clts
I feel drained
I feel the anxiety
I feel tired
I have a good barometer
I need the space before and after
I really like clt
I really love this work
I think I did ok
I want to help you
I’m pretty proud about my sense of values [Aha!]
If I had been aware of the BPD set
Image of God underneath it all
Impact on conceptualization
Impact on way of being in room
Implication of flow
Important part of our working on trust
Important realization
Impressed with Clt efforts/accomplishment
Impulse to read a lot
In my face
 172

Increased clt tolerance to vulnerability

Increased comfort and ease after “aha”
Incredibly challenging
Ineffable
Institutional pressure
Integrated
Intellectual
Interesting
Interpersonal
Intertwined
Interventions
Invested in a different way
It can be scary
Judgment was off
Just allowing clt space
Just get connected
Just the way I work
Keeping my cool when clt can’t keep hers
Know where to go with this
Knowing how these ways of being are about making it through
Laugh together
Left school
Less anxious
Less bored with BPD
Let it wash out
Letting the process open up
Letting the smoke clear
Long process to trust accuracy of Clt report
Long time to fix
Long time to work through
Major melt down
Manipulative
Masters in theology
May not look pretty
Missed Axis II with this Clt
Missing something important
Mission statement on mirror
Model checking in with self for clts
More anxious with BPD
More attachment to trying to help
More confident in clients
 173

More fun than straight axis I

More interpersonal process with clts with BPD
More than other clts/Hit on stuff in me
More than other clts/Pull stuff out of me
My awareness of letting all the stuff drip off me
My awareness of the gift of other people
My deep core self
My desire to help
My job is to be present
My spirituality
My value
Narcissism
Navigate emphasis on Axis I vs Axis II
Need space after
Need space before
Need sx relief
New clt awareness of own feelings
No every moment
No way to divorce that from me
Normally a signal of something going on
Not about coming out smelling like a rose
Not having that set in mind is so frustrating
Not pushing Clt
Not rocket science
Not to over control clt
Oh my god, I missed this
On the edge of Clt making important move
Opportunity to see blind spots as Thx
Opportunity to step back
Overt vs Covert drama
Passive
Passive aggression
Passive aggressive presentation
Passive body angry face
People person
PhD integrating spirituality and psychology
Phenomenal of her
Physical presentation different from what she said
Plant a seed
Power
Presenting issue/PTSD
 174

Presenting problem vs Underlying problem

Protocols for BPD
Provide space for refection
Psychiatrist
Psychodynamic supervisor
Push-Pull
Push-Pull (recurrent theme)
Questioning clt truthfulness
Questioning/What is clt getting from Tx
Questioning/Why does she keep coming?
Rare for me to miss “it”
Rarely see work come to fruition
Reading is not the answer
Really challenging
Really core with all clts and especially BPD clts
Regret
Re-ground during breaks
Relationship as therapeutic tool
Reminds me of why I work
Reverence
Reverence
Ritual /Close my door
Ritual/Breathe
Ritual/Close my eyes
Ritual/connect with wise self
Ritual/ground myself
Ritual/Let a wave of calm wash over me
Rupture
Rye smile
Sacredness of the work
Sad for awful things that happen to clt
Sadness about time misspent
Sense of achievement
Sense of god within
Sense of grace
Sense of pride in clt?
Sharing with colleagues
She had to be hospitalized
She’s a pain in the ass and I like her
Shift
Shut down in session
 175

Inter Rater Coding

Working with BPD can be unpredictable

Working with BPD can be distressing

Thx as essential source of support

BPD clients demand truth in Tx

Accusations

Tx with BPD clts requires affective engagement

Tx with BPD clts evokes somatic responses

Allowing bx to be form of communication

Work with BPD clts requires atypical approaches

Awareness of Clt trauma can be helpful

Tx with BPD requires full attention/presence/grounding

Need for clarity around boundaries

Thx need flexibility around boundaries

BPD challenges even experienced Thx

Creativity/Creative thinking required

Work with BPD challenging but rewarding

Work with BPD improves clinician skills

Continual Thx self-reflection essential

Dialectical nature of work

Thx working with BPD need to be mindful of language choices

Pull vs Push

Power relations
 176

Thx working with BPD need to be prepared to have interventions/methods

challenged/questioned

Thx working with BPD need strategies for addressing/managing threats of self-harm

