11. Sensitivity & Support - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy
Chapter 11: SENSITIVITY and SUPPORT


Allowing and even facilitating the child having and feeling stress, frustration, and failure while suffering seems tantamount to throwing the child into the water and seeing if he or she can swim.  The recommendations are not for adults to abandon the child to be on his or her own, but to allow for formative confrontation with challenging experiences.  Adults need to judiciously provide verbal affirmations or nurturing along with other actions necessary to support the child.  The earlier directives to stress, frustrate, make sure the child fails and suffers too, without qualification sounds neglectful or abusive.  People in authoritative positions need to monitor and regulate the process with sensitivity to individual's challenges, needs, and strengths.  Sensitivity must define support.  As each individual differs, the individual with borderline personality disorder has challenges with unique and special qualities and needs.  Borderline personality disorder manifests differently among various people. As a result, each person's qualities and needs often require specific support. Sandra, Oliver, Natasha, and Gwyn despite sharing borderline tendencies or issues with Frieda are examples of how support sensitive to individual issues should vary.

Sandra whose emotionally disconnected father shut her out of his life, directs the therapist to address her existential annihilation when her husband forgets to call.  The therapy should quickly affirm that her partner should be careful to call as scheduled, but not dwell on his "transgression" as horrific.  Instead, along with validating her hurt and distress, Sandra is guided to find the symbolism of her partner's behavior relative to her childhood stress or traumas.  The partner can be an active support agent with information and an outsider's perspective of Sandra's family dynamics.  She should be affirmed as being able to feel alone without falling into dysfunctional responses.  If she quickly gets triggered into problematic reactions, then Sandra is charged to curtail either the duration or the intensity or both of her behaviors.  Sandra can be directed by the therapist to empower the partner to intervene behaviorally or inject verbally predetermined prompts or cues to Sandra to modify responses.

Awareness of Oliver's parents who continually "praised" him as a way to express their displeasure and manipulate him into "good" choices, directs the therapist to have Oliver identify his self-doubt and find a secure base of self-worth.  The therapist should intervene if the partner gets impatient about Oliver's insecurity, focusing the partner to be clear and explicit with communication.  Therapy should hold Oliver responsible for recognizing his anxiety, identify the illogical linkages between interpretations and emotions, and interrupt the negative thinking.  The therapist should ask Oliver what he does with his anxiety and what he can do instead, thus making it his responsibility.

Since Natasha gets triggered and self-medicates with excessive drinking and subsequent poor choices, sensitivity to her process may focus on stopping, interrupting, minimizing, or reducing her alcohol use.  Or, therapy may focus on making either better or less destructive choices when drunk.  Or, therapy may work on reducing the negative consequences of poor choices when drunk.  This can involve working with the partner to have mutually agreed upon plans in place for each negatively progressive stage.  Sensitivity to Natasha accepts that once triggered, her initial toxic choices may not available to be stopped.  Rather than try to do what has proven to be currently impossible, the couple is directed to second, third, fourth, and lesser choices that are doable.  
The therapist discovered that Gwyn's mother emotionally erased her by becoming overwhelmed with depression and self-pity.  Gwyn could not ever have a need or a sad feeling because her mother would always trump her with a litany of life tragedies: her angry father, her drunken husband, immigration, scrimping to find something to eat as a pre-teen, menopause, stretch marks… always something more awful than Gwyn's pathetic complaints.  Gwyn's mother would seemingly validate her by saying, "Poor Gwyn, you…" but then dismiss her by adding "but…" leading to the same poor Mama script.  If Gwyn ever tried to assert herself, much less express her emotional distress, her mother would punish her by falling into a black depression for days.  Everyone else in the family would shun Gwyn for causing Mama to be sad and for being so selfish.  Sensitivity to Gwyn required the therapist to go beyond having Gwyn and her partner express needs to also having them overtly validate each other's needs.  The therapist introduced changing the conjunction "but" to their communication to replace the implied "but" that Gwyn anticipated.  Prompted to validate by saying "I hear you… I understand you… I get what you mean and need…" Gwyn and her partner were to add, "and no 'buts.'"  Her partner learned to add, "…and there's no 'but" to this."  Gwyn learned if her anxiety started to trigger to ask, "Any 'buts' to this?"

