I Hate You—Don't Leave Me (22 page)

Therapists with differing styles may perform equally well with borderlines. Conversely, doctors who possess special expertise or interest in BPD and who generally do well with borderline patients cannot guarantee success with every patient.

A patient can choose from a variety of mental health professionals. Though psychiatrists, following their medical training, have years of exposure to psychotherapy techniques (and, as physicians, are the only professionals capable of dealing with concurrent medical illnesses, prescribing medications, and arranging hospitalization), other skilled professionals—psychologists, social workers, counselors, psychiatric nurse-clinicians—may also attain expertise in psychotherapy with borderline patients.

In general, a therapist who works well with BPD possesses certain qualities that a prospective patient can usually recognize. He should be experienced in the treatment of BPD and remain tolerant and accepting in order to help the patient develop object constancy (see chapter 2). He should be flexible and innovative, in order to adapt to the contortions through which therapy with a borderline may twist him. He should possess a sense of humor, or at least a clear sense of proportion, to present an appropriate model for the patient and to protect himself from the relentless intensity that such therapy requires.

Just as the doctor evaluates the patient during the initial assessment interviews, so should the patient evaluate the doctor to determine if they can work together effectively.

First, the patient should consider whether he is comfortable with the therapist's personality and style. Will he be able to talk with him openly and candidly? Is he too intimidating, too pushy, too wimpy, too seductive?

Secondly, do the therapist's assessment and goals coincide with the patient's? Treatment should be a collaboration in which both parties share the same view and use the same language. What should therapy hope to achieve? How will you know when you get there? About how long should it take?

Finally, are the recommended methods acceptable to the patient? There should be agreement on the type of psychotherapy advocated and the suggested frequency of meetings. Will the doctor and patient meet individually or together with others? Will there be a combination of approaches, which might include, say, individual therapy on a weekly basis, along with intermittent conjoint meetings with the spouse? Will therapy be more exploratory or more supportive? Will medications or hospitalization likely be employed? What kinds of medicines and which hospitals?

This initial assessment period usually requires at least one interview, often more. Both the patient and the doctor should be evaluating their ability and willingness to work with the other. Such an evaluation should be recognized as a kind of “no-fault” interchange: it is irrelevant and probably impossible to blame the therapist or the patient for the inability to establish rapport. It is necessary only to determine whether a therapeutic alliance is possible. However, if a patient continues to find every psychotherapist he interviews unacceptable, his commitment to treatment should be questioned. Perhaps he is searching for the “perfect” doctor who will take care of him or whom he can manipulate. Or he should consider the possibility that he is merely avoiding therapy and should perhaps choose an admittedly imperfect doctor and get on with the task of getting better.

Once therapy is under way, it is not unusual for treatment to stop and start, or for the form of therapy to change over time. Adjustments may be necessary because the borderline may require changes in his treatment as he progresses.

Sometimes, however, it is difficult to distinguish when therapy is stuck from when it is working through painful issues; it is sometimes difficult to separate dependency and fear of moving on from the agonizing realization of unfinished business. At such times there will arise a question of whether to proceed along the same lines or to take a step back and regroup. Should treatment begin to involve family members? Should group therapy be considered? Should therapist and patient reevaluate medications? At this point a consultation with another doctor may be indicated. Often the treating therapist will suggest this, but sometimes the patient must consider this option on his own.

Although the patient may fear that a doctor is offended by a request for a second opinion, a competent and confident therapist would not object to, or be defensive about, such a request. It is, however, an area for exploration in the therapy itself, in order to assess whether the patient's wish for a second evaluation might constitute a running away from difficult issues or represent an unconscious angry rebuke. A second opinion may be helpful for both the patient and the doctor in providing a fresh outlook on the progress of treatment.

Appreciating treatment as a collaborative alliance is the most important step in maximizing therapy. The borderline frequently loses sight of this primary principle. Instead, she sometimes approaches treatment as if the purpose were to please the doctor or to fight with him, to be taken care of or to pretend to have no problems. Some patients look at therapy as the opportunity to get away, get even, or get an ally. But the real goal of treatment should be to
get better
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The borderline may need to be frequently reminded of the parameters of therapy. He should understand the ground rules, including the doctor's availability and limitations, the time and resource constraints, and the agreed-upon mutual goals.

The patient must not lose sight of the fact that he is bravely committing himself, his time, and his resources to the frightening task of trying to understand himself better and to effect alterations in his life pattern. Honesty in therapy is therefore of paramount importance for the
patient's
sake. He must not conceal painful areas or play games with the therapist to whom he has entrusted his care. He should abandon his need to control, or wish to be liked by, the therapist. In the borderline's quest to satisfy a presumed role, he may lose sight of the fact that it is not his obligation to please the therapist but to work with him as a partner.

Most important, the patient should always feel that he is actively collaborating in his treatment. He should avoid either the extreme of assuming a totally passive role, deferring completely to the doctor, or that of becoming a competitive, contentious rival, unwilling to listen to contributions from the therapist. Molding a viable relationship with the therapist becomes the borderline's first and, initially, most important task in embarking on a journey toward mental health.

Many clinicians divide therapy orientations into exploratory and supportive treatments. Though both styles overlap, they are distinguished by the intensity of therapy and the techniques utilized. As we will see in the next chapter, a number of therapy strategies are used for the treatment of BPD. Some employ one style or the other; some combine elements of both.