Thx awareness of effect of Clt tone vs inner experience

Importance of understanding concrete thinking

Thx comparison of typical vs BPD clts

Thx maturation process over time

BPD clts can challenge even complacent Thx

Thx role to contain not retaliate

Creative is an asset for Thx

Thx can feel intruded upon by BPD clts

Higher level of self-disclosure may be required with BPD clients

Developmental perspective can be helpful

Multiple dialectics

Novel approaches to Thx required

Thx perspective shifts from early to later career

Thx can feel that they are expected to read minds

Memories of working with BPD clts indelible

Working with BPD triggers negative responses

Working with BPD meaningful

Working with BPD purposeful

Working with BPD can be rewarding

Working with BPD often frustrating

 177

Gratitude for forced accountability

Awareness of the Thx client needs

Clear communication is essential

Thx need a strategy for responding between Tx

Thx help BPD clients own feelings

Thx help BPD clients with affect regulation

Work with BPD clients is humbling

Work with BPD clients can be stimulating

Thx as essential person in clients life

Success with BPD clients requires vigilance

Thx can learn from BPD clients

BPD clients provide Thx with opportunities to learn and grown

BPD clients are often intelligent in a rewarding way

Thx awareness of relationship dynamic

Thx have to accommodate bx from BPD clients that they would not tolerate in non-Clts

Enjoying a challenge is a helpful asset for Thx who work with BPD

Imagination is an asset for Thx

Immediate feeling of intimacy can be uncomfortable for Thx

Irony is part of Tx with BPD clients

BPD has its own language

BPD learning curve is steep

Contact with colleagues can be helpful

Tx with BPD clients can require higher than usual level of accountability
 178

Mis-attunement can be interpreted as meanness by Clt

Value of successful Tx relationship when most other relationships fail

BPD clients can challenge Thx perception that their motives are always good

Thx have to learn to cope with feelings that their best is often not good enough

Thx who work with BPD have to be able to manage a high level of uncertainty

Thx who work with BPD have to tolerate being misunderstood/actions misinterpreted

Thx have to be able to reconcile the reality that they cannot provide everything the Clt needs

Thx need awareness that they are not Clt’s only lifeline/source of support even though it can

seem that way at times

Need to manage contact between sessions

Thx awareness of parallel process

Questioning as an essential tool for Thx

Value of quiet/grounding

Role of Ritual

Self-work as vital part of Thx preparation

Work with BPD can be stimulating

Importance of recognizing paradoxical responses

Applying paradoxical interventions

Alchemical aspects of work with BPD clients

Thx need to be prepared to encounter the unexpected

Thx need to manage time away from office

Reminders that what Thx has to offer is of value can increase Thx resilience
 179

Appendix K: Phone Screen

Thank you for your interest in this research. This initial phone screen is to better determine if
you meet the inclusion criteria to participate in this study. I’m going to ask you a few questions
and if you meet criteria, I would like to gather some of your personal contact information and set
up a time to meet in person to administer a semistructured interview and two quantitative scales.

Inclusion 1: Are you currently over the age of 21? YES NO

If yes…

Inclusion 2: Are you currently a licensed mental health professional? YES NO

If yes…

In what mental health profession are you licensed?

PhD PsyD LCSW LMFT LMHC/A

Inclusion 3: Are you currently treating at least two individuals diagnosed with Borderline
Personality Disorder? YES NO

If yes…

Inclusion 4: Have you been treating both of these individuals for at least 1 year? YES NO

If yes…

Thank you, you have been selected to participate in this mixed-methods study. Could you please
give me some additional contact information:

Email address __________________________________________

Primary phone number ___________________________________

When are you available to meet for a 2 hour period to discuss your experience of working with
individuals diagnosed with borderline personality disorder (have calendar prepared) and give
participant my contact information for schedule changes & conflicts.