The individual with borderline personality disorder often is heavily invested, financially and emotionally in the therapist liking him or her. More than wanting to be seen as the one who is right, the individual needs to be accepted. Despite everything the individual may do to be accepted, including making the therapist feel charming, interesting, and likeable, the therapist needs to remember that he or she (the therapist) is not special. And the therapist should let the individual know that no matter what he or she has done, does, and will do in therapy… or has done positively in the couple, that the therapist is still not special. The therapist may claim that this client is special. And in some ways, he or she is special- primarily because this person is in therapy with the therapist. The client in the room is always special to the therapist. However, with a full caseload, the therapist has a whole schedule full of special clients! Frieda is not so special that she can expect the therapist to respond to a phone call at any time of day or night. She is not so special that Selena has other clients immediately relinquish to her the prime 6 pm appointment. In other words, all clients are special, so being special to the therapist is normal! No individual is special in that he or she is not human or does not function within a spectrum of humanity. No one is immune from the requirements of living with other people. The therapist needs to hold each client accountable to the expectations of the real world. In the real world, most people won't think of the individual as, much less treat him or her as if he or she is special. Yet does not being in love and a partner in a couple make one special?
Unfortunately in an intimate relationship, specialness is a double-edged sword. When the person accepts an intimate someone as special, it encourages him or her to ignore and accept behaviors that otherwise may not be tolerated from another- a not special other. There is also the expectation that there will be special regard and treatment reciprocated- that is, received as well as given. As the relationship develops, however the initial bloom of excitement and specialness often recedes. The person becomes less tolerant of annoying behaviors and more demanding of good treatment. Moreover, initial tolerance of annoying behavior however does not predict whether the person will tolerate chaotic emotionally annihilating behavior from borderline eruptions. A dilemma of the individual with borderline personality disorder is a desire to be held as special along with a deadly fear of not being special enough to be loved. When the individual with borderline personality disorder gets triggered, his or her resultant behavior can be so toxic that it cannot be accepted. The relationship loses viability in the eyes and heart of the partner. Yet his or her later apologies and pleas to resume the relationship ask that the rules of respect and intimacy functionally not be enforced. Ignoring normal standards and boundaries in a relationship would be based on somehow, that both the individual who had lashed out and the emotionally ripped partner are in turn or simultaneously "special." Or, that the relationship is "special." The therapist needs to directly challenge the mythology of specialness. The individual (actor or recipient) and the relationship cannot be special enough to endure borderline drama without injuries and probable destruction.
In the bloom of new love, a person often gives his or her intimate partner a second chance, a third chance, and a fourth chance and more… because he or she is special! Cliff gave Frieda innumerable chances because she was special to him. But can an individual count on those repeated chances as the relationship eventually enters the real world? After initial attraction, lust, exploration, and discovery, the couple slides into housekeeping chores, budgeting, vacation planning, and family planning. Practical and symbolic challenges trigger each member. The individual with borderline personality disorder however is massively triggered by anything… by nothing… by nothing special. No matter how unpredictable, erratic, or obnoxious the child's behavior, his or her parents usually still love him or her. The blood bond between biological parents and children create an obligation, commitment, and investment that preclude any consideration of opting out. However, the same is not true between romantic partners. Romantic partners initially choose one another and are quite aware that they can opt out as well. Cliff chose Frieda as much as she chose him. Cliff could un-chose Frieda as well. Even if love makes repeated emotional destruction more tolerable, the relationship often cannot be sustained through repeated violations forever. Even if the couple stays together, it may do so in a corrupted form.
