Essay on The Strengths and Weaknesses of the Therapist
by W. W. Meissner
From the Jason Aronson Collection
Without question the most important ingredient in the therapeutic matrix is the therapist himself. The therapist's personality enters into the therapeutic process in a more significant way in the treatment of borderline patients than with any other group of patients. The reasons for this are clear, especially the unavoidably interactive quality of the therapeutic relation and the activation of projective and introjective mechanisms. These are continually pushing or pulling the therapist into countertransference positions that have the potential for frustrating or impeding therapeutic progress. The therapist's own susceptibility to responding in countertransference terms or to getting embroiled in a transference/countertransference interaction is in part a function of his own personality structure.
A factor that is not well studied but may have considerable importance in the treatment of borderline patients is the matter of therapistpatient fit. The importance of this dimension has been demonstrated with other types of patients and has even more sway in the approach to therapy that a given therapist might take. Some therapists do better in maintaining a therapeutic structure, setting appropriate limits, maintaining the parameters of the therapeutic relation, keeping the patient at the therapeutic task, avoiding countertransference traps, and reinforcing the patient's responsible involvement in the treatment. These therapists find greater success with patients who need that kind of structure in order to gain any benefit from the therapeutic process. For lower-order borderlines who show a significant degree of instability, lability, and tendencies to act out, the approach may be optimal. Other therapists seem to find greater success in maintaining a nurturant, empathic, holding environment within which patients have the opportunity to gain important self-enhancing inputs that have been lacking in their developmental experience.
For most borderline patients, it is safe to say that they need both structure and empathic support. A given therapist may have a greater capacity to provide one dimension than another, and this is a function of his own personality, developmental history, maturity, unresolved conflicts, and values. This dimension cannot be changed by training; the most that can be expected is that he gain some degree of awareness and sensitivity to these limitations in himself and understand the impact they can have on the therapeutic process. A therapist should not be disappointed or take it as a sign of incompetence or unsuitability for therapeutic work if he cannot interact successfully with a given patient or type of patient. If such factors interfere significantly with his work, this might indicate the need for some therapeutic work on himself. Many training programs, especially psychoanalytic ones, presume that these factors operate in everyone, so that a training analysis is a required part of the program.
An important part of the capacity of the therapist is his flexibility. In the treatment of patients within the borderline spectrum, no single approach is possible, not only because of the variety of the range of pathology but also because of the variability from session to session, from moment to moment, in the therapeutic work. Effective treatment of these patients requires that the therapist be able to assess the nature of the patient's basic pathology and to adapt the therapeutic approach to the characteristics and needs of that level of pathology.
If adaptability in therapeutic approach can be thought of as a kind of macroadaptation, flexibility may be a form of microadaptation. Depending on the lability and instability in the patient's personality structure, the clinical presentation can vary considerably. In relatively unstable patients, the configuration may shift quickly from an objective, reasonable, thoughtful, ego-based orientation to one that is regressive and reflective of the underlying introjective configuration ‹whether activating the aggressor or victim introject ‹or even shift rapidly back and forth between them. Emergence of these configurations can precipitate projections that can rapidly undermine the therapeutic alliance. The patient may suddenly and unexpectedly become paranoid, or depressed, distrustful, or angry.
Other patients, whose psychic structure is better knit and stable, may suddenly shift to a more regressive posture ‹a time-limited, episodic, regressive shift that is often surprising in view of the patient's otherwise consistent and nonregressive functioning. In the face of these variations, the therapist must be ready to shift accordingly and to meet the needs of the patient at that moment, becoming more or less active, setting limits when useful, focusing on the distortions in the therapeutic alliance, providing the necessary degree of holding, and so forth. The good therapist must learn to bob and weave and roll with the punches. The therapist has to modify his technique as a result of his ongoing diagnostic reading of the patient. This reading requires an attentive focusing on the multiple aspects of the therapeutic interaction and on the level of the patient's functioning. This would include an assessment of the level of defensive organization, ego functioning, object relations (especially in the moment-to-moment interaction with the therapist), superego functioning, and particularly the data relevant to the introjective configurations (aggressor, victim, superior, and inferior).
