A Psychodynamic Approach to Co-occurring Borderline Personality and Substance Use Disorders in the Emergency Department

Substance use disorders and borderline personality disorder are common and highly stigmatized medical conditions (1, 2). They are two of the leading psychiatric diagnoses of patients who are evaluated in the medical emergency department (ED), particularly for overdose, intoxication, trauma, or self-harm (3).

Patients with acute symptoms of these and other severe mental illnesses can invite chaos and logistical challenges, stirring up strong feelings among ED clinicians (4). The intensity of such patient encounters can challenge a clinician’s ability to feel effective and helpful and can engender feelings of anxiety, manipulation, and anger. These feelings may contribute to clinicians’ less favorable and more stigmatizing attitudes toward these patients than toward patients with other general medical or psychiatric conditions (5). Negative attitudes put these vulnerable populations at risk for poor care (6, 7) because they can lead to patients being patronized, humiliated, mistrusted, or refused treatment (8, 9). These attitudes may also impede communication and rapport, leading to patients’ subsequent experiences of rejection, hopelessness, and humiliation—feelings that can trigger relapse or continued use of substances (10).

To address these concerns, this article outlines brief psychodynamic strategies drawn from applied transference-focused psychotherapy to help clinicians manage their own reactions to difficult encounters with patients in emergency medical settings. These concepts target the feelings of frustration and helplessness that may arise for clinicians treating patients with acute, co-occurring borderline personality and substance use disorders. Similar approaches have been shown to be useful in clinical interactions across patient populations and diagnoses as well as across different medical settings and specialties, even when a clinician does not have an established relationship with their patient (11, 12). Unlike psychotherapy, which requires longer periods of rapport building to facilitate a patient’s readiness for engagement, these strategies can optimize patient care by utilizing a clinician’s ability to recognize and manage countertransference.

Theoretical Background

Borderline personality disorder can be conceptualized as a problem of identity that contributes to difficulties experiencing oneself and others with complexity or richness (13). These challenges lead to a vulnerability to interpersonal distortion that often manifests in sudden shifts of mood or self-worth resulting from perceived rejection or approval by others. Such affective instability creates chaos in personal and professional relationships, and an individual may use substances, self-injury, or other risky behaviors to manage painful feelings. Fear and suspicion of persecutory experiences (or their perceived inverse, moments of perfect understanding and care) organize an individual’s relational world, which can lead to clinical interactions that feel (to the clinician) surprisingly charged, frustrating, and volatile.

Patients who are intoxicated by or withdraw from substances are susceptible to marked fluctuations in mood states that are directly related to the effects of substance use on neurotransmitter pathways (14). Executive function and emotion regulation are tenuous, and physiologic homeostasis is disturbed. Even without comorbid personality dysfunction, the capacity for effective interpersonal communication under such circumstances is impaired.

In certain theoretical frameworks, transference is the activation of an internalized experience of a given person that is transferred to someone in that person’s current experience—in this case, the ED clinician. Transference is shifting and dynamic, varying with the patient’s internal representations and the circumstance of a particular moment (13). Countertransference comprises a clinician’s reactions to their patient’s transference and is influenced by the physical and psychological experiences that shape the clinician’s state of mind (15). In the fast-paced ED setting, countertransference often comes into a clinician’s awareness only when it becomes difficult and negative, for example, when a patient’s disruptive behavior begins to interfere with a clinician’s workflow.

Enactment

Some patients with co-occurring borderline personality disorder and substance use disorders struggle to communicate their experience effectively because of acute psychological difficulty, intolerable emotion, or chronic impairment, further alienating the treating clinician. Enactment may then occur, whereby the clinician and patient unwittingly act out the expected or familiar dynamics that dominate the patient’s frightening internal world (13). The patient’s inability to tolerate awareness of these unconscious stirrings propels their projections into the clinical situation. Clinicians may feel as if they are losing control of the encounter and may notice feelings of fear, anger, or avoidance that reflect some part of their patient’s own experience. Attending to these reactions and internal biases may help defuse the enactment (16).

Many patients with active substance use disorders, borderline personality disorder, or both frequently use interpersonally maladaptive defenses. These defenses are formed to be protective and are acquired in an effort to manage circumstances that feel dangerous or provoke anxiety. The patient’s mobilization of these powerful and often aggressive defenses may arouse dread, anger, and repulsion in the treating clinician. These feelings can lead the treating clinician to feel overwhelmed, controlled, and compelled to react (3). Hateful feelings, in particular, may be uncomfortable, intense, and forceful; the clinician may unconsciously disavow or embrace these feelings, both of which put the clinician at risk for straying from their clinical responsibilities and straining their own mental health (17, 18). A hateful countertransference may tempt the clinician to use clinical interventions (e.g., underdosing pain medications or “forgetting” to bring blankets to the bedside) for punitive or humiliating purposes or to avoid setting boundaries for safety because of guilt about their own aggressive feelings. Alternatively, the clinician may avoid ongoing frustration through clinical abandonment of the patient, either dismissing their concerns or making underinvestigated clinical conclusions. Such temptations risk adverse medical consequences for the patient and a breach of the standard of care. Recognizing and acknowledging these feelings and reactive temptations as part of the countertransference can empower clinicians to proceed with safer and wiser interventions.