The partner of the individual with borderline personality disorder may eventually start to acquiesce whenever there is conflict. Cliff who was already conflict-avoidant from his family-of-origin experiences gave in to Frieda's intensity regularly. Comparable to when children or adults have thrown frequent tantrums, the individual's tantrums can intimidate others to change behavior against their will. Moreover, after a few tantrums or borderline eruptions, the threat of another tantrum or eruption is sufficient to intimidate the partner. When accused of some transgression, the accosted partner will often defer logic and reality rather than get embroiled in a futile tornado of accusations. If the partner actually dares to stand his or her ground, it draws the individual with borderline personality disorder's full nuclear payload of vitriol. The partner often allows the individual with borderline personality disorder to "win," because he or she has come to prefer surrender than getting devastated or enraged. The partner tolerates losing because the borderline partner must avoid feeling any loss. Disappointment is a part of the real world of the couple… of any relationship and in any situation. Yet, winning or losing a simple argument may ignite huge shifts in mood for the individual with borderline personality disorder. The loss is often functionally negligible, but symbolically annihilating. Eventually, the partner in the couple may not or cannot tolerate such moods. The partner may lose the desire to understand or find compassion for the individual with borderline personality disorder over time, and begin to put little if any effort into working on change. It becomes too much work for too little reward. The individual may intellectually understand that his or her partner cannot continue to endure the drama, but lose track of it in his or her borderline process.
CANNOT SUFFER AND SURVIVE
Essentially, the individual with borderline personality disorder asserts that he or she cannot suffer and survive. Whether someone such as Frieda articulates this overtly or not, his or her stance is that suffering is intolerable and must be extinguished. His or her experience is that the suffering becomes debilitating. When the individual suffered as a young child, the parents were not there to hold and contain the pain, nor to foster the resiliency that one needs to draw upon to endure it. Pain was not a momentary period of distress, but drew him or her into an abyss of terrifying abandonment and loneliness. Compulsive acting out (hurtful stabs at the partner or the therapist) is an attempt to jump away from the intolerable abyss. In the moment of despair, the individual is not conscious of the consequences (especially, long-term consequences) of the behavior; or at best, are only semi-conscious and unable to restrict negative behavior. However, suffering occurs in relationships; and great suffering occurs in intimate relationships. As much as the individual tries to avoid suffering, it is unavoidable. A partner or therapist who supports attempts to avoid suffering may inadvertently imply that eliminating suffering is possible. Cliff tried to make sure that Frieda did not suffer. It was what she demanded of him, and as a loving committed foolish partner he tried to do it!
The therapist should teach the individual with borderline personality disorder that he/she can suffer and still behave appropriately… in fact must suffer. The individual must even embrace suffering to be able to survive and grow. Therapy must reveal and contest the individual with borderline personality disorder's core paradigm or associated foundational paradigms. Failure to do so will by default reinforce a life perspective of being unable to survive difficult disappointing and intense emotional experiences. The individual has continually tried to avoid emotionally disappointing experiences and find a perfect partner who will never disappoint him or her. The individual has been and will be continually disappointed by his or her partner's imperfection. Basically, the individual with borderline personality disorder is disappointed at the partner's humanity and inability to anticipate or intuit the individual's deepest unspoken unconscious desires and needs. The individual with borderline personality disorder holds this impossible relationship rule that his or her partner should know these desires and needs even before he or she becomes aware of them. As a result, deeply disappointed the individual suffers tremendously because he or she feels that he or she cannot bear suffering. The individual repeatedly cycles through anxiety and depression. He or she suffers anxiety from anticipating disappointment again even as life and the relationship may be going well currently. The individual suffers depression anticipating, enduring, and after feeling betrayed, abandoned, and rejected again.
The individual with borderline personality persists in seeing him or herself as totally dependent and helpless. He or she believes there is nothing within his or her power to change or manage needs and stress. The individual feels out of control dealing with every day issues and normal emotions activated by ordinary living. Control is held by other people, in particular the intimate partner or parent figure despite evidence to the contrary that the individual either keeps him or herself stuck or the other people may be completely reasonable. During the weekly "fight-of-the-week" discussion in therapy, Cliff brought up an argument that started with Cliff showing Frieda an ad for a hybrid gas-electric vehicle. Cliff knew that her car was not very dependable anymore. Cliff had suggested that Frieda should look into getting a hybrid car. It made sense to him because she had a long daily commute that cost a lot of money with her gas-guzzling old car. He pointed out that she had gotten more than the old car's value and that they had the income and savings to either buy a new car outright or could easily finance one with their good credit. Frieda immediately snapped at Cliff for trying to make her choose "his" kind of car. She accused him of trying to control her… of trying to make her an "techno-geek" like him with the technologically innovative gas-electric hybrid car.
