I Hate You—Don't Leave Me (21 page)

All treatment approaches strive for a common goal: more effective functioning in a world that is experienced as less mystifying, less harmful, and more pleasurable. The process usually involves developing insight into the unproductiveness of current behaviors. This is the easy part. More difficult is the process of reworking old reflexes and developing new ways of dealing with life's stresses.

The most important part of any therapy is the relationship between the patient and therapist. This interaction forms the foundation for trust, object constancy, and emotional intimacy. The therapist must become a trusted figure, a mirror to reflect a developing consistent identity. Starting with this relationship, the borderline learns to extend to others appropriate expectations and trust.

The primary goal of the therapist is to work toward losing (not keeping) his patient. This is accomplished by directing the patient's attention to certain areas for examination, not by controlling him. Though the therapist serves as the navigator, pointing out landscapes of interest and helping to re-route the itinerary around storm conditions, it is the patient who must remain firmly in the pilot's seat. Family and loved ones are also sometimes included on this journey. A major objective is for the patient to return home and improve relationships, not to abandon them.

Some people are fearful of psychiatry and psychotherapy, perceiving the process as a form of “mind control” or behavior modification perpetrated on helpless, dependent patients who are molded into robots by bearded, Svengali-like mesmerists. The aim of psychotherapy is to help a patient individuate and achieve more freedom and personal dignity. Unfortunately, just as some people erroneously believe that you can be hypnotized against your will, so some believe you can be “therapized” against your will. Popular culture, especially cinema, frequently portrays the “shrink” as either a bumbling fool, more in need of treatment than his patients, or a nefarious, brilliant criminal. Such irrational fears may deprive people of opportunities to escape self-imposed captivity and achieve self-acceptance.

Because of the past prominence of psychoanalysis, which characteristically requires several years of intensive, frequent treatment, most people view any form of psychotherapy as being extended and drawn out, and therefore very expensive. The addition of medications and specialized treatments to the therapeutic armamentarium are responses to the need for practical and affordable treatment methods. Broken bones heal and infections clear up, but scars on the psyche may require longer treatment.

If therapy terminates quickly, one may question if it was too superficial. If it extends for many years, one may wonder if it is merely intellectual game playing that enriches psychotherapists while financially enslaving their dependent and helpless patients.

How long should therapy last? The answer depends on the specific goals. Resolution of specific, targeted symptoms—such as depression, severe anxiety, or temper outbursts—may be accomplished in relatively brief time spans, such as weeks or months. If the goal is more profound restructuring, a longer duration will be required. Over time BPD is usually “cured.” This means that the patient, by strict definition, no longer exhibits five of the nine defining DSM-IV criteria. However, some individuals may continue to suffer from disabling symptoms, which can require continued treatment.

Therapy may be interrupted. It is not unusual for borderlines to engage in several separate rounds of therapy, with different therapists and different techniques. Breaks in therapy may be useful to solidify ideas, or to try out new insights, or merely to catch up with life and allow time to grow and mature. Financial limitations, significant life changes, or just a need for a respite from the intensity of treatment may mandate a time-out. Sometimes years of therapy may be necessary to achieve substantive changes in functioning. When the changes come slowly, it can be difficult to determine whether more work should proceed, or if “this is as good as it gets.” The therapist must consider both the borderline's propensity to run from confrontations with his unhealthy behaviors and his tendency to cling dependently to the therapist (and others).

For some borderlines, therapy may never formally end. They may derive great benefit from continuing intermittent contacts with a trusted therapist. Such arrangements would be considered “refueling stops” on the road to greater independence, provided the patient does not rely on these contacts to drive his life.

As we shall see later in this and the next chapter, there are several established therapeutic approaches for the treatment of BPD. They may proceed in individual, group, or family settings. Most of these are derived from two primary orientations:
psychodynamic psychotherapy
and
cognitive-behavioral therapy
. In the former, discussion of the past and present are utilized to discover patterns that may forge a more productive future. This form of therapy is more intensive, with sessions conducted several times a week and usually continuing for a longer period. Effective therapy must employ a structured, consistent format with clear goals. Yet there must also be flexibility to adapt to changing needs. Cognitive-behavioral approaches focus on changing current thinking processes and repetitive behaviors that are disabling; this type of therapy is less concerned about the past. Treatment is more problem-focused and often time-limited. Some therapy programs combine both orientations.

Whatever the structure, the therapist tries to guide clients to examine their experience and serves as a touchstone for experimenting with new behaviors. Ultimately, the patient begins to accept his own choices in life and to change his self-image as a helpless pawn moved by forces beyond his control. Much of this process emerges from the primary relationship between therapist and patient. Often, in any therapy, both develop intense feelings, called
transference
and
countertransference
.

Transference refers to the patient's unrealistic projections onto the therapist of feelings and attitudes previously experienced from other important persons in the patient's life. For example, a patient may get very angry with the doctor, based not on the doctor's communications, but on feelings that the doctor is much like his mother, who in the past elicited much anger from him. Or, a patient may feel she has fallen in love with her therapist, who represents a fantasied, all-powerful, protective father figure. By itself, transference is neither negative nor positive, but it is always a distortion, a projection of past emotions onto current objects.

Borderline transference is likely to be extremely inconsistent, just like other aspects of the patient's life. The borderline will see the therapist as caring, capable, and honest one moment, deceitful, devious, and unfeeling the next. These distortions make the establishment of an alliance with the therapist most difficult. Yet establishing and sustaining this alliance is the most important part of any treatment.

