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Treatment Strategies with
Borderline Personality Clients

Is the Treater Your Parent?

Written by Kathi Stringer

August 6, 2003

Forward:

Work of this sort is long past due.  I often receive letters from persons with borderline personality organization that are hurting.  Their hurt runs so deep that they are attaching to their treater in a prenatal way in hopes to make up for all they missed, and are still missing.  As treatment continues the client’s longing for the perfect parent can become desperate, in fact so desperate the client may begin to think the treater really IS their parent.  The parental fantasy can become that intense.  If the fantasy (fantasy transference) escalates to these proportions, treatment is practically doomed for failure if not addressed by the treater.  Since a treater is not able to provide that kind (concrete) of supervision, holding and nurturing, it is important that the treater clarifies the difference between a ‘abstract therapeutic relationship’ (can do) and a ‘concrete relationship’ (cannot do) as treatment progresses. 

However, there are very EFFECTIVE ways (abstract – can do) in which a treater can supervise, hold and nurture the client that can promote healing and growth, and that is the purpose this paper. 

Scope

This material is aimed mostly at treating the client with abandonment and separation issues with borderline personality symptoms.  First, we will look at concepts and distortions assumed by the client and some treaters (the treater is my parent) to prepare a realistic treatment modality.  Next, we will move into the working “framework” and “containment” to maintain stability to deliver treatment.  Finally, we will discuss a ‘balance’ treatment strategy to offer new and corrective experiences for the client. 

Review of Identity Fragmentation

Individuals that tend to dissociate (depersonalization) are usually fragmented.  There is a sense of tuning out, leaving the here-and-now, or feeling as though one is watching from a distance what is taking place between self and other.  At times there can be memory loss or flight-of-time. 

Due to fragmentation of the closed core psych structures (one part of the mind is not conscious of what the other part of the mind is doing), the internal links between structures are ‘split’ and obscure.  The defense of dissociation (a primitive defense mechanism) is an extensive from of ‘splitting’ to repress ambivalence (conflict – opposing forces).   If both parts of the mind were ‘joined’ before the individual was ready, the conflict could send the individual over the edge.  This is why treatment is important to create a safe place to slowly add more ‘links’ to diminish splitting of the mind (personality fragmentation) toward a ‘co-conscious.’ 

Usually when levels of stress (internal or external source) elevate the individual into confusion, depersonalization can occur.   For example, lets say there was not sufficient attunement between the child and parent during the critical developmental phases.  Through repetition, stress mounted and the child checked out of reality and into a fantasy place that was gratifying and rewarding.  Now we have a regression toward infantile fantasy, a primitive defense to ward off the unacceptable stimulus of reality.  This reminds me of a line in the flick Jurassic Park when fertile eggs were discovered on an island full of female dinosaurs.  As the horrified expedition team looked on, a chaos theorist solemnly reflected aloud, “Nature always finds a way.”  Indeed, nature had found a way to continue life even though there weren’t any male dinosaurs on the island!  Defense mechanisms work in much the same way.  When reality is too chaotic nature finds a way for the individual to survive through defense mechanisms [1].  Treatment is usually necessary when primitive defense mechanisms become chronic and a style of relating to reality.  

Silence and Aggression

Silence in treatment can come off as several things.  A client may be confused and not know where to go next in the therapeutic topic, or there may be so many different places to go that the client hopes the treater can lend a hand.  Or, silence can also be a passive-aggressive stance (passive-aggressive, meaning a feeling is not verbalized directly but rather with indirect aggressive actions).   Silence can be a way of relating this attitude toward the treater, “Read between the lines.  I am mad at you!  You are not helping me!  You don’t have a clue as to what my needs are!  You are making me feel worse because I was right all along, I can’t be helped! You are just like everyone else in my life that has failed me!”  The treater may try to figure out what the client is thinking and say something like “Is it helpful for me to sit with you in silence?  Okay, you are not communicating, perhaps it will be helpful if I will sit here in silence with you.”  As in childhood, the attunement appears to have failed again in the here-and-now.  By now the client’s veins may be bulging in their neck and are thinking about dumping the clueless treater as rage is mounting out of frustration.

