Sh*t You Wish You Learned in Grad School with Jennifer Agee, LCPC

Episode 32: Is it BPD, Bipolar, or C-PTSD? featuring Lisa Duez

November 23, 2022 Jennifer Agee, LCPC Season 1 Episode 32
Sh*t You Wish You Learned in Grad School with Jennifer Agee, LCPC
Episode 32: Is it BPD, Bipolar, or C-PTSD? featuring Lisa Duez
Show Notes Transcript

Lisa Duez, LCSW, CSAC, EMDR Therapist and Approved Consultant and I help you understand the nuance of differential diagnosis with Borderline Personality Disorder, Bipolar Disorder and Complex PTSD. It is tough as a clinician to distinguish between these differing diagnoses sometimes. Lisa and I have years of experience and we are sharing what you need to understand to diagnose accurately. 

While most of us do not enjoy diagnosing, it is very important to understand what diagnoses we are treating so our clients can receive the very best and most appropriate care. The underlying causes for the symptoms our clients are experiencing often have very different treatment requirements so getting it right matters. Lisa and I are here to help!


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Jennifer Agee: Hello. Hello. And welcome to Sh*t You Wish You Learned in Grad School. I am your host, Jennifer Agee, licensed clinical professional counselor. With me today is Lisa Duez. She is the CEO of Turning Point Counseling and Consulting, and you are in for a real treat with this topic today. So welcome to the show.

Lisa Duez: Thank you so much. I'm so happy to be here. 

Jennifer Agee: So, tell me, Lisa, what is something that you wish you learned in grad school? 

Lisa Duez: Oh goodness. Um, I think, you know, differential diagnosis between all these, uh, letters that we have, BPD, bipolar disorder, chronic PTSD. I think that's just, that's a nuance that we need a little bit more help with.

Jennifer Agee: Yeah, I agree. It's something that comes up a lot in clinical supervision. Um, where we're really talking about these different diagnoses because there's so much overlap, it gets very difficult, especially for newer clinicians who aren't as familiar with the nuance of how these different things look. Um, so I'm really glad we're talking about it today. Thank you for being on the show. 

Lisa Duez: You're welcome. You know, I was thinking about this topic in particular, and it's almost like these three are like, um, they're twins. They're not identical twins, but, or triplets. I'm sorry. But they're, they're triplets, but they're not identical, but they are definitely, um, related very related.

Jennifer Agee: Yeah. Well, and I think a, a lot of the current thinking about borderline personality disorder, um, and complex PTSD, specifically, I'm gonna put, um, borderline — or I'm gonna put bipolar disorder to the side here for a second — but specifically with BPD and complex PTSD. One of the, the things that I'm hearing a lot about is just really looking at it as complex trauma and attachment wounds.

Lisa Duez: Mm-hmm. 

Jennifer Agee: Is that the lens that you start to see these things as well?

Lisa Duez: I do. I'm a, I'm a trauma therapist, so I, I see everything that way. And I think, um, as I, kind of, came up in the field when I learned that BPD is a response, is a trauma response, I, I definitely understood it a lot better. Um, that it is, you know, at its core, um, you know, working with the self that, that has just not been developed or, uh, the self that thinks they're gonna be abandoned, and, and that does form in childhood. 

Jennifer Agee: Yeah. And it is so hard. We, what we know right now from neuroscience is that up to about 36 months of age is when most of our neural networks for attachment are formed. At least that's the last, latest things I've been reading. Um... 

Lisa Duez: Yeah. 

Jennifer Agee: And if those traumas happen really early in life, they're very difficult for people to overcome. And people find all sorts of adaptive ways to continue to have their needs met. 

Lisa Duez: Yeah, because I mean, at, at our core human, we're going to survive, and it's our human need to belong and you know, we're going to belong one way or another. And the, you know, the under-regulation of the distress of BPD is just that person trying to survive, is trying to survive, trying to notice me, notice me, notice me. 

Jennifer Agee: Yeah. 

Lisa Duez: Um, unfortunately, sometimes it doesn't play well in certain situations. 