In frustration, Cliff had said, "Forget about it. I don't care! Drive your old car and have it break down on you!" To Frieda, this became Cliff wanting her to have car trouble in some isolated place and getting raped. When Cliff argued that he wasn't saying anything like that, and that she got it wrong, Frieda went to a higher level of anger. "So, I'm crazy huh?! Anything else you hate about me?" Somehow, to Cliff's amazement Frieda had began accusing him of not liking how she dressed, what she ate, and what music she liked… of not being satisfied with her. To top it off, Cliff said that Frieda accused him of staring lustily at Demi Moore in the "Charlie's Angels" movie. "She isn't even a real person! She's an actress in a movie. I don't know Demi Moore! I don't date Demi Moore. Next thing I knew, Frieda was interrogating me about whether I found her attractive. If I like older women… or was it Cameron Diaz who turned me on! And then she totally ripped me when I admitted I though Lucy Liu was cute! I'm supposed to think they're hot! It's a movie. Me and Frieda are the real deal. But it's too crazy sometimes."
In this situation, when the therapist suggests or negotiates attitude, behavior, or personality changes, the individual with borderline personality disorder often denies the possibility of change or growth. He or she experience suggestions by the therapist or partner as attempts to transform him or her into some other person's image of him or her (McGlashan, 1983, page 52). The therapist may be seen as colluding with the first betrayer (Cliff in this case). The individual with borderline personality disorder projects fear of control onto the therapist as well. This type of behavior corrupts the relationship. If the individual with borderline personality disorder rages and lashing out do not destroy partner's trust in the relationship, the continuous hypervigilance and hypersensitivity (functionally, paranoia) can wear down the partner. The partner eventually gives up from constantly being convicted of crimes he or she did not commit and continually failing tests without knowing they were being given. The partner fails tests that the individual with borderline personality disorder does not know he or she was even giving! Thus, the individual with borderline personality disorder could not have warned the partner to be wary of not crossing lines that are symbolically important from deep within the borderline psyche. The relationship dynamics revolve around various permutations and portions of the individual with borderline personality disorder trying not to be ignited, be hurt, lash out, apologizing, and trying to make the partner respond better.
All these strategies are based on the individual with borderline personality disorder's assertion that he or she cannot tolerate suffering and should therefore eliminate suffering. Both the individual with borderline personality disorder and the partner have been unsuccessful in keeping the relationship healthy and rewarding. The individual's anxiety is amplified from previous betrayal, abandonment, and rejection experiences and reactions that have worn out and driven away previous intimate partners. Yet when entering into couple therapy, the individual usually asks the therapist to help improve the same fundamental problematic strategies with the implicit assumption that his or her core paradigm is appropriate. If the therapist accepts the conditions and goals for improving their relationship, then therapy will focus in various permutations and portions on getting the individual with borderline personality disorder not to be hurt, not to lash out, apologize better, and be more effective at getting the partner to forgive him or her. The therapist is especially compelled to instruct the partner how to respond "better"- more effectively and efficiently soothe the individual's suffering and not trigger suffering. If not particularly self-aware or sophisticated about his or her process, the individual with borderline personality disorder will often assert that the therapist should help fix the partner to not "be mean" and to do a better job caring for him or her.
