Navigating complexities in borderline personality disorder

In this in-depth interview, Dr Antoinette Miric explores the complexities of treating borderline personality disorder, from managing transference and fear of abandonment to navigating comorbidities like PTSD and substance misuse. She emphasises the importance of boundaries, clinician self-care, and integrated approaches, balancing crisis intervention with patient autonomy.

Medical Academic Perspectives 04 - August/September 2025

Dr Antoinette Miric

Dr Antoinette Miric

Medical Academic (MA): Hi Dr Miric, let’s begin with the ethical and clinical challenges of maintaining therapeutic alliances with borderline personality disorder patients, particularly when transference, dependency, and fear of abandonment arise. How do these dynamics typically manifest, and how can clinicians respond effectively?

Dr Antoinette Miric (AM): Fear of abandonment is a central issue. It often underlies intense reactions to perceived slights or changes in therapeutic routines. For instance, a clinician’s holiday or rescheduled appointment might trigger profound distress, sometimes expressed as anger or withdrawal. Recognising these reactions as part of the patient’s pathology, rather than personal criticism, is key. Clinicians must strive to remain steady, compassionate, and boundaried, even when faced with volatility.

Transference and countertransference are a critical part of borderline personality disorder management. In transference, patients unconsciously project feelings from past relationships onto the clinician, while countertransference, the clinician’s emotional response, can reveal unspoken aspects of the patient’s inner world. With these patients, countertransference often involves frustration, helplessness, or anxiety.

It’s essential to differentiate which emotions belong to the clinician’s own history and which are elicited by the patient’s projections. For example, a patient’s unbearable feelings of worthlessness might be "deposited" into the clinician, who then experiences despair. Supervision and self-reflection are vital to untangle this.

MA: You’ve mentioned boundaries. Could you elaborate on their role and common pitfalls you encounter in practice?

AM: Certainly. Boundaries provide the scaffolding for safe, effective treatment. Consistency, in session times, communication, and professional conduct, helps patients develop trust. However, a frequent mistake is over-flexibility, such as extending sessions or responding to frequent out-of-hours contact. While well-intentioned, this can erode therapeutic structure and inadvertently reinforce dependency.

I’ve seen cases where clinicians, fearing abandonment crises, become excessively available, only to find the patient’s demands escalate. Clear, compassionate limits are paradoxically more containing. For example, instead of agreeing to daily check-ins during a crisis, a clinician might say, "I understand your distress, but we’ll address this thoroughly in our next scheduled session. Here’s a crisis contact if you need urgent help."

MA: These dynamics sound emotionally taxing. How can clinicians mitigate burnout?

AM: Self-care isn’t optional—it’s an ethical imperative. First, education is protective. Training in modalities like dialectical behaviour therapy (DBT) equips clinicians with tools to manage complex cases effectively. Regular supervision is equally crucial; it offers space to process countertransference and refine strategies. Peer support groups can also normalise the challenges unique to this work.

On a personal level, therapists must attend to their own mental health. Therapy isn’t just for patients—it helps clinicians recognise their vulnerabilities, such as a tendency to over-identify with patients or "rescue" them. Physical health matters too: sleep, exercise, and hobbies replenish emotional reserves. Burnout thrives in isolation, so connecting with colleagues to share experiences is invaluable.

The goal is to build the patient’s crisis coping skills so they rely less on acute services. Collaborative safety planning is key, assisting patients to co-create plans detailing warning signs, self-soothing techniques, and when to seek help.

MA: Turning to comorbidities, how do conditions like PTSD or substance misuse complicate treatment, and what integrated approaches help?

AM: Comorbidity is the norm, not the exception. Trauma histories are pervasive, and studies suggest up to 70% of borderline patients experienced childhood abuse, often leading to complex PTSD. Substance misuse frequently coexists, with patients using drugs or alcohol to numb emotional pain or impulsively self-soothe. These layers demand a phased approach. For instance, stabilising substance use through harm reduction (e.g., managed alcohol programmes or opioid substitution) might precede trauma-focused therapy, as patients need sufficient emotional regulation skills before revisiting traumatic memories.

Integrated care teams are ideal. A patient might see a psychiatrist for medication, a psychologist for trauma therapy, and a support worker for social needs. Collaboration prevents fragmented care—for example, ensuring a patient’s DBT therapist communicates with their prescriber to align strategies during mood episodes.

MA: How should clinicians balance immediate risk management (e.g., hospitalisation) with fostering long-term autonomy?

AM: This is a tightrope walk. Short-term interventions like hospitalisation can save lives but may reinforce dependency if overused. The goal is to build the patient’s crisis coping skills so they rely less on acute services. Collaborative safety planning is key, assisting patients to co-create plans detailing warning signs, self-soothing techniques, and when to seek help. This empowers them to take ownership while knowing support exists.

When I need to breach confidentiality, I inform the patient that I am contacting their designated emergency contact. I explain my concerns and the ethical rationale for my decision. I encourage the patient to communicate their concerns directly to the contact person first. If they are unable or unwilling to do so, I make it clear that I will step in and share the necessary information.

MA: Finally, what’s the evidence for medications like lamotrigine in managing borderline symptoms, and when should clinicians avoid polypharmacy?

AM: In terms of evidence for these medications, I think it's important to note that we’re not using them for borderline personality disorder per se. Many of these patients will be on SSRIs to treat their comorbid anxiety or depression. They are also often diagnosed with ADHD, in which case you have stimulants in the mix as well.

Lamotrigine is often used off-label and may reduce the intensity of mood swings. Crucially, sedatives like sleeping tablets and benzodiazepines are best avoided—their addiction potential is high in this population.

Dr Antoinette Miric is a psychiatrist with a particular interest in women’s mental health, anxiety and mood disorders. She has been in private practice since 2014 and currently operates from the Oxford Health Care Centre in Saxonwold, Johannesburg.