Jennifer Agee: What are some of the primary characteristics that you look for when you are trying to differentiate between, let's say, BPD, bipolar, and CPTSD? 

Lisa Duez: So, BPD is a personality disorder, so that's that patterned thought that someone has. Um, under-regulation of, um, intense distress related to perceived abandonment and sometimes actually real abandonment. Um, so it differentiates from PTSD because PTSD and CPTSD is overregulation of things. So that's my big clue is how do they control their environment? Um, does someone with, um, BPD is always trying to do more, do more, do more. You know, that that famous book, I Hate You, Don't Leave Me, where you're kind of confused, where someone with PT-, CPTSD — these, all these acronyms are, um, you know, a little bit numb sometimes. So it's that overregulation versus numbing. 

Jennifer Agee: Hmm, that's, that's a really good point. One of the things I've noticed a lot with, um, borderline, BPD is that clients will often really talk about that emptiness, right? That, that internal sense of emptiness that comes from that root of abandonment. And one of the things I've talked to a lot of my clinical supervisees about when we're talking about BPD versus, uh, borderline — I'm sorry, BPD part, that we've got so many an acronyms here, it's like crazy — when we're talking about borderline personality disorder versus bipolar disorder is that, although there are some very similar looks and feels in terms of that emptiness does often come with pretty low lows and those feelings of connection or pursuit of someone or new connections can come with really high highs, the motivation and energy shifting is really different. So with, um, BPD, I've noticed that there's usually a, a precursor event that happens, right? Either withdrawal... 

Lisa Duez: Yeah. 

Jennifer Agee: Of attention or affection or the lavish or new connection of attention or affection that then increases the behaviors that you see. Whereas with bipolar disorder, those energetic shifts, although sometimes can be prompted by external stimuli, often are happening in the body as a part of its cycle or regulation. And so those flows can come without a prompt. So for example, I've had many clients who've said, " I can tell a few days before one of my episodes, a bipolar, um, episode is going to happen. I can just feel that I'm off. I know something's not right. Uh..." 

Lisa Duez: Yeah. 

Jennifer Agee: "And then I slip into a major depression, and I feel horrible, or I even have suicidal thoughts, but it doesn't match my life. Everything in my life is actually going pretty good. Job's good, spouse is good, whatever, but I just wanna get it into the bathtub and cry. It doesn't match. 

Lisa Duez: Yeah. 

Jennifer Agee: Yeah. Whereas with the, um... 

Lisa Duez: Right. I think it's... 

Jennifer Agee: Go ahead. 

Lisa Duez: I was gonna say, I just think it's the, um, difference between the mood versus being empty. You know, the, the, the regulation of the up and down, up and down. Like you said, the, the mood doesn't fit the circumstance. 

Jennifer Agee: Yeah. 

Lisa Duez: Um, versus just that would be bipolar disorder, and there's a bunch of different kinds of that, versus just feeling empty all the time and trying to regulate and do something with that emptiness and, you know, um, go towards someone because you're feeling, uh, abandoned, and you can't, you know, really work with an emotion or you can't understand a relationship. And you're really not clear of who you are. I think somebody with bipolar disorder is probably a little bit more clear about who they are... 

Jennifer Agee: Mm-hmm. 

Lisa Duez: Than somebody with borderline, like their sense of self. 

Jennifer Agee: Yeah, the sense of self often with clients who have borderline personality disorder is shifting and changing based on who they need to be in order to receive acceptance from the person that they're trying to receive that from. At least that's what I've found.

Lisa Duez: Yeah, I think so. I think, and then I think what happens is that for whatever reason they're not doing the emotional regulation. They haven't been, they haven't had the model of the emotional regulation. Um, and I always tell it's like everything is, everything is like at a 500 level when most things in life are at a 2. But everything's at a 500. So they don't understand how to filter what's, what's not 500 and what is 500. And so, everything is 500. And so, everything is an event. 

Jennifer Agee: Yeah. Okay. 