Parental Affiliation

Many borderline personality disorder clients are starving for parental nurturing and affection.  They may harbor unarticulated fantasies that the treater will swoop them up out of the abyss and somehow contain them in security.  Most borderline personality disorder clients are highly fragmented and the thought of containment by the treater is compulsively revisited in their mind without any ability to understand the restrictive nature of such a fantasy.   Let’s consider the clash of the “parental therapeutic relationship” vs. “parental relationship.”

Ideal Parental Relationship (concrete)

The child lives with the primary caretaker.  The primary caretaker (mother in this example) is responsible to help the child facilitate through the developmental phases to promote age appropriate functioning [1].   Mother wakes up the child in the morning, prepares food, washes clothes, nurtures, disciplines, and engages in all aspects of the child’s life.  And, mother does not charge the child to go through this process. 

Parental Therapeutic Relationship (abstract) 

The treater is paid to help the client go through the developmental process and the client is emotionally concrete in their thinking and has no clue how to relate to an abstract therapeutic relationship.  For example, if a treater tries to verbalize to the client that she (the client) has value, it works about as well as disappearing ink.  It sinks in for a time, but dissolves as the internal agents take over.  The signature is on the contract today (I have value) but tomorrow the signature is gone (I have no value) and the contract is meaningless.  The more the treater tries to convince the client they have value, the more the client is reminded later that the signature keeps disappearing.  This dynamic appears to render the client more and more hopeless.  Possibly, because the treater is communicating in the abstract and the client is hearing in the concrete. 

Let’s pause for moment a look at the source of concrete understanding within the borderline personality disorder client.  In the treatment setting the client is hurting; at a loss to articulate their needs, and words of nurturing mean nearly zip.  The client in treatment is essentially a child [4] when it comes to absorbing a treaters message.  If the message is directed to the fake adult, the ink of the message disappears.  If the message is targeted to the true borderline personality disorder functioning of the client (child), the message tends to reach its target.   The fake higher functioning adult begins to disappear as treatment moves on.  To some treaters it appears therapy is making the client worse, when in fact they have finally unmasked the fake adult and the developmental process can resume.

It appears to be difficult to communicate an abstract therapeutic relationship with a concrete client that understands ‘messages in action’ and NOT verbal messages.  For example, how do you explain to a regressed concrete personality fragment the idea of abstract thinking?  It can’t be done because it takes abstract thinking to understand the concept.  Gabbard [2] illustrates in his video lecture this problem in one of his clients, “Doctor, you are not listening to me, I only need a hug.  Doctor, I know all that, but you are still not listening to me.  I only need a hug!”  At this point Gabbard roles his eyes during lecture as if to relate to his audience how difficult it is to relate to a client that is fantasizing about a concrete parental relationship. 

Treaters should be careful that sessions don’t become chronically boring, uneventful and idle with the passing of chitchat.  Chitchat looks like, “you have value, you have value, you have value.”  The client becomes bored with this and even frustrated thinking the treater hasn’t even reached first base in understanding the client.  

Parental Containment

The major function of a parent is to be consistent (constant object - security) and nurture their child.  There is a balance between the two; one without the other is nearly worthless.  For example, to nurture a child without boundaries of security and safety comes off as homeless (abandonment).  On the flip side, to provide boundaries without nurturing comes off as imprisonment (engulfment).  Both nurturing and boundaries in BALANCE (attunement) are required to facilitate a child through the developmental phases.  This same formula also works for the borderline personality disorder client, but modified into the abstract out of the concrete.

Workable Solutions

Prolonged Client Contact

A treater cannot physically hold a client because this will open up the abyss in the client that will consume the therapeutic relationship.  For a borderline personality disorder client, it is practically impossible for prolonged holding to be therapeutic, but rather a malignant one.  I view this as malignant holding because there is not enough time in the therapeutic hour to modify the vast emptiness but rather wake up the starving child that will demand more, and set unreasonable entitlement in motion. 