Therapist sensitivity may prompt verbal modeling to help the emotionally shut down or emotionally over-reactive individual articulate feelings in language he or she can understand and eventually, personally use.  If the individual has problems with impulsivity and hyperactivity, the supportive therapist identifies potentially challenging situations in advance.  Then therapy can strategize clear and firm boundaries before problematic behavior develops.  The sensitive therapist reframes intimacy and social challenges for the individual with borderline personality disorder so that challenged self-esteem can be regained through guided problem solving.  In general, the therapist can anticipate likely stumbling blocks and triggers based on awareness of the individual's borderline traits and history emotionally and behaviorally.  Thus prepared, both members can institute planned and scripted preventative measures and use the therapist's guidance and agreed upon boundaries to preclude more intense problems.  The sensitivity of the therapist encourages and requires the sensitivity of the partner to the individual's borderline process.  Increased sensitivity does not make the partner responsible to never trigger or to perfectly soothe, but it empowers understanding, compassion, and appropriate support.  The partner is empowered partly by learning what he or she has never been able to do and cannot do- specifically, what he or she cannot undo.

The individual is not well served with generic or projected therapist sensitivity.  Generic sensitivity assumes that other people's experiences are universally applicable to a specific individual.  While it is useful to consider characteristics of a borderline personality disorder diagnosis or note borderline tendencies, there is great variability from one individual to another although both may warrant the diagnosis.  For example, assumptions that the individual with borderline personality disorder is often a victim of sexual abuse could prompt generic sexual trauma therapeutic support inappropriate for someone without such trauma.  Another assumption may be that self-medication and/or eating disorders are common in the individual with borderline personality disorder, which would direct therapy potentially from other issues of greater relevance for the individual.  Projected sensitivity occurs when the therapist anxiously projects his or her personal issues as applicable to an individual. For example, if the therapist felt he or she was rejected when disciplined in childhood, the therapist might assume that the individual with strict parents also felt rejected when disciplined.  As a result, the therapist may assertively investigate emotional abandonment from rigid parenting to the degree that the therapist loses credibility with the individual.  With all the demands of the therapeutic process, personal growth for the therapist to address personal issues becomes critical.

"A further aspect of the strain of working with borderline clients is the almost constant testing of one's ability to stay in role as a counselor… The counselor will be modeled on various attributes of the unhelpful or actively hostile or abusive objects, which populate the client's internal world.  Hence for periods of the work the counsellor's identity as a helpful, understanding and nurturing figure will be under severe attack" (Spurling, 2003, page 36).  Instinctive reactions by the therapist may not be therapeutically productive.  In fact, many reactions could mirror anticipated rejection and abandonment.  The therapist has to be able to maintain personal and professional integrity while managing personal and professional attacks directed at him or her from the individual with borderline personality disorder.  This requires the therapist to undergo significant personal psychic development.  Such growth leads to better abilities to distinguish between client needs and therapist anxiety, and subsequently to avoid unnecessary support that can be intrusive or otherwise, counter-therapeutic.  No matter how well intended, unnecessary support can breed resentment or worse, teach vulnerability.  The individual may conclude the therapist doesn't really understand them.  Therapist awareness of each person's individuality enables the therapist to offer the specific therapeutic intervention and support that each individual needs.

SKILLS and STRENGTH
When supported with sensitivity, the individual develops skills and strength from facing challenges.  Emotional, mental, and spiritual strength come from personal struggle.  It is required to manage emotions.  Strength is not only taking on and surmounting arduous tasks, but also bouncing back from frustration and failure.  Strength, therefore includes the quality of resilience.  Problem solving involves developing specific skills through experiences from success and failure.  Skills and strength positively reciprocate to further increase skills and strength.  The more skillfully individuals address challenges the more strength improves.  And, greater strength with subsequent confidence and resiliency facilitate skills.  Strength and specific skills are required to compensate for specific borderline personality issues.  Therapy should target the nine criteria listed for the diagnosis in the DSM-IV or the impairments and traits in the DSM-V... and B-A-R- betrayal, abandonment, and rejection.  With regard to emotional intelligence discussed earlier, the individual with borderline personality disorder has skills deficits in four dimensions of emotion processing.