Couple therapy that attempts to follow the individual with borderline personality disorder's strategies and goals will fail. No matter how much growth and change the couple tries to activate, the partner will do something again and the individual with borderline personality disorder will be hurt again, lash out again, and continue to apologize (perhaps with greater intellectual and psychological insight and language gained from therapy). The partner still is unable to adequately soothe the individual with borderline personality disorder. The partner's frustration will continue to grow and his or her investment in the relationship will deteriorate. And, the individual with borderline personality disorder will feel ever more shame and doom. The therapist must reset the goals of therapy by revealing and challenging the core paradigm of suffering being insufferable. After dozens, hundreds, or thousands of failures to not trigger and from not soothing adequately, the partner will be relieved of his or her impossible requirements. Part of therapy will be examining why the partner had accepted the mission impossible of never triggering and perfect soothing in the first place; and then, why he or she persisted despite clear evidence of the individual with borderline personality disorder's clearly dysfunctional process and expectations… and cruel punishments. Getting the individual with borderline personality disorder to accept that he or she must suffer and can survive will require extensive, skillful, and artistic therapeutic work. In doing so, the therapist must manage the individual's almost certain experience of betrayal, abandonment, and rejection by the therapist.
The following principles are referred to as the "SFFS SS SS SF" process for parents and other adults working with children. Originally titled "How to Create a Powerful and Successful Child," it is completely applicable to adults and particularly for the individual with borderline personality disorder. It can be re-titled "How to Empower Individuals for Life Challenges." It attacks the basic mythology of the frailty of the individual. The process recommended interrupts the cycle that leads to depression and anxiety and eventually, to destructive behaviors such as vengeance by the individual with borderline tendencies. Each of the principles discussed in the next section may be challenging or readily accepted depending on personal cultural definitions and standards. Examining them for their cultural relevance is important. They may be challenging per gender expectations and models. In particular, the principles may strike at the core of family-of-origin training and experiences for the individual with borderline personality disorder. In essence, these are possibly exactly not what was practiced or practiced dysfunctionally in the upbringing of the individual with borderline personality disorder. As a result, these principles direct the transformative process for the individual with borderline personality disorder to become effective and empowered in life and relationships. The therapist can use these principles for therapy with many clients and perhaps, most appropriately with borderline personality disorder in individual and couple therapy.
The first set of four premises may sound counter-intuitive in particular for individuals with borderline personality disorder. For their emotional and psychological health, adults need to disappoint children: specifically to stress them; allow frustration and failure; and, let them suffer while experiencing stress, frustration, and failure! Non-biological adults, in particular teachers play critical roles in this process. Teachers have to enforce real world demands among a whole classroom of children. Teachers that treasure the uniqueness of each child will adapt and flex support and instruction to individual needs. However, they cannot individualize and treat each child as special the way parents can. The child inside and outside of the home needs formative challenges in order to become confident, competent, and powerful. There is an implicit process for building the powerful and successful child. In adulthood, the individual in the community becomes the individual in a couple, in family, at a job, and so forth. The balance between the individual with borderline personality disorder's needs and the other partner's needs define the quality of the couple's relationship. As it initially may appear to be resoundingly harsh treatment for a child, the process recommended appears dangerously threatening as well for an emotionally abused, traumatized, neglected, insecurely attached, or individual with borderline personality disorder. However the process represents and replicates nurturing and empowering caregiving in childhood and subsequent effective therapy for the adult.
Stress does not destroy people, although unremitting stress can be destructive. Robert Sapolsky, professor of biological sciences (2005) explained a multitude of negative neurological and physical consequences from constant stress. Excessive stress, especially when it is traumatic causes extreme emotional or psychological disruptions. Allowing for the child and individual to experience stress does not mean that it should be allowed to become excessive and thus, traumatizing and harmful. Excessive stress can draw a person's energy and attention away from dealing with or resolving daily life demands. Eliminating all stress is impossible other than by dying! Avoiding stress is also impossible. The ability to deal successfully with stress helps define one's ability to be successful. Avoiding stress results in avoiding opportunities to learn how to successfully deal with stress. Disappointment is a regular part of life. Is it fair that one child has a challenges and another doesn't? Is it fair that one individual has wonderful parents while another has alcoholic abusive parents? Or, another person has lost a parent to early death- perhaps, suicide, homicide, or drug overdose? Whether fair or not, the fact remains that the individual through happenstance, luck, or genetics may have one or more major challenges. Rather than futilely obsessing about disappointments and limitations, the individual needs to accept life can often be fundamentally unfair.
