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

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.

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.

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.

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.

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.

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.

The authors thank Frank Yeomans, M.D., and Eve Caligor, M.D., for their thoughtful comments on earlier versions of the manuscript.