In the beginning stages of therapy, the borderline both craves and fears closeness to the therapist. He wants to be taken care of but fears being overwhelmed and controlled. He attempts to seduce the doctor into taking care of him and rebels against his attempts to “control his life.” As the therapist remains steadfast and consistent in withstanding his tirades, object constancy develops—the borderline begins to trust that the therapist will not abandon him. From this beachhead of trust, the borderline can venture out with new relationships and establish more trusting contacts. Initially, however, such new friendships can be difficult to sustain for the borderline, who, in the past, may have perceived his formation of new alliances as a form of disloyalty. He may even fear that his mate, friend, or therapist may become jealous and enraged if he broadens his social contacts.

As the borderline progresses, he settles into a more comfortable, trusting dependency. As he prepares for termination, however, there may again be a resurgence of turmoil in the relationship. He may pine for his previous ways of functioning and resent needing to proceed onward; he may feel like a tiring swimmer who realizes he has already swum more than halfway across the lake, and now rather than return to the shore must continue on to the other side before resting.

At this point the borderline must also deal with his separate-ness and recognize that he, not the therapist, has effected change. Like Dumbo, who first attributes his flying ability to his “magic feather” but then realizes it is due to his own talents, the borderline must begin to recognize and accept his own abilities to function independently. And he must develop new coping mechanisms to replace the ones that no longer work.

As the borderline improves, the intensity of the transference diminishes. The anger, impulsive behaviors, and mood changes—often directed at, or for the benefit of, the therapist—become less severe. Panicky dependency may gradually wither and be replaced by a growing self-confidence; anger erupts less often, replaced by greater determination to be in charge of one's own life. Impatience and caprice diminish, because the borderline begins to develop a separate sense of identity that can evolve without the need for parasitic attachment.

Countertransference refers to the therapist's own emotional reactions to the patient, which are based less on realistic considerations than on the therapist's past experiences and needs. An example is the doctor who perceives the patient as more needy and helpless than is truly the case because of the doctor's need to be a caretaker, to perceive himself as compassionate, and to avoid confrontation.

The borderline is often very perceptive about others, including the therapist. This sensitivity often provokes the therapist's own unresolved feelings. The doctor's needs for appreciation, affection, and control can sometimes prompt him into inappropriate behavior. He may be overly protective of the patient and encourage dependency. He may be overly controlling, demanding that the patient carry out his recommendations. He may complain of his own problems and induce the patient to take care of him. He may extract information from the patient for financial gain or mere titillation. He may even enter into a sexual relationship with the patient “to teach intimacy.” The therapist may rationalize all these as necessary for a “very sick” patient, but in reality they are satisfying his own needs. It is these countertransference feelings that result in most examples of unethical behavior between a trusted doctor or therapist and patient.

The borderline can provoke feelings of anger, frustration, self-doubt, and hopelessness in the therapist that mirror his own. Goaded into emotions that challenge his professional self-worth, the therapist may experience genuine countertransference hate for the patient and view him as untreatable. Treatment of the borderline personality can be so infuriating that the term “borderline” has been inaccurately used sometimes by professionals as a derogatory label for any patient who is extremely irritating or who does not respond well to therapy. In these cases “borderline” more accurately reflects the countertransference frustration of a therapist than a scientific diagnosis of his patient.

All of the treatments described in this book can be productive approaches to the borderline patient, though no therapeutic techniques have been shown to be uniformly curative in all cases. The only factor that seems to correlate consistently with improvement is a positive, mutually respectful relationship between patient and therapist.

Even when a doctor is successful in treating one or many borderline patients, this does not guarantee automatic success in treating others. The primary determining factor of success is usually a positive, optimistic feeling shared between the participants—a kind of patient-therapist “fit.”

A good fit is difficult to define precisely, but refers to the abilities of both the patient and therapist to tolerate the predictable turbulence of therapy, while maintaining a sturdy alliance as therapy proceeds.

Because treatment of BPD may entail a combination of several therapies—individual, group, and family psychotherapies, medications, and hospitalization—the therapist's role in treatment may be as varied as the different therapies available. The doctor may be confrontational or nondirective; he may either spontaneously exhort and suggest or initiate fewer exchanges and expect the patient to assume a heavier burden for the therapy process. More important than the particular doctor or treatment method is the feeling of comfort and trust experienced by both patient and therapist. Both must perceive commitment, reliability, and true partnership from the other.

To achieve this feeling of mutual comfort, both patient and doctor must understand and share common objectives. They should agree upon methods and have compatible styles. Most important, the therapist must recognize when he is treating a borderline patient.

The therapist should suspect that he is dealing with BPD when he takes on a patient whose past psychiatric history includes contradictory diagnoses, multiple past hospitalizations, or trials of many medications. The patient may report being “kicked out” of previous therapies and becoming persona non grata in the local emergency room, having frequented the ER enough times to have earned a nickname (such as “Overdose Eddie”) from the medical staff.

The experienced doctor will also be able to trust his countertransference reactions to the patient. Borderlines usually elicit very strong emotional reactions from others, including therapists. If early on in the evaluation, the therapist experiences strong feelings of wanting to protect or rescue the patient, of responsibility for the patient, or of extreme anger toward the patient, he should recognize that his intense responses may signify reactions to a borderline personality.