The individual with borderline personality disorder has an antagonistic relationship with stress. Stress in the individual may be seen as the consequence of an attachment injury that is ignited by "any incident where an individual's partner is perceived to be inaccessible or unresponsive in a critical moment, especially when attachment needs are particularly salient. This is a clinically significant phenomenon in that it results in a tear in the fabric of, or disconnection in, the attachment bond creating negative interactional cycles that perpetuate relational distress" (Naaman et al., 2005, page 56). Relational distress- his or her experiences with stress were overwhelming, and thus stress becomes identified as dangerous, intolerable, and to be eliminated or avoided. Acceptance of stress enables people, including the individual with borderline personality disorder to accept affirmative struggles to seize available power and control for life. Having a physical disability, learning disabilities, ADHD, Aspergers Syndrome, or being gifted brings stresses to an individual. However, being an oppressed minority in an intolerant society is stressful too… or, being female in a sexist society. Stressed barely begins to describe growing up with abusive parents and developing a personality disorder, insecure attachment, or PTSD. Many historically respected and influential individuals however struggled with stress and trauma and achieved character, wisdom, and greatness as a result. The Serenity Prayer commonly attributed to Reinhold Niebuhr (aahistory.com, 2008) asks for one to be granted "the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference..." It does not ask for one to be stress-free!
The individual experiences new stress in new situations all his or her life. Eventually, couplehood can ignite the individual's responses that perplex or hurt the other partner. Recognizing the symbolism of the triggering stress enables the individual to differentiate current issues from the original stress, abuse, or trauma. Unable to differentiate current stress from historical stress, the individual also does not differentiate historical anxiety, fear, pain, or hurt from his or her partner's behavior. This often sets off cycle of negative actions, withdrawal, and vengeance- typical borderline behaviors that are incomprehensible to another person. Both members get drawn unproductively to the current stress or drama. The therapist should expose original stressors that lead to the individual's sensitivity and sense of vulnerability. Examination of old stresses and traumas will be unavoidably stressful. The individual with borderline personality disorder will be particularly stressed to examine his or her responsibility in the dysfunctional process of the relationship. The partner will be stressed to consider how his or her responses support the dysfunctional behavior, and to consider confronting the individual with borderline personality disorder. Yet, as stress- that is, dealing with stress is necessary to the developmental process, dealing with the stress of the conflict or issues in the relationship is also necessary. The therapist offers a model of dealing with stress by bringing up stress issues in therapy. His or her willingness to accept therapeutic stress- negative client reactions sets the confronting culture of therapy that parallels the confronting culture essential for growth in the couple.
FRUSTRATION AND FAILURE
Stress often leads to frustration. Frustration is often intrinsic to experiencing stress. Perseverance and success despite frustration develops the greatest self-esteem, sense of potency, and mastery. Handling frustration is critical to maturity. Frustration often accompanies stress in childhood for a variety of reasons. The individual with learning disabilities is often frustrated with academic challenges and later, vocational challenges that others get easily. Someone with ADHD get frustrated when others impede his or her impulsivity and hyperactivity. Missing social cues, getting teased, and difficulty in making friends frustrates the individual with Aspergers Syndrome. Despite frustration that often is quite severe for the individual, the next question needs to be, "And, now what?" If as a child, the individual was led to expect things to be easy, frustrating challenges then make him or her feel doomed and helpless. The individual may become ashamed, infuriated at oneself, others, and anyone or anything else in the community unfortunate to be within striking distance. Adults need to let a child experience frustration and while simultaneously letting him or her know that they will be available for guidance if needed. The child needs to be required to manage frustration appropriately. Thus, adults need to place the child, the individual with the partner, and the therapist with the individual with borderline personality disorder and his or her partner in situations that will be challenging or difficult for them. As the caregiver can prompt the child, the therapist can prompt the client with, "And, now what are you going to do next?"