Delusion and Fantasy

Client Delusion: – Treater is my parent
Treater Fantasy: – I am the client’s perfect parent

At the onset of treatment a borderline personality disorder client usually hopes this treater will ‘be the one’ that will ‘make things right.’  The treater is usually cautious while at the same time hopes to help the client.  As time moves on, the treater may give clues that are parentally attractive to the borderline personality disorder client and then between sessions the client will usually modify their internal fantasy that their treater is actually becoming their parent (fantasy transference).   This becomes dangerous when the treater’s ‘fixing’ abilities are aroused beyond the therapeutic boundaries (into malignant) to meet every hurt of the client (diminished countertransference management).  For example, because the client cannot ‘hear’ the treaters words and only briefly take-in the treaters action provoked by the client’s action, the following usually takes place. 

  • The treater may become inundated with phone calls (action)
      

  • The sessions may become chronically extended (action)
      

  • The client may try to woo the treater to physically hold the them (action)
      

  • The client may ‘run’ hoping the treater with catch the client (rapprochement action [1])
      

  • The client may “fill in the blank” (action)

Notice the above actions were grounded in the concrete because the client unconsciously believes ‘action’ is doing something.  Action is perceived as moving somewhere but unemotional words are viewed as stagnating chitchat.  As we move through the work we will see how words can be transformed into action by the skillful treater.

Engineering and Planning

I have often heard these words, “Kathi, you are able to help so many people.  How is it that you cannot help yourself?”   My usual response goes something like this, “There is a lot of difference between designing and building Disneyland (outside) then actually spending a day in the park enjoying the rides (inside).  For example, “how can an expert brain surgeon operate on herself?”  She can’t.  The best she can hope for is to find a qualified and experienced surgeon.   What I’m speaking of here is Winnicott’s vision of the ‘holding environment.’  And I often hear, “Why don’t you just say what you need?”   I return the question, “Does it feel better to get flowers unexpectedly or after you request them?”  The answer has always been “to get surprised with the flowers, because that way, it really counts”.   A savvy treater will have insight to this strategy and will design and operate the holding environment along these lines, because a client’s behavior is usually a dead give-a-way as to what they need.  

Therapeutic Containment

A treater may wonder, “How do I figure out what the client needs?”  If the treater understands the client has borderline personality disorder, the designing process of the holding environment can begin immediately.  Even though there are 156 possible symptomatic combinations for Borderline Personality Disorder, there are common hallmarks that rise out of the mix.  Ridged personality traits, underlying anger, emotional instability and problems with impulsivity (See ya! I was looking for a treater when I walked in here, and I’m looking for one now!).  All of which leads to a common therapeutic theme, which is ‘containment’.

Therapy Interfering Acting Out

A frustrated treater may pull out this wildcard “This is therapy interfering behavior” after an argument breaks out and the treater is unable to navigate the dilemma to a successful therapeutic advancement.  The unskillful use of this wildcard can setback treatment because it can come off as “the last resort of the incompetent” which, many times is usually the case.  For example, a client picked up on an attitude within the treater that the client had experienced in the past that was connected to severe emotional abuse.  Accordingly, the client’s emotions rise (fusion ready [1]) and the client’s repressed anger that is linked to treater’s attitude is resurrected from the client’s past.  We now have a Grade-A negative transference brewing the holding environment.  A savvy treater will realize this energy (turbo advancement) is useful to act as a modifier toward healing.

Vignette

During the hospital intake a borderline personality disorder inpatient client expressed that she could not handle being put into a group with child abusers.  However, because the client was ‘well-read and informative’ she was put into the abuser group because it was thought ‘she could handle it.’  During the group session things got too graphic (child molestation) and this triggered the client and she left the group feeling unheard.  She was shaking (transference in the works) when she related the group discussion to the program manager.  The program manager promised it wouldn’t happen again.  The following day the ‘abused survivors’ (women) were combined with ‘child molestation offenders’ (men) in a role-play session due to the small group size.  During a role-play a child molester pretended to talk to his sexual abusive uncle that molested him as a child. He said, “Uncle, you messed me up.  When you fondled me (very graphic) you MADE ME do this to others when I grew up.”  The borderline personality disorder client immediately left the room.  Later that day the client had a private session with the inpatient treater. 

Treater: “You look upset.”

Client: “I am upset. Something happened in group and I am very angry about it.”

Treater: “What happened?”