Lisa Duez: And everything is [INAUDIBLE], whereas somebody that's a little bipolar, it's almost like they, they know it, they know it's coming. Just like you said, they know, they can tell. They can tell when the mood, when they can tell when their mood is gonna shift. Um, although with borderline personality, just sort of, you do have mood swings. Um, it's just that length and frequency that's different with the two. 

Jennifer Agee: Yeah, and I, and I think because of the mood shifts that take place, that's why a lot of people with borderline personality disorder often get dually diagnosed with bipolar disorder because... 

Lisa Duez: Yeah.

Jennifer Agee: Um, sometimes it genuinely may fit, but also I think sometimes when you see some of these more extreme behaviors sometimes come out, um, people, people don't have the time when they're in the ER room or whatever, where someone is maybe being, uh, being seen for an episode, they put whatever's down that fits. They don't necessarily take the time to dive deep into what is the root cause of what has triggered this response or this reaction. 

Lisa Duez: Yeah. And, and like I said, they're tough cause they're cousins. And they're so, um, they're very similar. I mean it, and if you don't understand the nuance of the under-regulation versus like the mania, the dips in mood, it, it can look the same. And I see a lot of people that have both, and it is hard to tease it out.

Jennifer Agee: Yeah. 

Lisa Duez: Sometimes they'll come in, and they'll be bipolar, and I'll, I'll ask them about medication, and they won't be on medication for bipolar disorder. Um, and I'm like, what, why? Or for whatever choices, but, but, uh, it ends up being that the person, it ends up that something gets a little bit more, that the diagnosis becomes a little bit more clear that it's one versus the other.

Jennifer Agee: Right. And I think that's where the benefit of time with the client comes in. ' Cause as you get to know them, you un- you'll see either the mood shifts that come or go, um, you know, regardless of external stimuli, or you'll see the patterns of behavior that come up with relationships that they're in and around. And I know for me, um — this is my woo-woo part of myself — but there is a feeling often that I will feel when I have a client... 

Lisa Duez: Uh-huh. Me too. 

Jennifer Agee: That has borderline personality disorder. It's a, for me, it's like a very felt experience.

Lisa Duez: I do too. We... Yeah, we do too. It's funny 'cause we were talking about that at staffing the other day about how we kind of just know. 

Jennifer Agee: Yeah, yeah.

Lisa Duez: I don't know how we know, but we know.

Jennifer Agee: Yeah. For me, it's my, my strong nurturer first gets pulled up, right? I think that helper healer in me feels, I can feel the, the gaping wound of attachment in there, and that helper healer in me, it pulls out my nurturing part of self. And so, if I'm finding myself feeling those feelings when I'm with a client, that's one of my tells that I need to be aware of what's happening in the room, what's happening within myself, and what their system is trying to tell or convey to my system. 

Lisa Duez: And it's almost like they are reaching for you and they need more from you than you can give them. 

Jennifer Agee: Yeah, absolutely.

Lisa Duez: You know, they want more, more of a relationship. More, more, more, more, more. And, and they are looking for you to be that figure that, they are looking for you not to abandon them. And they're looking for you to be that figure that they did not have. 

Jennifer Agee: Yeah. 

Lisa Duez: Um, and it is tough. Um, it's tough. It's a tough, um, but I, I don't wanna ever lose hope, um, because there are treatment, there are treatment options that work very well.

Jennifer Agee: Yeah. 

Lisa Duez: Uh, with that stuff, I never wanna lose hope for people. I know that, you know, BPD gets a wrap. Sometimes it's not great. You know, also, uh, there's hope. 

Jennifer Agee: Absolutely. Lo-, I mean, lots of people heal from this, um, and learn to re- 

Lisa Duez: Oh, for sure. 

Jennifer Agee: Reregulate their systems better. What is it that you feel when you're in the room with a client that has BPD? What does your system tell you?