Perception of own feelings and the feelings of others was significantly less accurate,

Discriminates poorly between own emotions and the emotions of other people,

Shows significantly fewer ambivalent reactions,

Makes significantly more mistakes in recognizing the mimic expression of emotions in other people.

In addition, the intensity of negative emotions was significantly higher.  Fear (which may represent the wish to escape from an intimate), anger (hate), anxiety, and depression appear to be the major emotional moods of the individual with borderline personality disorder (Leichsenring, 2004, page 11).  Beyond general communication skills or example often taught in couple therapy, these would be specific areas for skills development for the therapy including the individual with borderline personality disorder.  Recommendations should focus on sensitivity to the borderline personality experience in order to offer specific support to build relevant skills and strength.  The therapist must also deepen diagnostic sensitivity to direct therapy towards addressing specific skill deficits and weaknesses from the individual's particular experiences.  The therapist works with the individual with borderline personality disorder to develop the skills and strength to deal with real or imagined abandonment.  Two individuals may need different skills and areas of strength for comparable but different needs.  Or, they may be sensitive in different ways.

While Angelina's abandonment fears within her borderline characteristics, for example are ignited by lateness, Quinn's similar abandonment fears may be triggered by curt communication.  Specific skills, perhaps based on cognitive behavioral principles may help the first person, while different skills to improve direct communication may be more suited to the second person.  Rather than permitting the individual to replicate problematic frantic efforts, the therapist in session and by his or her partner at home prompts the individual with borderline personality disorder towards productive efforts that do not intensify negativity.  When he runs late, Angelina makes calls to her partner's celphone every two minutes leaving ever more anxious and angry messages.  Quinn urgently asks his partner the minutia of details, and getting perfunctory grunts or single words in reply, then interrogates him even more intensely.  Angelina can be guided to set up a concrete schedule of when she should call, how often she may call, and what she can say.  She may be taught mindfulness techniques to ground herself.  Mindfulness practice may help Quinn as well, but therapy should direct him to develop self-awareness of his anxiety about what he wants in the communication.  He can be given boundaries as to how many questions he may ask.  Quinn needs to develop skills and strength to tolerate his anxiety. The therapist teaches Quinn to do reality checks about his partner's care for him versus his communication style.  Reality testing often varies in functionality for the individual with borderline personality disorder (Chessick, 1979, page 531).  Frequent reality checks can help the individual with borderline personality disorder avoid his or her propensity to alternately idealize and devalue the partner.

Angelina and Quinn's partners (or Cliff) are neither perfect nor perfect jerks.  Angelina and Quinn can be prompted in therapy to create a list of positive experiences that confirm partners' commitment to the relationship.  The list for Angelina should focus on experiences that confirm availability and connection despite physical separation.  Quinn's list should focus on non-verbal communications, especially behaviors that confirm his partner valuing him.  Angelina and Quinn should learn to refer to their respective lists to find strength and self-soothing.  Adjunctive lists can include previous mistaken interpretations of partner behaviors and subsequent, positive outcomes in intimacy.  Each of their partners is guided to resist over-reaction to the borderline idealization and devaluation.  He or she learns to remain grounded by giving concrete feedback whether praised or attacked.  Concrete feedback to Angelina includes a return call and reassurance that lateness was not from dismissing her needs.  Concrete feedback to Quinn includes translating non-verbal communication into verbal language that Quinn understands, including specific affirmation of caring as opposed to dismissal.