Client: “I felt used.  I felt used in the service of this hospital.”

Treater: “How so?”

Client:  “I told the intake person I could not handle being put in the same group as the offenders and she felt I could handle it.  I couldn’t.  Then, the next day I was exposed to the same graphic material.  Not only that, but the person wouldn’t take responsibility for his actions and blamed it on this uncle that “he made him do it!” I am so angry with that.  Why did I have to hear that?  Why was I exposed again after I made it clear it triggered me?”  (Full activated transference)

Treater:  “We feel it is good for the offender to face victims for insight.”

Client: “If I stayed in the group, he wouldn’t like what I would have to say.”

Treater: “You should had stayed and told him how it affected you and he could have learned from your views, and you would have been able to vent.”

Client: “Are you kidding me?  I would have blown the guy out of the water.  He Made Me?  What kind of statement is that? By exposing him to my anger, I would have traumatized him to a point there would be no way out.”  

Treater: “Then that would be inappropriate. 

Client: “Exactly, then why was I put in there with him?”

Treater: “We are not getting anywhere, we need to move on.”

Invalidated Client: “I was told that what is said in group, stays in group unless we discuss it with our treaters.  I have no one to talk to but you.  The other staff is too busy.”

Treater: “What do you want me to say?”

Hopeless Client: “I have to tell you what to say?”

Treater: “The group is over.  Nothing can be done.  We need to move on.”

Client: “But I’m still very angry about this.”

Treater: “This is therapy interfering behavior.  We need to move on.”

Frustrated Client: “I can’t move on.  I’m angry.  I feel invalidated.”  (Near tears.

Treater: “We need to move on.  This is therapy interfering acting out.”

Confused Client: “I can’t move on!”

Treater: “What do you want me to say?”

Client: “You want me to ask for my own flowers?"

Treater: “What?”

Angry Client: “How about the ABC’s of therapy?  How about validating what just happened to me?”

Treater: “What do you mean?”

Angry Client: “How about, Ann, I’m sorry that happened to you.  If it had happened to me, I would be upset too.  Let’s talk about why it upset you so much and see what is behind that.”

Treater: “But I didn’t say that and if I did say it now it wouldn’t matter as much to you.”

Misunderstood Client: “Right, because I had to ask for the flowers.”

Treater: “What?”

In vignette above, the treater blew it.  The treater had a chance to work with the client’s aroused angry feelings that were amplified and connected to old unresolved angry feelings from the past (a prime negative transference).  Between the problems in group and the treater claiming the client’s anger was therapy interfering (pulling the incompetent wild card), the anger concreted the client’s beliefs the world is bad, and a chance at being understood is hopeless. Had the treater validated the client in the mist of the anger (height of the negative transference), most of that energy could have been modified into a healing experience. 

The Container and Framework

his is the first step, the construction of the operating framework.  There are parameters in which the therapeutic work can be carried out.  The use of the word ‘rules’ seems harsh and invites challenge.  For example: “This is not within the parameters of our working relationship” (reminded of agreement –problem solving) comes off better then “you are breaking the rules” (accusatory - defensive)

After intake and getting the client’s history we move to the next step, which is to establish a micro therapeutic alliance [6].  For example:

Framework (Plan A)

Treater: Have you ever trusted anyone?

Client:  No, I trust no one.  People cannot be trusted for the most part.

Treater: Did you trust your last treater?

Client: Not all the way. I held back in places.

Treater: Okay, do you trust your best friend?

Client:  For the most part, almost all the way.

Treater: “I can’t ask for more then that. You will learn to trust me at least as much as your best friend.  I realize it will take some time, and I expect you will test me, but you will learn to trust me.”

Client:  I don’t play those games. I don’t and won’t test. 

Treater:  In any case, you will find out I can be trusted.  Are you willing to give me that chance?

Client:  I want too.

Treater:  That’s good enough for me.  I’ll take it.

The example above, the treater focused on trust.  Even though the client was ambivalent and ‘gun-shy’ on the issues of trust, the treater provided the genesis of consistency, (formation of the constant object),  “You will learn to trust me.”  This exchange was attractive to the client and enabled the treater to proceed to the next step; to establish a JOINT agreement that the client is in treatment to get help [6].