Lisa Duez: Oh, gosh. I just, I think it's more the conversation that we have when I start to understand like, okay, I'm not following, I don't understand what's actually going on. And I get a little bit, um, kind of a, a little bit of a, I don't know, I don't think my nurturer comes out, but I get a little bit of a chill or just, you know, I, I, my gut kind of tells me and I just, kind of, tell myself go with your gut, go with your gut. This is, kind of, what you're seeing. Um, the way that they speak gets a little confusing to me because you have the undercurrent of, um, you know, secondary gain. Every time what they're talking about, secondary gain. And, and most people with borderline personality disorders will tell you. 

Jennifer Agee: Yeah. 

Lisa Duez: Um, and so they'll walk into the office, and they'll sit down and they say, "I have BPD." Okay, here we go. 

Jennifer Agee: Okay. Okay. I'll tell you, you know, there have been, I've had a couple of clients who I misdiagnosed. I mean, I have to own that. I absolutely misdiagnosed them. 

Lisa Duez: Yeah. Yeah. It's not hard to do. It's not.

Jennifer Agee: And, but here's how I figured out that I had misdiagnosed them with bipolar when it was really BPD that was the primary issue we needed to be working on. It was when other people in their life came into the session, and then when I heard... 

Lisa Duez: Mm-hmm.

Jennifer Agee: The totally dueling versions of reality of what happened. 

Lisa Duez: Right. 

Jennifer Agee: You're like, something's not right. So, if three members of your family are telling the story one way and you are reporting the story in a very different way, where you are completely the victim of the story, um, and the other members of the family may discuss how, yes, there, there might have been a hurt that was created and then you, you know, threatened to hang yourself and stu- in front of the family or what... I mean, there are chunks of information that then when other people came in, I was like, oh, I really missed that. I missed it.

Lisa Duez: Yeah. Yeah, because you heard the one side of it. And often, because of a abandonment issues, I think a lot of borderlines do have the, the victim, you know, the victim mentality type thing, and you know, because they don't really have that secure sense of self, so they will paint themselves in a light where people feel sorry for them. And they need that. And I think that's that needing of nurturing. And if you feel sorry for me, you're not gonna leave me.

Jennifer Agee: Absolutely. And I think that's what comes up in me, that nurturing part comes up in me, which also, because I've been a therapist for more than 22 years now, now what comes up when I notice that strong, strong nurturer comes up is also a warning signal on the inside to be mindful of, um, how I am interacting with this person so that I don't do harm unintentionally by becoming overly nurturing. 

Lisa Duez: Right.

Jennifer Agee: Or by, um, having [INDISCERNIBLE] your boundaries and letting them, you know, contact me after hours or different things like that. And I know different modalities are open to contact after hours, but if that's not a part of your practice and that's not a part of the boundaries that you have with your client, you know, absolutely you don't need to do that. But... 

Lisa Duez: It's, like, you spell it out in informed consent and you keep going. 

Jennifer Agee: Mm-hmm. Yeah. So it's all these little nuances to things that, once, once you have experienced it a few times and pay attention to how you feel with different diagnoses, I found that that's really good information. 

Lisa Duez: Yeah. Yeah, I think so. I, I kind of usually get a little, a little, um, a little stand up on the back of my neck a little bit sometimes.

Jennifer Agee: Mm-hmm. 

Lisa Duez: And that, that gut, you have to trust it. Um, because you do know. You know, therapists, we do understand. We're very intuitive, and we do understand people. We, we understand people I think more than we give ourselves credit for. Definitely. 

Jennifer Agee: It's very interesting because, um, manipulation is a high part of working with clients who have borderline personality disorder, right? And I don't judge that because that's a part of them trying to meet a need, right? And so, um, just like a toddler will try and meet needs in, in really unhealthy ways to get your attention, you know, throwing the cup at your head or something if you're not paying attention to them, right, sometimes they, the reaction is bigger, um, than you would like in order for them to get your attention. And so, I don't, I don't judge it, but I think a lot of therapists are also pretty tuned in to manipulation, and we can feel it in the room. 

Lisa Duez: Mm-hmm. 

