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Barry J. Koch Ph.D.
Community and Counseling Center
110 S. College Ave
Oxford, OH 45056
Callers who suffer from Borderline Personality Disorder (BPD) are among the most common repeat callers and
the most frequent users of crisis hotline services. The intensity of the needs of these callers is not easily contained
within a business-hours-only treatment structure. Crisis hotlines therefore provide a unique opportunity to offer
essential adjunctive therapeutic contacts and affect containment at times when other services are not available.
Optimal management of repeat hotline callers with BPD includes the following steps:
Educate staff to identify manifestations of borderline pathology on a crisis hotline
Staff need to be trained to identify a caller's use of the primitive defenses associated with BPD, specifically
denial, splitting, and projection. Staff need to be taught to put the intense anxiety sometimes exhibited in hotline
calls into the proper developmental context (presence of primitive annihilation anxiety). The person suffering
from BPD sees the world as a boundless, dangerous place that does not easily meet needs. This worldview
accounts for some of the behaviors that are often experienced by hotline staff as manipulative. It is also
imperative for staff to be aware that these callers have not yet reached the developmental milestone of object
constancy. They are thus not capable of holding the world in their minds as a stable representation. As a result,
life changes may cause feelings of potential fragmentation.
Set the structure
The out-of-boundary behavioral manifestations of this disorder pose unique problems. A crisis hotline should thus serve as a therapeutic holding environment, providing the caller with a structure to operate within which is reliable and clear in its behavioral expectations. Though many different staff persons may talk to the caller on the hotline, it is very important that one person, preferably the hotline director, work with the caller to create and clarify the specific elements of the treatment structure, and be available for the inevitable questions and challenges that arise regarding the structure.
Behavioral limits regarding the amount of calls, length of calls, or other aspects of the service may be necessary for callers who have demonstrated overly demanding or excessive behaviors. For example, callers who insist on multiple lengthy calls each day will need the acceptable number of calls and call length to be pre-defined and limited.
The caller's internalized object relations tell them that no one does what they say, no one operates within proper
boundaries, and no one cares enough to enforce these boundaries in the name of safety. For this reason, the
structure needs to be firmly, empathically, and consistently enforced.
Use process-over-content response orientation when handling calls
If there is a pre-defined structure, stay within the boundaries of that plan. When listening to the caller pay more attention to the process than the content. The content is often unreliable, distorted, scattered, and difficult to follow. It is easy to get lost or overwhelmed in the multi-level confusing details and miss the larger picture of what the caller is trying to communicate (usually feelings of being overwhelmed or scared or hurt). Reflect these feelings rather than trying to grapple with understanding or verifying the confusing details.
Watch for the caller's tendency to rapidly shift from idealizing in one minute to devaluing the next. This is one manifestation of the defense mechanism of splitting. Callers will often project their feelings onto the counselor, which can easily cause frustration and anger. Counselors are encouraged to identify their own feelings, develop a thick skin, and not take either the idealizing or devaluing content personally.
Watch for the tendency to get overly involved with the caller. These callers have such poor judgement in their life decisions that they will often present excessive chaos and neediness. A counselor may be vulnerable to being pulled into thinking they have the ability to decrease the suffering if they go "the extra mile" for this caller, and eventually feel in over their head.
These callers can fragment and lose touch with reality. Some will engage in self-abusive or self-mutilating
behavior. If a caller threatens to cut herself or himself, for example, assess for the need for medical intervention.
If there is no immediate need for medical attention, listen empathically and keep the structure intact. Encourage
the caller to talk about the feelings (as opposed to acting them out) which are inspiring the wish to do self-harm.
In some cases, the caller will cut no matter what, so be aware that this is a possibility. It may be necessary to call
the local psychiatric outreach service for a psychiatric assessment or refer the caller to the hospital.
Attend to powerful feelings within staff regarding their contacts with these callers
One of the major challenges for hotline directors in managing callers with BPD lies in the tendency of these callers to inspire powerful feelings among staff. Especially when limits are enforced, callers will often aim strong negative transference feelings at the hotline counselor. The counselor, in turn, often feels confusion, frustration, anger, etc. as they struggle to understand these seemingly overblown reactions. No matter how well one understands borderline pathology, powerful experiences such as these can be experienced as de-stabilizing for some hotline counselors. For this reason, hotline counselors need a structure to operate within which provides access to immediate opportunities to process their own feelings about these calls.
One manifestation of the fragmented internal life of the person suffering from BPD is the tendency to spread the
pieces of his or her life story among many different people (such as different members of a hotline staff). Each
person is given a disconnected piece, but no one is given the whole story. This is another example of the defense
mechanism of splitting. It can lead to staff dissent. For this reason, hotline counselors need to be encouraged to
talk frequently with each other regarding consistent application of a caller's treatment plan, to avoid problems
with splitting.
Coordination with outside services
A crisis hotline is best used as an important adjunct to a primary psychotherapy relationship, not as a substitute
for this essential relationship. The tendency toward splitting mentioned in the previous section makes ongoing
periodic communication among members of the caller's treatment team (primary psychotherapist, case manager,
psychiatrist, hotline, etc.) imperative. Without it, the treatment itself will be used as another tool through which
to perpetrate chaos and confirm the maladaptive worldview.
Crisis hotline directors should attempt to obtain signed releases of information from callers who are frequent users of the hotline. If a caller refuses to provide this release (which is his or her right), and the hotline director feels like the possibility of therapeutic benefit is compromised as a result of not having the capability to coordinate treatment with collateral providers, the hotline director may choose to insist on a signed release, explaining to the caller that this is a necessary condition of treatment, and that quality treatment is not possible without it.
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