Treater: I don’t know you well enough to know what you need right now, because every person is different, but I will learn. Does that seem fair to you?

Client:  Yes

Treater: (nodding) I have learned that when working with clients it is helpful to establish constancy, structure and a routine. 

Client:  That’s one of my problems.  The way I feel about myself, I don’t really care about even establishing structure. 

Treater:  Are you here because you hope I can help you?

Client:  Kind of.

Treater:  Would it be fair to suggest there is a part of you that wants very much to get better even though a bigger part may not want too?

Client:  Sometimes I can feel that part, like right now.

Treater:  (nodding) That is the part I hope will keep you coming into treatment so I can work with the bigger, sadder, and more hurtful parts of you and help them feel better.  Do you think you are able to do that?

Client:  I want too.

Treater:  Are you willing to give it a try?

Client:  I want too. (Very long pause) Yes, I want to try.

Treater:  (nodding) I’m glad that you decided to try.  I congratulate you.

The treater has explained the framework identifiers in advance and has established the beginning of a working relationship.  Next, the treater must establish a treatment time that should remain constant in day and time to help the client develop a feeling of containment (a feeling of being held).  Once treatment the schedule and frequency are worked out, the treater explains what they need (empathically!) from the client, which is basically to come into treatment (no matter how bad the client feels), and aim to be on time, and make an effort on some level to work with the treater, if only a little.  Half the work is just showing up!

The Framework Summary:  (Plan A)

  • Treater leadership – “You will learn to trust me”

  • The client admits to needing help

  • The treater is engaged (you will test me)

  • The client agrees to come into treatment no matter how badly they feel

The Container (Plan B)

The container (Bion) ‘contains’ the framework of the therapeutic treatment AND contains the client.  The container is a membrane that ‘holds’ the client.  This ‘holding membrane’ can be much more effective than the physical holding of the client. 

If a container is not ‘constant’ it is basically worthless and can setback treatment until the client believes the container has been repaired.  Beware treater; the client will inspect (repeated testing of the repairs) the container before treatment is able to advance.  In essence, a faulty container can make the treater work 10 times harder!  For example, a suspicion of a faulty track containing a roller coaster car is likely to get exanimation through a magnifying glass. 

It may be helpful for the treater to discuss with the client (in a nurturing way) how the container works with safety issues.  For example, “If you do A, I will follow up with B, and this not a punishment (penalty), but rather a consequence to keep you safe and to help you learn” (discipline), OR, “If you unable to control yourself ‘A’, for safety reasons, I will have to take control by doing “B.”   

There is no malice involved here, but rather a demonstration of constancy that was not modeled in the past with the client (constant object).  This is also a corrective experience. 

Vignette 

Gabbard [2] illustrates a segment of the container perfectly in his APA video lecture.

Client: I can’t understand it.  I don’t know what the big deal is.

Treater: What are you talking about?

Client: I keep getting put into the hospital and it messes up my job.  I think I am one of the higher function people out there.  This doesn’t make any sense to me.

Treater: What do you think you are doing to end up in there?

Client:  I don’t know.  Except sometimes I cut on myself. 

Treater:  You don’t think that is a reason for being hospitalized?

Client:  No.  I mean the cuts are not life threatening.  It’s just something that I do from time-to-time.  I don’t know what the big deal is.

Treater: Well, in our culture, we view people that cut themselves as needing immediate treatment in a secure environment.  Hospitalization is simply the result of the consequences of self-harm in our society. 

In this vignette the client had a rather bland lack of denial that cutting resulted in hospitalization.  The treater however, concreted the link between cutting and hospitalization.  This awareness promoted the framework of treatment AND contained the client.  The treater was able to demonstrate to the client that self-dangerous behaviors are a no-brainer toward more extreme measures of containment that are carried out as-matter-fact.  Therapeutic Parameters, Active engagement and Consistency (PAC Container) are key toward effective containment for growth.

The Therapeutic Tools

Goals vs. Vector

At times the word ‘goals’ can arouse ambivalence toward self-destruction, and invites self-sabotage in the borderline personality disorder client.  In cases like this the word ‘vector’ is helpful.  Vector is not a goal, but a looking in direction of, a setting the feet on a path of.  Vector is a journey in the right direction and not the destination.  Vector helps promote positive alliance in a positive aimed direction rather then the destination-based risk to failure.