Exploratory psychotherapy is a modification of classical psychoanalysis. Sessions are usually conducted two or more times per week. This form of therapy is more intensive than supportive therapy (see page 161), and has a more ambitious goal—to alter personality structure. The therapist provides little direct guidance to the patient, utilizing confrontation instead to point out the destructiveness of specific behaviors and to interpret unconscious precedents in the hopes of eradicating them.

As in less intensive forms of therapy, a primary focus is on here-and-now issues. Genetic reconstruction, with its concentration on childhood and developmental issues, is important, but emphasized less than in classical psychoanalysis. The major goals in the early, overlapping stages of treatment are to diminish behaviors that are self-destructive and disruptive to the treatment process (including prematurely terminating therapy), to solidify the patient's commitment to change, and to establish a trusting, reliable relationship between patient and doctor. Later stages emphasize the processes of formulating a separate, self-accepting sense of identity, establishing constant and trusting relationships, and tolerating aloneness and separations (including those from the therapist) adaptively.
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Transference in exploratory therapy is more intense and prominent than in supportive therapy. Dependency on the therapist, together with idealization and devaluation, are experienced more passionately, as in classical psychoanalysis.

Supportive psychotherapy is usually conducted on a once-weekly basis. Direct advice, education, and reassurance replace the confrontation and interpretation of unconscious material typically used in exploratory therapy.

This approach is meant to be less intense and to bolster more adaptive defenses than exploratory therapy. In supportive psychotherapy the doctor may reinforce suppression, discouraging discussion of painful memories that cannot be resolved. Rather than question the roots of minor obsessive concerns, the therapist may encourage them as “hobbies” or minor eccentricities. For example, a patient's need to keep his apartment spotless may not be dissected as to causes, but be acknowledged as a useful means to retain a sense of mastery and control when feeling overwhelmed. This contrasts with psychoanalysis, in which the aim is to analyze defenses and then eradicate them.

Focusing on current, more practical issues, supportive therapy tries to quash suicidal and other self-destructive behaviors rather than to explore them fully. Impulsive actions and chaotic interpersonal relationships are identified and confronted, without necessarily acquiring insight into the underlying factors that caused them.

Supportive therapy may continue on a regular basis for some time before dwindling to an as-needed frequency. Intermittent contacts may continue indefinitely, and the therapist's continued availability may be very important. Therapy gradually terminates when other lasting relationships form and gratifying activities become more important in the patient's life.

In supportive therapy the patient tends to be less dependent on the therapist and to form a less intense transference. Though some clinicians argue that this form of therapy is less likely to institute lasting change in borderline patients, others have induced significant behavioral modifications in borderline patients with this kind of treatment.

Treating the borderline in a group makes perfect sense. A group allows the borderline patient to dilute the intensity of feelings directed toward one individual (such as the therapist) by recognizing emotions stimulated by others. In a group the borderline can more easily control the constant struggle between emotional closeness and distance; unlike individual therapy, in which the spotlight is always on him, the borderline can attract or avoid attention in a group. Confrontations by other group members may sometimes be more readily accepted than those from the idealized or devalued therapist, because a peer may be perceived as someone “who really understands what I'm going through.” The borderline's demanding nature, egocentrism, isolating withdrawal, abrasiveness, and social deviance can all be more effectively challenged by group peers. In addition, the borderline may accept more readily the group's expressions of hope, caring, and altruism.
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The progress of other group members can serve as a model for growth. When a group patient attains a goal, he serves as an inspiration to others in the group, who have observed his growth and have vicariously shared his successes. The rivalry and competition so characteristic of borderline relationships are vividly demonstrated within the group setting and can be identified and addressed in ways that would be inaccessible in individual therapy. In a mixed group (that is, one containing lower and higher functioning borderlines or non-borderlines), all participants may benefit. Healthier patients can serve as models for more adaptive ways of functioning. And, for those who have difficulty expressing emotion, the borderline can reciprocate by demonstrating greater access to emotion. Finally, a group provides a living, breathing experimental laboratory in which the borderline can attempt different patterns of behavior with other people, without the risk of penalties from the “outside world.”

However, the features that make group therapy a potentially attractive treatment for borderlines are the very reasons many such patients resist group settings. The demand for individual attention, the envy and distrust of others, the contradictory wish for, and fear of, intense closeness all contribute to the reluctance of many borderline patients to enter group treatment. Higher functioning borderlines can tolerate these frustrations of group therapy and use the “in vivo” experiences to address defects in interrelating. Lower functioning borderlines, however, often will not join and, if they do, will not stay.

The borderline patient may experience significant obstacles in psychodynamic group therapy. His self-absorption and lack of empathy often prevent involvement with others' problems. If the borderline's concerns are too deviant or the material too intense, he may feel isolated and disconnected. For example, a patient who discusses childhood incest, or deviant sexual practices, or severe chemical abuse may fear that he may shock the other group members. And, indeed, some members may have difficulty relating to upsetting material. Some borderlines may share the feeling that their needs are not being met by the therapist. In such situations they may attempt to take care of each other in the ways that they fantasized they could be cared for. This may lead to contacts between patients outside of the group setting and perpetuation of dependency needs as they try to “treat” each other. Romances or business dealings between group members usually end disastrously, because these patients will not be able to use the group objectively to explore the relationship, which is often a continuation of unproductive searches to be cared for.