Jennifer Agee: And then this, I've noticed for myself, this interesting dynamic I have to internally work against happens where the very thing that they are really, really desiring from me, because of the manipulation in my own stuff, becomes the one thing I don't want to give them, right? Um, so for example, that, um, pay attention to me, pay attention to me, I've got urgent things happening all the time outside of session, and I need you to pay attention. Because it's, it's trying to be taken from me in a manipulative way, some part of me does not want to give that. And so, I know that's, that's my own... 

Lisa Duez: Yeah.

Jennifer Agee: Stuff that comes up. But I do notice that that's a dynamic that I have to be super aware of when I am working with clients that do have a diagnosis of borderline.

Lisa Duez: Yeah. And I find with clients that have a diagnosis of borderline that I can be a little bit more direct with them about some of my statements about, "Hey, you are doing this; you are being manipulative right now; you...," and they receive that. 

Jennifer Agee: Mm-hmm. 

Lisa Duez: And, and I may not say that to everyone, and, or might say it in a different way, but I find that sometimes it's okay to be a little bit more just you are gonna call it because it's that part of themself that they don't understand that you are trying to reach, but they can't access that part yet. They don't have the insight, so they can't self-introspect. They can't introspect and say, "Oh yeah, I guess I am being a little bit more..." So, you can say to them, "Hey, you know, when you called me at three o'clock in the morning and I didn't pick up, you know, and [INDISCERNIBLE], and you, you know, know, you can say to them those things and they'll receive it. Where I may not say it to everyone that way, um, but they, I found that, okay, this kind of works. All right. Let me, let me keep doing this. It's okay. 

Jennifer Agee: Yeah. 

Lisa Duez: Um, because if they're, they are not going to leave you. 

Jennifer Agee: Right. I, I had a, I had a client with borderline who, um, she really needed higher level of care than I could provide. And, um, we do have some very good, um, comprehensive programs in our area that specialize in borderline personality disorder. They have full, you know, Linehan protocols and all of that stuff. And I don't have that. 

Lisa Duez: Wow. Yeah. 

Jennifer Agee: No, I, I just don't. Um, and so I referred her out, and she got mad. Like, obviously, perceived it as rejection, and I offered to do all the soft transitions and all of that stuff. But the reality is, I was not, I was doing her a disservice by continuing to see her because she really needed more complex wraparound care. And, um, there was a period of time where she, she tried to just absolutely wreck my world online. I mean, there's no way around it. It was not a pretty few weeks. 

Lisa Duez: Yeah. Yeah. 

Jennifer Agee: And I did call her out on it because I, I, I did know that it was her, and I knew through some of the things that happened, and, um, she copped to it. You know, she was just like, I was really mad, and, you know, she copped to it completely, and we had a good conversation about it. And I was able to say, I'm not angry with you for doing this. I understand... 

Lisa Duez: Mm-hmm. 

Jennifer Agee: That it's a part of your hurt. And when hurt people are hurt, they hurt other people. And I understand that [CROSSTALK] this was, this was just a part of, um, of your hurt coming out. And I'm not angry about that. And because I was able to not be reactive with her in the way a lot of other people in her life had been reactive, um, when she had done more of these extreme behaviors, to this day, she'll still send me email updates with how she's doing, even though I did not continue to see her, which I took that as a massive, massive win. 

Lisa Duez: Yeah, I think so. I mean, it's, she was regulated enough to understand that and maybe check in with you here and there. I, I think that's, that's good. You know, um, and it's just like they have this, this very intense intensity about them. Everything is intense because they're, they fear they're abandoned. So they're very intense with everything. They're very intense with their therapists. They're very intense with their relationships. They don't understand how to really just take it slow. They don't do that part. 

Jennifer Agee: Mm-hmm. Well, sex and sexuality, issues around sexuality, is another area that I see sometimes, um, comes up that could be seen as overlapping both with bipolar disorder and, um, borderline personality disorder because... 

Lisa Duez: Absolutely. 

Jennifer Agee: Often with mania or hypomania, comes some sexually acting out behaviors. And often with borderline personality disorder, there are some sexually acting out behaviors as well, but the motivation is different. 