The partner is encouraged to clarify over-generalization ("all the time") accusations by taking responsibility for specific occurrences while acknowledging the upset to the individual.  The partner commits to attending to and improving behavior as concretely differentiated from being perfect.  Trying to be perfect had failed miserably for Cliff.  Therapy should also help the individual with borderline personality disorder and his or her partner develop processes such as grounding routines and rituals to reassert and maintain a sense of self.  The therapist may teach Gestalt empty chair techniques to distinguish a positive self from the negative self.  Each specific individual may require different routines or rituals for self-confirmation and centering depending on religious, spiritual, cultural, or other experiences.  Learning concrete skills and behaviors to block (initially, more realistically slow down, divert, and possibly interrupt) impulsive self-damaging reactions simultaneously build strength to deal with overwhelming feelings.  Any process to lower reactivity may also help keep the individual with borderline personality disorder from decompensating with resultant transient, stress-related paranoid ideation or severe dissociative symptoms.  Although the reactive cycle of the individual with borderline personality disorder operates quickly, the therapist nevertheless seeks to guide the individual and partner to insert specific behaviors that may forestall suicidal behavior, gestures, or threats or self-mutilating behavior.  Virtually all of the recommendations are intended to be productive, but even without directly improving targeted borderline issues they may be effective simply because they may interrupt the borderline reactive cycle.

However, with suicidal or other self-harming behaviors, therapy must immediately shift from problem solving or depth work to safety first.  Safety protocols should be incorporated into the process.  The therapist needs to aware that the individual with borderline personality disorder is more likely to commit or try to commit suicide than the person without such issues.  Non-fatal suicidal gestures that are intended to affect others can become completed suicide if circumstances play out not as planned.  When therapeutic assessment uncovers a history of suicide attempts, suicidal gestures, and other self-harming behaviors among the individual's acting out behavior, therapy should both work to prevent such behavior and also find therapeutic opportunities for behavior that cannot be prevented.  "…the development of a working alliance or therapeutic alliance is a crucial issue in the psychotherapy of the borderline patient- as it is in the psychotherapy of many other patients- and it is the formation of this working alliance along with the correct procedure for limiting the patient's dangerous acting out, that common sense tells us is the first task in the intensive psychotherapy of such patients" (Chessick, 1979, page 535).  As the individual becomes more invested in working through his or her problems and as the therapeutic alliance deepens, the primary-process gratification of impulses in dangerous acting out and suicidal threats and attempts tends to lessen.  However, it is a very significant issue early in therapy.  The therapist must set strong boundaries and expectations for the individual.

Dangerous, self-destructive behaviors, and other threats to self preclude the possibility of effective therapy as it precludes development of a viable intimate couple's relationship.  Chessick recommends "it is our task during the entire therapy to demand a limitation on any behavior on the part of the patient that is future-foreclosing either of the patient's career or life or therapy.  This limitation comes first and nothing else should be discussed in the therapy until it is observed; if the patient refuses to limit such activities no therapy can take place.  Actually, the ultimate test of whether the patient is really motivated for psychotherapy comes in his willingness to limit self-destructive behavior.  If such behavior continues the patient probably must be hospitalized and vital limits place on him by the hospital milieu" (Chessick, 1979, page 535).  While asserting safety first, the skilled therapist may find a way to artistically reframe a suicide attempt from being consequential of weakness and a lack of skills to an affirmative- even powerful attempt to solve the problem.  From this perspective, the individual can be guided to reframe the problem (for example, an inability to tolerate suffering versus suffering that confuses rational thinking versus too much suffering… even that suffering is an indication of importance) or to reconsider the attempted solution (for example, ending versus soothing versus reducing suffering versus a break from suffering).  The therapist cannot expect any specific reframe can make enough of a difference for the individual with borderline personality disorder.  However, it is incumbent on the therapist to explore for some specific reframe that resonates for an individual.  The individual and the partner may develop the skills to eventually identify and reframe negative behaviors in ways that contribute to overall progress.