The ED Encounter

For the clinician, the ED is a familiar, routinized setting for daily fast-paced work involving multiple concurrent tasks. The demands of the job may feel exhilarating or exhausting, depending on the day, and different variables affect the clinician’s experience in any given moment and fluctuate with the rhythms of the setting: the end or beginning of the shift, the evening rush, the overnight lull. The acuity of cases on a clinician’s patient panel, the aftermath of a code, personal stressors, and even mundane experiences such as hunger can affect the clinician’s psychological state.

For most patients, even those who visit the ED frequently, an ED visit is likely to be uncomfortable, inconvenient, and frightening—a situation over which the patient may feel little control. Patients experiencing intoxication or emotional dysregulation may find the ED particularly threatening, distorting their experience of the situation and activating dysfunctional patterns.

The experiences of the patient and the clinician at the moment of encounter shape the interaction and the sense that they have of each other and themselves. The clinician might wish or expect the patient to provide a clear history, engage respectfully, and adhere to their recommendations. At the same time, the patient may wish and expect the clinician to make them feel better, have limitless time for them, and provide clear answers and solutions. Both parties have expectations for the interaction that may be reasonable or unreasonable. These expectations—which may be explicit or implicit, conscious or unconscious—are shaped by the roles, experiences, personalities, and personal beliefs of the patient and of the clinician. The alignment of clinician and patient expectations at this encounter will inform the transference and countertransference and contribute to either collaboration or struggle.

Pattern Recognition in the ED

A 44-year-old man with a history of poorly controlled diabetes (nonadherent to metformin 1,500 mg/day) arrives to the ED with a chief complaint of an upset stomach for 5 hours, associated with generalized pain and goosebumps. He reports having used heroin and cocaine 10–12 hours before arrival. Emergency medical services personnel report that the patient refused a finger stick in the field; in the ED, the patient refuses a urine sample and further interview. During the discussion with the resident, the patient throws his food on the floor and states, “How can I trust you? You don’t know anything! The nurse is the only one who cares about me.” According to the registered nurse’s note, the patient was irritable and rude during intravenous (IV) placement.

This patient presentation may cause an immediate reaction for many ED clinicians. This reaction may be associated with anticipation of conflict or an overwhelming interaction. For many individuals with co-occurring borderline personality disorder and substance use disorders, expressions and behaviors of distress may obstruct and interfere with assessment and treatment. Feelings of frustration and annoyance with (or alienation from) a patient, however, may alert a thoughtful clinician to bring greater awareness to a difficult encounter. The attention the clinician pays to their own reaction, and thus also to the dynamics of the interaction, can enable more effective and perhaps more empathic treatment for the patient. The following emotional themes, among others, commonly arise for clinicians in the ED.

“This Patient Is Getting to Me”

A reflexive reaction to a patient, whether flagrant or subtle, that is atypical in the clinician’s normal range of responses is worth noting. The clinician may feel annoyed, put off, or particularly useless or incompetent, even though the patient’s primary concern is not especially unusual. The clinician may notice the patient’s distress and have doubts about their own decision making, perhaps creating a moment of worry about doing something wrong or not doing enough. Such a patient may arouse opposite reactions among different clinicians—or even in the same clinician, depending on the day or the clinician’s state of mind. Whether subtle or more pronounced, such feelings influence how and to what extent the clinician will engage with such a patient.

“This Patient Is Causing Me Problems”

Patients in the throes of intoxication or withdrawal, with or without a personality disorder, often create chaos through action. Patients may throw food, pull out IV lines, use substances onsite, or threaten to hurt themselves or staff. Members of the treatment team may find themselves unprepared to continually manage the physical environment. This scenario can leave the treatment team feeling stuck in a cycle of defensive reaction. The treating clinician may feel exasperated and angry at having to manage these chaotic events instead of fulfilling their typical clinical tasks.

“This Patient Doesn’t Even Want My Help”

Some patients make clinicians feel defeated. The patient may ignore the clinician’s presence or appear irritated with or even hostile toward them. The clinician may feel that the patient does not want to be helped or that they are malingering. A patient who visits the ED frequently can make the treatment team feel that, as with all past efforts, any future investment in that patient would be wasted or futile. Feeling resentful about “doing all the work,” the clinician may be tempted to limit engagement; if they ignore the patient long enough, perhaps the patient will soon be ready to leave. These feelings may be further exacerbated by divisions within the treatment team; a patient’s tendency to alternately idealize some clinicians and devalue others may inflame interactions among team members. These dynamics, which often feed off tangible differences between team members (e.g., differing credentials or perceived status, genders, races, or levels or types of training), can create rifts between collaborating physicians, physicians and nurses, and medical and security staff.

Strategies for Self-Management

A psychodynamic understanding of the patient encounter can help the clinician use transference-focused tools to facilitate more effective clinical interactions in the ED. Of course, conducting psychotherapy is not possible or appropriate in the emergency setting. Application of the following strategies, however, may facilitate a more therapeutic interaction that helps both the clinician and patient manage the challenges of a difficult encounter.