Throughout life and with the partner in the relationship, the individual with borderline personality disorder has experienced great frustration. When the couple enters therapy, the members may anticipate the therapist will relieve them of frustration. Frieda is frustrated that Cliff does not take care of her anxiety or does not perform adequately. Cliff is frustrated that despite his dedicated attempts, Frieda still blows up on him periodically. They both expect Selena to reduce their frustration. Quite to the contrary, the therapist's actions in therapy will most likely increase their frustration. There is an entire spectrum of behaviors and strategies that the individual and couple have tried and been frustrated over. The therapist will be introducing and re-introducing them to even more behaviors and strategies that will inevitably be frustrating as well. Success requires perseverance despite frustration since simple solutions tend not to work. The individual, partner, and the couple have already tried all the simple solutions. Effective solutions only become effective through trial and error. That inevitably means experiencing extensive frustration… often excruciating frustration.
Perseverance also means dealing with the frustration of failure. Life is often about tremendous frustration AND devastating failure! Therapy also inevitably involves frustration and failure. The therapist who does not incorporate frustration and failure into therapeutic strategy may ultimately doom effective therapy. No one strikes gold 100 percent of the time. To be successful, people need to be comfortable with failure or the possibility of failure. To fail and persevere and become successful reflects resiliency. When adults manipulate circumstances to make it easy, the child will assume that success is the norm. This produces unrealistic expectations that the other kids on the playground are going to let him or her win the race. The other candidate will let him or her have the job! The partner can and will completely adapt to meet ones needs and expectations despite not being told what those may be! While everyone experiences failure, however the individual with problematic parents often experiences much more failure. The individual with borderline personality disorder may label him or herself as a failure for not being able to maintain the emotional equilibrium or to sustain relationships. The therapist who expects easy success with a borderline client in individual therapy or in couple therapy has not worked with a borderline client! Or, if the therapist has what seems to be early success in therapy, he or she may be set up for the therapeutic slaughter later when borderline sensitivities get triggered. The therapist should predict to the couple that there would be frequent failures in the therapeutic process and in the couple's process during therapy.
Learning to embrace failure or accepting performance short of perfection may be particularly challenging for the individual with borderline issues. Everyone involved in therapy needs to expect and accept failure as a prerequisite for achieving eventual success. The individual's acceptance of stress, frustration, and failure as intrinsic to the process may be the first goal of therapy. Parents not only need to let the child fail, but to make sure there is failure! But doesn't it already happen too much for the child with challenges and has happened too often for the individual with borderline personality disorder? Perhaps, but it's still necessary. As strange as it sounds, adults need to celebrate the child's failure! And the therapist needs to celebrate the partners' failures! "Messed up? Awesome! Let's see how many times it takes before you get it!" Without failure, there is no success. "You got it! You kept on trying even when you failed over and over. Great!" The challenge for the individual with borderline personality disorder is that his or her experience of intimacy failure has been and continues to be so emotionally and psychically devastating, that he or she has avoided failure at all costs. The challenge for the therapist is to enable the individual with borderline personality disorder to do risk failure and endure emotional devastation anyway.
Suffering is another unavoidable experience of living in the real world. Stress, frustration, and failure cause intense emotional reactions, including depression, anxiety, fear, pain, rejection, loneliness, abandonment, hurt, and shame. Overprotective adults must overcome their instincts and let the child suffer. "Yes, it will be hard, and you can still do it." "No, it doesn't feel good, and you can still be OK." If adults let the child suffer, they are asserting confidence that the child can handle it. From childhood into adulthood, the individual who may not yet have the confidence that he or she will be OK depends on important and valued persons' confidence in him or her. The therapist must hold the individual with borderline personality disorder as capable and competent of handling suffering. The therapist asserts that the individual with borderline personality disorder can and must suffer again... that the couple can and must suffer again.