Don’t Cheat

A famed treater advocated that blackmailing the client to get them to be treatment compliment might be necessary.  Her strategy was to FIRST develop a STRONG therapeutic alliance and then threaten to dump the client (the execution boundary [5]) if they failed to improve.  She reasoned that a client might not want improve to keep the treatment going, in which case the treater should say, “If you don’t improve, you will lose me much quicker!”

This strategy certainly challenges the concept of trust!  It can come off as a cheater that changes the rules as they go. This can certainly be viewed as a cowardly sneak attack.  A tactic like this could possibly explain why there is a dropout rate for the more sensitive borderline personality disorder  clients that have a history of being abusively manipulated by others.  The strong therapeutic alliance got mirrored back to the client abusively in much the same way it was mirrored back to the child in service of the parent to keep the parent’s love.  A scheme like this can trigger and amplify similar anger within the client that is still not resolved from the past (mistrust transference).  The treater could step on a transference destructive landmine and blow up the therapeutic alliance.  Use caution.

Two techniques for Change (modification)

One technique would be to address the thought process (cognitive) and the other would be to provide a corrective experience for the client (psychodynamic).  Cognitive and psychodynamic models can bring about change while ‘supportive therapy’ may help the client continue to function without any real change.  It is important the treater has knowledge of the cognitive as well the psychodynamic methods for maximum therapeutic benefit for the client.  Lets look at this metaphor for clarification: 

There is a steam kettle on a stove with a large fire under it.  There are several pressure gages on the lid of the kettle that are maxed out.

The fire represents the source (closed core objects) of all the emotional hurts that are walled off and deep inside the client (unconscious).  The steam kettle represents the person (self) and the steam represents the PAIN inside the person.  The gages on the steam kettle when adjusted allow steam (pain) to escape and release some pressure. 

Now, the steam kettle is ready to blow at any second.  Lets look at our options to keep the steam kettle from blowing up:

We could adjust all the steam gages (cognitive management) or;

We could cut the fire (source of the pain) or,

We could cut the fire AND adjust the gages for maximum release of pain.

An effective treatment approach is much like the metaphor above.  The cognitive approach (think it out) will help get problems under control based in the here-and-now (releasing pain), but are not as likely to cut the unconscious source of the pain that a corrective experience from the treater can provide (The skillful use of introjective identification to offer modified objects to the client for assimilation). For the corrective experience psychodynamic treatment is useful (cutting the source of the pain).

Marsha Linahan has taken Arroan Beck’s (the originator [3]) theories of cognitive behavior therapy (CBT) and modified it to treat the borderline personality. Her version added Zen into the package and she termed it Dialectical Behavior Treatment (DBT).  She has outlined her treatment approach much like a decision-making flow chart.  For example, “Is the client doing ‘A’ or ‘B’?  If ‘A’, do this, if ‘B’ do that.”  On the upside, the great thing about a flow chart is that it takes a lot of guesswork out of how to help the client.  The down side is that it limits the skillful use of creativity to recreate an environment to address the old pain that drives the behaviors.  Rule of thumb, cognitive treatment can ‘manage’ the pain, and psychodynamic treatment can ‘eliminate’ the pain.  Therefore, it is usually best to manage the pain (DBT) [7] while the treater is also trying to eliminate the pain (psychodynamic).

Examine Cognitive Positions  (1)

The cognitive treater’s job is to educate the client about the 3-way linkage that ‘thoughts drive emotions, and emotions drive behaviors.’   The cognitive treater also challenges the beliefs of the client to sort out any ‘distortions’ that may be driving the emotions into behaviors (unraveling transferences).  The cognitive treater also educates the client to ‘respond’ (think) rather than to ‘react’ (knee-jerk) to situations (use of the wise mind). 