Step 1: Create an Environment of Safety

Establishing the safety of the clinician and the patient is often standard procedure in the emergency setting. Attention to the safety of patients with co-occurring borderline personality disorder and substance use disorders is particularly imperative given their chronic elevated risk of dangerous behavior and the added severity of symptoms associated with intoxication, withdrawal, and affect storms. Ensuring conditions of safety in these circumstances facilitates the clinician’s ability to make responsible clinical decisions and is crucial to managing a situation characterized by heightened emotions and physical threat. Clinicians may ensure safety by double-checking the patient’s medical workup, rethinking the differential diagnosis, or ordering constant security observation to manage risks of elopement or onsite substance use.

Step 2: Communicate the Boundaries and the Plan

Clear communication builds trust and reasonable expectations in the clinical encounter. Communication about boundaries is particularly necessary with patients who, in subtle or frank ways, violate the typical tacit agreements of the treatment encounter. Such difficulties may result from the neurobiological and emotional underpinnings of the patient’s distress, including anticipation or experience of excruciating withdrawal symptoms and characterological or substance-induced fear and paranoia. Clarity about what is happening and what to expect—“We’re going to obtain blood for lab testing,” “Security will be here to make sure you stay safe”—can be useful for patients who experience heightened anxiety and distress from uncertainty.

The patient may have already revealed a capacity for rage and outsized reactions, creating pressure for staff to not upset the patient further. Especially in these circumstances, clinicians who communicate directly, perhaps while acknowledging a potential reaction, can foster the patient’s trust during the encounter. For example, a clinician might say, “I have a feeling this might upset you, but we need to collect a urine sample,” or “It must be pretty irritating that I’m asking so many questions when you’re so uncomfortable, but I know you have some medical conditions that could be dangerous if I give you the wrong medication.”

Bargaining or deal making might allow the patient to feel some agency in regulating themselves, but setting boundaries does not require negotiation or making promises that the clinician cannot keep—under such circumstances, the patient may be especially prone to experiencing the resulting disappointment as a betrayal or a lie, eroding their trust in and cooperation with the treatment team. Instead, a clinician might say, “I wish I could promise that we’ll fix everything, but we still have some questions about your lab results that we’re trying to figure out. Tell me what is bothering you most right now. Let’s see what we can try to do to address that.”

The goals of firmness, boundary setting, and communication of consequences are meant to protect patients, not punish them. In this way, the clinician provides a cognitive-emotional support (containment) for the patient, who might not be able to manage on their own in that moment.

Step 3: Name Emotions, Acknowledge the Situation, and Provide Tools

Patients with behavioral or emotional dysregulation may feel out of control and chaotic when dealing with their setting, physiological symptoms, and heightened emotional state. A patient may escalate their behaviors and outbursts when they feel their distress is being ignored or has been lost in the shuffle. Even with a busy workday and a large patient panel, the clinician can provide some acknowledgment and containment of these feelings, allowing the patient to feel that their concerns, struggles, and needs are recognized and acknowledged: “You look really uncomfortable,” “I might be wrong, but I think you might be scared,” or “I can see that you’re angry.”

No magic formula exists for what to say; stating something simple and true often works best. It might not help the situation, but for some patients, this acknowledgment lowers their defenses enough to let them consider that the clinician may not be attacking them and that, possibly, the clinician has a sense of the patient’s experience and state of mind. As a result, it becomes less urgent for the patient to communicate disruptively. Acknowledgment of the situation, even if it may seem obvious to the clinician, can be grounding and reassuring for the patient: “You’re in pretty bad opioid withdrawal,” or “I know it’s really loud [noisy, bright] in here.”

At this point, concrete tools or options can be offered to reduce a patient’s distress. The clinician might say, “We’re going to give you some medication to ease the withdrawal,” or “We can close the curtains or move you to a quieter area.”

An important but often neglected intervention is the clinician’s communication of their understanding of what might be happening in the interaction with the patient. Communicating this understanding to the patient calmly and nonjudgmentally can provide a way for the clinician to acknowledge the patient’s experience with them in the moment while also offering a different way to relate. For example, “I think you might feel like I want you to be in withdrawal right now. That might be making it harder for me to do what I can to make sure you’re safe and comfortable.” Alternatively, a clinician might say, “It might feel like no one here wants to help you—I think that would be a terrifying feeling to have here [in the ED]. Maybe it would help if I can tell you what our plan is, and you tell me what questions you have about it.” For some patients, this communication may be enough to facilitate a different and more positive experience of the moment.

Conclusions

The treatment and management challenges of working with patients with co-occurring borderline personality disorder and substance use disorders may contribute to negative perceptions of these patients among clinicians. Development of transference-focused strategies (Box 1) related to awareness and management of negative countertransference can benefit clinicians and patients alike and help improve the quality of communication and the effectiveness of these interactions. These skills can be taught and utilized across clinical settings, training experiences, and diagnostic categories.