POWER AND CONTROL
Since the individual with borderline personality disorder alternately becomes deeply depressed and profoundly anxious, the therapist promotes skills for addressing the emotions.  Once consumed with depression or anxiety, the individual develop strength by engaging in planned behaviors to mitigate any negative consequences.  Almost any plan that the individual can activate will be helpful, since depression is based on hopelessness and helplessness, while anxiety is based on not being able to protect oneself from threats.  Inability or the failure to act or passive acceptance deepens depression/hopelessness and anxiety/helplessness.  Suicide attempts, gestures, and other self-harming behaviors are sometimes affirmative acts both as result of and as response to hopelessness and helplessness.  The therapist can usually uncover numerous alternative behaviors that the individual has opted not to attempt.  Some are clearly dysfunctional, while others involve risk, are scary, or violate spoken and unspoken rules.  Uncomfortable behaviors that offer the possibility of positive change or growth should be explored and certain behaviors judiciously encouraged.  There will be resistance against trying unfamiliar and risky, but potentially productive behavior.  Thus, a powerful therapeutic prompt is to "do it anyway," or " do something… anything anyway."  While many actions can be affirmative (especially, in place of negative behaviors), planning behaviors that self-soothe appropriately, reach out to the partner, own feelings, or improve a situation are preferred.  Developing skills and strength for affirmative behaviors helps get the individual with borderline personality disorder through otherwise unbearable periods without self or relationship damaging actions.  

ANGER EMPOWERS
Therapy helps the individual improve recognition and change responses to triggers that ignite intense anger or rages or instigate toxic arguments and even physical confrontations.  The energy of anger is powerful and often destructive to intimacy and self-interest.  As such, the individual with borderline personality disorder, the partner, and the therapist may spend a lot of effort to curtail anger.  And, everyone will be frustrated.  "Calm yourself down."  "Don't be so emotional."  "Don't be so angry."  "Pull yourself together."  "Don't get so excited."  "Let's not get carried away."  Such commands assume that the individual such as Frieda has choice and control over his/her emotions, including anger.  Another assumption is that emotions are somehow inherently negative, rather than purposeful.  Both assumptions are incorrect and dangerous.  Emotions are not only personal warnings to the person, but to the astute therapist, can offer cues that direct therapy to important needs.  Ignoring or attempting to suppress emotion, including anger is difficult and also dismissive.  A major paradigm shift is changing identification of the anger of the individual with borderline personality disorder from inherently dysfunctional or "bad," to seeing anger as honorable energy for serving survival that unfortunately has expressed dysfunctionally.  The anger is not dysfunction per se, but its expression may be dysfunctional.  Frieda getting angry is not the problem, but what she says and how she behaves when angry is the problem.  If the therapist or partner notices an emotional reaction that is disproportionate to the specific and current situation, then historical distresses or traumas or a borderline personality disorder may be likely causes.

Everyone gets angry at times.  Getting angry is the most natural thing in some situations.  Anger is a normal, healthy, and positive energy, if properly expressed.  Anger empowers the individual to take the risks that would otherwise be too fearful to consider.  Anger gives the individual the energy to challenge things that require challenging in order to take care of oneself.  Confrontation has danger for the individual with borderline personality disorder as he or she has learned from a lifetime of negative experiences.  Anger often gives the individual the energy to confront danger to seek justice or security. If the therapist or the partner tells a person, "Don't be so angry!  I don't see why you are so angry!" he or she is disabled from the energy and courage to fight for self-preservation.  It is more appropriate to acknowledge the anger coming from some righteous feeling, while simultaneously challenging and redirecting any inappropriate behavior.  This becomes a major paradigm shift from the anger being dysfunctional by default to anger being a poorly utilized tool for self-care.  Therapy then can teach appropriate use of anger for effective self-care.

Therapy that only focuses on managing the behavior or dealing with the repercussions of the borderline behavior does not deal with underlying anger.  If not addressed, the underlying anger and core desperation will almost certainly express in further problematic behavior that will challenge the partner and the therapist.  Anger is often normally not the primary emotion, but the secondary emotion.  Before anger, are underlying emotions that seek self-preservation, increased security, and nurturing.  In other words, before the powerful active secondary emotion of anger, there is a primary vulnerable emotion.  "…anger seems to follow a dynamic different from anxiety or sadness.  According to our results, BPD subjects perceive anger predominantly in succession to anxiety.  This result leads to the conclusion that psychotherapists and patients need to analyze carefully situations evoking anger and to watch out for preceding situations evoking anxiety.  Such an understanding of the emotional dynamic may help the individual patient to avoid anger-related dysfunctional behaviour (Reisch, 2008, page 47).  Unfortunately, the resulting borderline behavior can be highly problematic and destructive for everyone.  Such behavior can be so sensational, that it automatically draws everyone's attention.  Behavior has a precedent in the anger of the childhood transgressors.  Moreover, the anger can have emotional precedents.