Clearly the ideal therapist does not exist ‹not for any kind of therapy and especially not for the therapy of borderline patients. All therapists have their relative strengths and weaknesses, their skills and blind spots. The balance of strengths and weaknesses is often brought into stark relief by the work with difficult borderline patients. The most important strength for therapists undertaking this work is the capacity to remain steady on course despite the howling winds and raging seas that can so readily be whipped up in these patients. It is often this quality of the therapist and his interaction with the patient that carry the day. It may also be this quality that provides the essential element in developing a holding environment within which the patient can feel secure. This capacity stems from the therapist's ability to resist countertransference pulls and to maintain a balanced sense of his own personal and professional identity as well as perspective regarding his therapeutic role.
It is also important for the therapist to recognize and accept his own limitations. For none of these patients does any therapist have all the answerers. There are inherent limitations to what a given therapist can or is willing to tolerate. Even experienced therapists cannot work with too many of these patients at one time ‹my own judgment is that no therapist should try to work with more than one or two such patients at a time. This is especially true of the more primitive, affectively labile, acting-out patient in the hysterical continuum. It must be recognized, however, that we all do treat some of these patients, perhaps more than we realize. I am convinced that many find their way to the analytic couch ‹a fact recognized in the widening scope of psychoanalysis. The therapist must accept his limited capacity not only for working with numbers of such patients but also for effectiveness with each patient. This requires thoughtful consideration of what is involved in his role as therapist and a capacity to stick to those boundaries. Efforts to draw him out of this therapeutic role are a constant aspect of the therapeutic process with borderline patients, and the therapist must be alert to these pressures and steer his course accordingly.
An important matter is taking care of the therapist. Pacing is important. I do not recommend tight scheduling. The therapist needs time to unwind from often demanding and stressful sessions, time to gear up for other sessions that he knows will be difficult and challenging. He needs to take appropriate breaks, both during the course of the day's work and in the form of vacations. This is often difficult when working with borderline patients because of their marked sensitivity to separation and feelings of abandonment. There is a certain responsibility to meet the patient's need in this regard but it must be limited. The therapist must be able to schedule vacation periods adequate to meet his own needs; the difficulties created for the patient by these separations must be managed in whatever way is appropriate. There is no room for guilt in this matter. Not only is the therapist entitled to vacation breaks, but they are a necessary part of his continuing to work effectively. The therapist needs to pay attention to the quality of his life experience. A balanced and satisfying life is a powerful contributory factor in maintaining the capacity to work with difficult patients.
The last aspect I would stress is the importance of consultation and supervision in learning and doing therapy with borderline patients. The opportunities for therapeutic impasses and disruptions are many. Even for experienced therapists, consultation regarding troublesome cases is always a good idea. Often an uninvolved and objective look at the therapeutic interaction can pick up elements that the therapist might not have been able to see. Even if the consultation yields no more than confirmation that what can be done is being done or offers only sympathetic support, it can be helpful in moving the therapeutic work forward. For therapists who are still learning the ropes, good supervision is mandatory. There is much to be learned about the treatment process with these patients, if only the degree to which the capacity of the process and of the therapist himself is limited. Even for therapists who have mastered many of the basic techniques of psychotherapy, experience with borderline patients becomes an education in the vicissitudes of countertransference and transference/countertransference interaction, and in the basic understanding of the nature of the therapeutic process. None of us is immune to having a patient push us to the limit of our capacity in these areas, and we can learn something more about the therapeutic enterprise and about ourselves from the experience.
I. Pretreatment Issues
II.The Therapeutic Relationship
III. The Therapeutic Process
V. The Patients
Treatment of Patients in the Borderline Spectrum (sc)