Lisa Duez: Yeah. Yeah. I've had bipolar disorder clients basically said, "I was manic last week, and it was great, it was fun." And, you know, uh, and now they're experiencing the, the downside of that. And yeah, I think the borderline part of that is the, the instability and the fear of abandonment that I have to do these things in order to keep you. 

Jennifer Agee: Mm-hmm.

Lisa Duez: In order to get you to like me. You know, I can't just be me because they have that shift of their self-image. 

Jennifer Agee: Yeah. 

Lisa Duez: That's so, um, prevalent. 

Jennifer Agee: Mm-hmm. And I think for, especially for newer clinicians that are listening to this, when you listen to Lisa and I talk about this, one of the takeaways I wanna make sure that you have is really looking at the core motivation of behaviors. Um, is the core motivation of the behavior abandonment, or is it an energy shift? That in and of itself is going to tell you a lot of what you need to do, need to know when you're doing differential diagnosing. 

Lisa Duez: Yeah, I think that, that, that is the key to understanding the difference between a BPD and a bipolar person is, where's the energy?

Jennifer Agee: Mm-hmm. Mm-hmm. 

Lisa Duez: Where's our energy? Is it in their mood? Is it up and down? Do they feel like they're not thinking about things 'cause their, their mania is having them just, kind of, be all over the place, or are they taking their energy and they're moving it towards you and they're trying to envelope you in it?

Jennifer Agee: What a great phrase. I've not heard that, envelope you. But that, that is an awesome... 

Lisa Duez: Envelope you. They're gonna make you their [INDISCERNIBLE].

Jennifer Agee: Uhhuh. Yeah. Well... 

Lisa Duez: And I just made that up, but anyway. 

Jennifer Agee: Well, I mean, I think you should trademark or something, but, um, that goes to the extreme. 

Lisa Duez: You heard it here first. 

Jennifer Agee: Yeah. You heard it here first. Envelope you. But that, it goes to that extreme of how you are either idealized in the beginning, and then when, um, when it may be challenging, starts to take place later in the sessions, as you develop, um, a good rapport with the client, they may no longer put you on a pedestal. You may be in the opposite category where they are very displeased with you. 

Lisa Duez: Right. Because they... Have you ever had a border-, have you ever had a borderline client be mad at you? I mean, you said you have because you've had the online stuff, but it can be pretty intense also. Um... 

Jennifer Agee: Mm-hmm. It's hard not to get your... [CROSSTALK] Yeah. It's hard not to get your own stuff mixed into that. Really is. 

Lisa Duez: Yeah, it is. Yeah. I always, like, I would say, don't, you know, I mean it's hard to tell with people 'cause sometimes when you do outpatient, you don't really know until you know someone, but sometimes it's... If you're working with a, a high population of borderlines, you really have to do self-care. I think with anybody, but borderlines will definitely, since they envelope, um, you really have to take care of yourself. You know, I think with any clinician and any diagnosis, but, but this one, um, they are looking to, you know, soothe their abandonment through you.

Jennifer Agee: Yeah. I also... 

Lisa Duez: Oh, so that's a little bit of a different level. 

Jennifer Agee: Mm-hmm. I, I agree with you completely. It is, it is a different level. And, and even just looking at, um, self-care, I think getting, if this is a population you wanna focus on, I think getting good clinical supervision is important because... 

Lisa Duez: Oh, for sure. Yeah. 

Jennifer Agee: This is, this is a population where I think we are at very high risk of, um, not holding healthy boundaries, so... 

Lisa Duez: Mm-hmm. 

Jennifer Agee: Like, for me, I said my strong nurturer comes out, right? And so, I have to be very aware because my nurturer wants to come out and heal or rescue, of where my roles and my boundaries are and upholding those things. And if you're not talking to anyone about this stuff and slow fades are starting to happen on the back end, you can end up pretty far down, uh, away from where your initial boundaries were before you realize it sometimes with these clients because that, that...

Lisa Duez: Absolutely. 

Jennifer Agee: Encouragement that they give you that you are, you're the only one who understands me. And that really speaks to a lot of our helper healer parts, that kind of stuff.