Offering alternative behavior without eliminating or preventing the negative behavior will not work.  As long as the original negative behavior is an option for the individual with borderline personality disorder, he or she will not be receptive to learning a new behavior.  Or, if a specific negative behavior is stopped, it may be replaced by another negative behavior to satisfy still existing needs.  The individual with borderline personality disorder will not shift to a new alternative behavior if it does not serve the underlying motivation.  A different and potentially more fruitful approach may be not to try to stop the rage, but to re-direct or guide it into more productive behaviors that serve the underlying motivation.  Enraged behavior is reframed from just negative actions to behavior that seeks to serve important needs.   Behavior then is evaluated as being functional, slightly less dysfunctional, to exceedingly dysfunctional in meeting the individual's needs.  Therapy promotes behavior to slightly to significantly mitigate dysfunctionality in the couple, the partner's negative reaction, and the negative sense of self of the individual with borderline personality disorder.  Frieda, as an individual with borderline personality disorder instead of being told not to be so angry, is encouraged to find appropriate expression of anger: verbalizing, writing, problem solving, negotiation, and so forth.

SURVIVE and FLOURISH
"BPD patients in comparison with HCs (healthy controls) get stuck in anxiety and sadness, pointing to the phenomenon that BPD subjects get trapped in these emotions" (Reisch, 2008, page 46).  The sense of being stuck or doomed to the borderline existence and borderline characteristics causes the individual, his or her partner, and the therapist to fantasize a magical remedy (such as therapy) to break out of the trap.  Rather than quick and dramatic change, an incremental orientation of descending or lessening severity may be the most effective approach with the individual and certain situations.  Neither the therapist nor the couple ordinarily wants a disagreement or misunderstanding to be followed with intense hurtful words.  However, it may be desirable incremental change for the argument to be followed with hurtful words, rather than by a long period of silent resentment, with flying dishes, or an alcoholic binge.  Stomping feet and yelling is much better than stomping each other!  With a successful transition to silence instead of throwing dishes or drinking, then the individual with borderline personality disorder can be further directed for more incremental change.  He or she is prompted to verbalize with intensity but without yelling and threats—"I really don't like what you did!  Don't do it again!"  A next step would be verbalizing with lower intensity, and more overt problem-solving attempts.  And, so on and so forth.  Of course, the partner and the therapist want to move an individual (as a teacher or parent wishes to move a child) directly to the most civilized process.  However, for the individual with borderline personality disorder, a gradual incremental process may be much more realistic.  In lieu of a drama change from to productive processes, a gradual shift to slightly less destructive processes may allow for progressive growth.  The individual can gradually increase his or her ability to tolerate stress, frustration, failure, and suffering with practice.  The partner can make step-by-step gains in sensitivity, support, skills, and strength.  The therapist should orient change and growth from the more severe and inappropriate (insulting and cursing) to the less severe and still inappropriate (snide remarks and the silent treatment), and eventually to the appropriate (calm communication).

The individual with borderline personality disorder able to be stressed, frustrated, fail, and suffer when sensitively supported develops skills and strength to tolerate his or her existential borderline terror.  Someone such as Frieda must discover that he or she can survive the struggle against betrayal, abandonment, and rejection fears.  He or she finds that surviving the uncertainty and turmoil of building intimacy and trust with the partner is possible.  As the individual with borderline personality disorder gains greater confidence and experience surviving suffering, the couple evolves simultaneously.  In the couple, the partners may find a realistic gradual transition to be tangible indications to support hope for change together.  As the partners such as Frieda and Cliff change over time, they gain a sense that they can survive their emotional drama.  Mutually stressed, frustrated, failing, suffering, but given sensitive support from a skillful therapist like Selena and from each other, the partners develop skills and strength to continue trying.  They begin to believe that they can survive the process of growth and change, including the difficulty of couple therapy.  And once, the partners gain the sense that they can survive the process, then they may begin to hope that they can also be able to flourish as a couple.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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