When addressing possible cognitive distortions (transferences) it works out much better when the treater ‘invites’ the client to try on different perspectives through exploration rather than to demand the perspective compliance of the treater.  There is nothing worse (figuratively speaking) when a treater goes into a battle with the client and takes a stance the client is massively distorting everything.  This is an evasive way to invalidate the client all over again (creates mistrust).  This creates a situation where each of the participants are at odds with each other and the situation is advancing toward a static power struggle (resentment and going nowhere).  It is a MUCH wiser approach to ‘guide’ a client toward a possible distortion, examine it, play around with it, and try it on for size.  This way, the client ‘owns’ it; rather fight the perception of the treater (the invalidating object).

Modify Old Beliefs Through Corrective Experience. (2)

A treater is working with a client’s head (cognitive – thinking) AND is also working with their heart (complex emotions).  For example, many of us have had to make tough relationship decisions based on information from our head vs. our heart.  Usually the heart says to ‘stay’ in the relationship and the head says to ‘run as fast as you can.’  This creates ambivalence (opposing thoughts). 

The problem with an exclusive cognitive (thinking) approach toward therapy (addressing ambivalence and distortions) is that it only addresses the head and NOT the heart.  Emotions should not, and cannot be ignored.  Still, a cognitive behavior treater may say, “We do address emotions.  We help the client examine their thought process of how and where these emotions are stirred up.  We try to trace where the emotions are coming from and if we find distortions in the client’s thinking, it helps the client understand their thought process, and then they feel better.  Then the client is able to relate to people in a cognitive way that establishes a better working relationship.  This process snowballs in all parts of their lives until most of their problems diminish.”  However, many of us that have fallen in love and have been crushed on the other end would beg to differ.  A broken heart hurts no matter what rational views or evidence is offered to help mind rationalized away the hurt.  Hurt is hurt regardless of all any ‘cognitive” explanations to mitigate the damage.  The psychodynamic models addresses the old hurts that are still very much alive within the heart (closed core objects).

To address the source of the client’s pain, the treater must be aware of emotions that are stirred up in the therapeutic relationship.  When the client’s emotions are stirred up toward the treater based on previous experiences in the past from others, we have transference in the works [3].  Transference is resurrected emotions that were previously directed toward others and is now directed toward the treater.  Since no situation is EXACTLY the same, transference is ALWAYS a distortion.  However, even though the current situation with the therapist is distorted, it is still extremely useful to provide a vehicle for a corrective experience.  This can be an intense and emotionally involved role-play toward a better outcome.  The client resurrects the pain from the past (forming a transference) and the treater is the role target (transference target).  As the role-play unfolds, emotions can get worked up.  Then, with perfect timing, the treater can turn some of that anger or neediness into healing (modify the internal object). 

Treatment Red Flags

Remember, transference is always a distortion of the client’s thoughts from the past attributed toward the treater.   Countertransference is basically the old feelings aroused in the treater due to the client’s transference (the narrow sense).  

Several Transference and Countertransference Examples

Transference: The treater will be my perfect parent.  I have hoped to find this my whole life.

Countertransference: I will parent this client like a real parent because I remember how bad I felt when my mom was away for a year when I was little.

Problem: A real concrete parent/child relationship is impossible because the treater’s limited resources are not available.  Most treaters have existing caseloads and responsibilities to their families, and to themselves. 


Transference: My treater will attend to my every need and to my every hurt, no matter when, just like my aunt used to do for me one summer when I was little. 

Countertransference: I can make any exception for my client on any day and at any time.  I have the ability to ‘perfect’ treater.  I can do anything because my parents raised me that way. 

Problem:  If this trend begins to develop, the treater is getting setup to be victimized by the client (3 AM Phone calls every other night).  According, the defeated treater may begin avoiding the client [2] and swing completely in the other direction. This can retraumatize the client because the treater is now in the neglecting role of the original abuser, and the cycle continues whereby concreting the client’s beliefs “I am bad, I don’t matter.”  This dynamic personifies the treater’s narcissist countertransference since they are toying with grandiose fantasies of ‘all-serving.’  Of course addressing isolated or rough spots is helpful for the client and is encouraged, however, be prudent of a developing malignant pattern that can destroy the therapeutic alliance.  


Transference: I hate my treater because she never holds me, and she is like all the rest that never listened to me when I needed nurturing as a child. 