Lisa Duez: Yeah, I, I would agree. You definitely, you know, there, these are, all, these disorders are all born of trauma, and so you, you naturally wanna help. And I think, um, it's a lot of Velcro there. You do have to be careful. Because you do wanna model a healthy relationship. You wanna be that clinician that shows a borderline, somebody with BPD, what a healthy relationship does look like.

Jennifer Agee: Mm-hmm. 

Lisa Duez: Um, but you are, it is a battle sometimes. 

Jennifer Agee: Yeah. Do you find that when you work with this population, um, that you are often a transitional person of healthy attachment until they have other healthy attachments in their life? Or how do you clinically do that? 

Lisa Duez: I, I do. Um, it's a lot of talking about, um, you know, what my role is and some-, sometimes a lot of repetitive talking about what I, what I'm gonna do, what we can do, what we, what, what I can help you with, what I can't help you with. Do you remember that informed consent that you signed? Do you remember that it said this? You know, et cetera, et cetera, et cetera. You know, um, you know, it is hard because I have that strong nurturer part too. You know, I have a borderline client that, um, she just got a job, and she, I was the first person she emailed, and I'm very happy she got the job. I am because it's gonna be a really good for her and it represents a lot of healing for her. Um, so of course she emailed me when she got it, but then the follow-up was, email was, well, what should I wear? And blah, blah, blah, blah, blah. And I'm like, I gotta, you know, hey, let's talk about this next session. See you then. Um, so that, that's kind of something to, that kind of happens in, in whatever form that that looks like for that client. But they will, because you are the first probably healthy, one of the first healthy relationships they have had. Um, because they didn't get the benefit of regulation as a kid.

Jennifer Agee: Um, I think the example you gave was a perfect example. Because exactly what happens in that exchange that you just mentioned of, um, you're the first person I'm telling about this job, which I have lots of clients who will message me with good news, and I love that, you know? 

Lisa Duez: Yeah. 

Jennifer Agee: Then the follow-up part of it is: Can you be my big sister? Can you be my mother? Can you be my best friend and tell me what to wear? And should I bring cookies the first day? Like, all of those kinds of things is if the nuanced part of it goes beyond the sharing of the good news, which a lot of clients do into, can you then serve this other role for me?

Lisa Duez: Yeah. Yeah. Because she was looking for that, and you know, I was like, "Hey, I'm happy to talk to you, but I'm gonna see you next week. Let's talk about the cookies next week." You know, should you bring cookies or not? Probably should, but, you know. But it, it is, um... And I'm always happy for clients when they, um, do good things and I get messages too. But with a borderline, you do have a secondary game factor, um, that you always have to watch out for.

Jennifer Agee: Well, there's secondary gain for them, but honestly there's secondary gain for the clinician of them being as needed or important in someone's life or... 

Lisa Duez: Right. 

Jennifer Agee: The only person that's able, ever been able to get through to this person. So, I think that's why it's tricky and why I really think clinical supervision, um, or consultation groups are important if you specifically work with this population. 

Lisa Duez: Yeah, I, we do it, uh, weekly if we can. I think we have a practice where we just kind of walk each other's office and say, "Hey, can I staff a case?" And I would encourage that for everyone. 

Jennifer Agee: Mm-hmm. 

Lisa Duez: You know, it's, it's necessary. You know, you deserve that. Therapists deserve to have self-care and, you know, to understand, um, where their strengths lie. 

Jennifer Agee: Yeah. 

Lisa Duez: And understand when they need help. 

Jennifer Agee: Absolutely. Yeah. I mean, I've certainly had success stories with working with all three of these populations of, um, working with borderline personality disorder, bipolar disorder, and complex PTSD. And so, there's, there's always hope on the horizon. Like you said, you never ever want to lose that hope and, and enjoyment of working with clients. Um, it's also okay to say, if you've been working in really a really heavy space for a while with clients and you need lighter, a lighter caseload, um, for a little while, you need good old anxiety and depression, it's okay to shift it up. Because sometimes the energy that you put out with different, with clients that have different diagnoses does require something different of you. And it's okay to be honest about that. 