The therapist must refrain from rescuing the individual from his or her suffering and preventing him or her from experiencing suffering. Rescue is often the automatic instinct of caring people including and perhaps, especially the therapist. The individual almost always eventually experience emotional distress regardless of how much others try to protect or rescue. Suffering cannot be prevented, but can be managed to prevent debilitation and paralysis. As with stress, frustration, and failure, only experience and practice with suffering develops emotional intelligence skills. The individual who is treated as unable often assumes the identity of being disabled or incapable. The individual with borderline personality disorder, who has deeply suffered stress, frustration, and failure, struggles against self-definition as a failure in intimacy. He or she may self-define as being unable to tolerate suffering. The therapist who attempts to soothe well (that is, soothe perfectly) the individual's despair inevitably fails. He or she becomes another intimate person who has betrayed, abandoned, or rejected the individual. Attempting to soothe suffering has the unintended consequence of confirming to the individual that he or she cannot tolerate his or her intense emotions. The therapist confirms the individual's historical failures as inevitable and forever if he or she does not challenge the individual to suffer again. The individual's weakness is supported and intensified, as opposed to any strength uncovered and activated.
Accepting suffering may be the key to change for the individual with borderline personality disorder and to success as a member in a couple. His or her approach to life, to intimacy, and to therapy is predicated on his or her inability to suffer. This life paradigm has proven to be untenable in relationship after relationship. It may have also been proven unworkable in therapy after therapy with one therapist after another. Despite years of suffering, the individual with borderline personality disorder must be willing to suffer and thus, begin to experiment with alternate responses for when he or she suffers. Accepting the need to suffer comes out of the therapist's acceptance that the individual does and has suffered intensely. Carey (2011) said that "Dr. Linehan found that the tension of acceptance could at least keep people in the room: patients accept who they are, that they feel the mental squalls of rage, emptiness and anxiety far more intensely than most people do. In turn, the therapist accepts that given all this, cutting, burning and suicide attempts make some sense." The therapist accepts the reality of pain for the individual, and accepts that the individual's attempts to avoid and soothe pain were necessary attempts to survive. However, the therapist points out how these attempts have not worked and have complicated the individual's life and relationships. "Finally, the therapist elicits a commitment from the patient to change his or her behavior, a verbal pledge in exchange for a chance to live: 'Therapy does not work for people who are dead' is one way that Linehan puts it." The commitment to change behavior is a commitment to endure more suffering with hopefully, sufficient support that it will be more tolerable. It is important to note that the suffering may be more tolerable, not that it will be tolerable. It definitely will not be easy. Benefit and growth comes from suffering and surviving, which for the individual with borderline personality disorder means suffering terribly and still surviving. Therapy offers survival as the change. It offers survival as the change that can lead to a subsequent change- flourishing.
The therapist must not imply that the individual can improve and find a stable relationship without a willingness to suffer and try to survive. For the individual's life and process to be different, therapy and the therapist need to be different from previous models and paradigms already proved to be ineffective. The art of therapy would be how to adroitly challenge how the individual has used relationship and therapy failures to justify continued dysfunctional borderline responses. Dysfunctional behavior has persisted when the individual asserts his or her helplessness to change. "…the therapist… tries to move patients from this helpless position. Such efforts throw them into panic and 'vehement self-pity'" (McGlashan, 1983, page 52). The individual may resent the therapist's demands for him or her to assert power and control and make choices. Spurling (2003) describes, "The challenge for the… counselor is to be able to work with clients where the whole purpose of the counseling- which could be expressed for example as helping the client to think about their experience, or to acknowledge and experience the states of mind such as pain, guilt, loss and reparation associated with the depressive position- is unlikely to be achieved. What is more, if progress is made in that direction, if the client starts to link areas of experience together or to feel more in touch with such painful feelings- in other words if the counselor starts to function as a counselor- then the client is likely to feel pushed towards experiencing a psychic catastrophe. Counseling with the borderline client therefore has to be conducted in the shadow of an understanding that the treatment is likely to make the client worse, and probably at times will do so" (Spurling, 2003, page 36). Skillful confrontation of multiple relationship and therapy failures confirms the lack of viability of the individual with borderline personality disorder's basic paradigm. Thus, the therapist seeks acceptance by the individual with borderline personality disorder that suffering has to be a requirement for change.