Countertransference:  I need to start holding my client so I can get through to her because I can recall what that feeling feels like.

Problem: Prolonged and physically holding the client can open up a can of worms because this can be an expansion of the abyss that already resides in the client.  It would be like serving dinner to a starving person and after the first bite the dinner is taken away. Where is the satisfaction in that?  There is not enough time in the treatment hour to address the devastation of pain with holding.  Abstract ‘holding’ with ‘containment’ is much more therapeutic. 


  Transference: I really hate you right now.  You are like my abusive foster home.

Countertransference:  Based on the way you are acting right now, you deserved what you got. Perhaps if you had understood your abuser more, none of this would have happened. Perhaps I should advise you to apologize the abuser.

Problem: This shifts the responsibility from the offender to his prey. The abused must have done something to bring about their own maltreatment  - or simply were emotionally "unavailable" to help the abuser with his problems. Healing is guaranteed if only the victim were willing to participate in a treatment plan and communicate with the abuser [8].

Summery:

  • A personality that dissociates is usually fragmented.

  • Silence can be aggression toward the treater.

  • An Ideal Parental Relationship (concrete) is unrealistic. 

  • A Parental Therapeutic Relationship (abstract) can modify a client’s core beliefs and can be VERY therapeutic.

  • A BALANCE between Framework and Containment of Treatment are key.

  • Prolonged contact with the client can wake up demanding entitlement. 

  • The treater is not the client’s actual child.

  • Being ‘surprised’ with flowers is better then asking for them at times.

  • At the onset of a diagnosis of BPD at treater can begin constructing the containment process. 

  • Taking a stance of “This Therapy Interfering Acting Out” to avoid a challenge can be viewed in some cases as the incompetent ‘wildcard.’ 

  • Viewing the treatment environment as ‘parameters’ invites problem solving, whereas  ‘Rules’ suggest an accusatory and defensive stance. 

  • Goals can wake up old experiences of failure, whereas, a Vector aims in the direction of improvement and can diminish the ‘goal anxiety’ of failure.

  • For every plan ‘A’, have a plan ‘B’ to maintain a constant container.  Be consistent!

  • “Blackmail” therapy can come across as a cheater, and magnify mistrust. 

  • Cognitive therapy leans more toward managing pain, and psychodynamic therapy leans more toward pain elimination.  Both are useful. 

  • Transferences and Countertransferences need to be monitored by the treater.  And understandings of these dynamics are also helpful for the client.

Conclusion

Hopefully this work has stimulated the client and the treater.  This material has taken the task to articulate the difference between a therapeutic relationship vs. a malignant relationship.  In a therapeutic relationship emotions are aroused for change (modification) because the container is strong (every plan A has a plan B) and balanced with the operating framework (the modifer).  A maligment relationship is harmful because distortions are not addressed, the container is flawed and powerful emotions are not modified into healing (negative transferences are not channeled to modify closed core objects within the client).

To The Client

Please be careful that a parental fantasy toward the treater does not turn into an unmanageable obstacle. Use this material to keep a healthy perspective. Let healing work for you based on your aroused emotions facilitated by a skillful treater.  

References: 

1. An Object Relations Approach to Understanding Unusual Behaviors and Disturbances – Kathi Stringer (2003)
http://www.toddlertime.com/general/disturbances.htm 

2. An Object Relations Approach to Understanding Unusual Behaviors and Disturbances – Kathi Stringer (2003)
http://www.toddlertime.com/general/disturbances.htm 

3. Integrated Treatment of Borderline Personality Disorder – Glen O. Gabbard, M.D.

4. Prisoners of Hate – Aaron T. Beck, M.D. 

5. I Hate You, Don’t Leave Me – Jerold J. Kreisman M.D.

6. Borderline Hatred and the Execution Boundary – Kathi Stringer
http://www.toddlertime.com/borderline/execution-boundary.htm

7. Technique used by Tracy Shockey  MSW

8. Cognitive Behavior Treatment of Borderline Personality Disorder – Marsha Linehan Ph.D.

9. Malignant Self Love – Narcissism Revisited, Sam Vaknin, Ph.D.
http://samvak.tripod.com/archive44.html