Lisa Duez: Yeah. And I think you can say, "Hey, I just need a couple EAP cases or something, or I just wanna talk with someone that's having some job stress." Uh, it's absolutely fine. It's, I think it's, um, I think it's, I know it's in our code of ethics to do that. 

Jennifer Agee: Mm-hmm. 

Lisa Duez: To work within our scope of practice.

Jennifer Agee: So, what treatment lens, 'cause I know you guys do a lot of DBT and stuff, like what treatment lens do you treat from?

Lisa Duez: Uh, for borderline and borderline is, is a DBT, uh, which, which is what works best, and also a little ACT sometimes. 

Jennifer Agee: I love that. Yeah. 

Lisa Duez: Because... Yeah, I love it too. I, I've recently been getting into it a little bit more, but just the very easy things for them to remember: accept, choose, take action. 

Jennifer Agee: Mm-hmm.

Lisa Duez: Um, and they benefit so much from that structure of either that or, um, DBT of, hey, emotional regulation, let's pull out your worksheet, you know? They, they are, um... Borderline clients are often the students of therapy, I call them. They're the ones where I can say, hey, I got this great workbook; let's work through it together. Um, where I say, hey, I have this homework, and they do it. 

Jennifer Agee: Mm-hmm. 

Lisa Duez: You know. Yeah. They do it. They'll, they'll do the diary cards for DBT. They'll do the worksheets, uh, because in some level I think they understand. Um, they want to please. You know, they don't want to be abandoned, but, but you're also helping them, you know, say, hey, did you, did you get anything out of that distress tolerance? Um, you know, because they wanna please you, so they'll do the work. 

Jennifer Agee: Mm-hmm. 

Lisa Duez: And they won't miss their appointments.

Jennifer Agee: Yeah, that's true. They, they typically don't. 

Lisa Duez: They don't miss their appointments. 

Jennifer Agee: Mm-hmm. And I'll tell you, it, it does pull up, you know, that very compassionate side of me because the wounds that they carry around are so deep and so painful. To walk through the world and feel like you were truly not loved and valued fully by someone, would be painful. 

Lisa Duez: I had asked someone at one point, or read it somewhere about, well, how did it, how did it even get to be called borderline? You know, where did that name come from? And the name comes from the fact that they do walk between the world of rational and irrational emotionality, and that's why they are named borderline.

Jennifer Agee: I've never heard that. I learned something new today. 

Lisa Duez: Yeah. You learned something new. That's Dr. — I forgot — Dr. Lester. He's a big personality disorder guy. Um, so he talked about in his training about that's why they're called borderline 'cause they are literally walking the borderline of, you know, I guess, uh, you know, emotional and non-emotional, that they, they walk that line every day. And I thought, gosh, that's awful.

Jennifer Agee: Yeah, it is. 

Lisa Duez: Yeah. Tough stuff. It gives me a lot of compassion for them. 

Jennifer Agee: Absolutely. Um, thank you so much for being on. This was a really good conversation, and honestly, I wish that someone had had this conversation with me when I started 22 years ago. Because, of course, that sometimes we have to learn the hard way. And I'm glad that you're, you were here with [INAUDIBLE]. 

Lisa Duez: Yeah. And this is all stuff that I've learned. 'Cause nobody had this conversation with me 22 years ago either. 

Jennifer Agee: Mm-hmm. 

Lisa Duez: So, I had to learn it. Um, you know, there, there's, uh, I don't know, there's hope there. I always say don't lose hope. 

Jennifer Agee: No, absolutely. Never lose hope.

Lisa Duez: Yeah, never. 

Jennifer Agee: Lisa, how can people get in touch with you? 

Lisa Duez: I'm out, um, on the East Coast at, um, in Virginia Beach, uh, Turning Point Counseling and Consulting. So our website is turningpointva, Virginia on the end, dot com. 

Jennifer Agee: Awesome. Thank you again for being on the podcast, and if you'd like to connect more with me or any of my retreats,, or any of the social media links below. Get out there and live your best dang life.