16. Therapist Vulnerabilities - 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 16: THERAPIST VULNERABILITIES


A person's normal reactions to the individual's behavior theoretically, for the therapist become counter-transference to be used in the therapy.  "Many borderline patients will generate strong negative countertransference reactions in clinicians, which can lead in turn to a style of care where patients find themselves bound by restrictive 'limit-setting' agreements that are as much about protecting the clinician as about treating the patient" (Smith et al., 2004, page 137).  Otherwise effective and common therapeutic interventions or benign comments can elicit vengeful behavior from the individual.  It becomes critical for the therapist to re-conceptualize the individual and reframe borderline personality disorder in a way that the therapist's reactivity is not ignited to the detriment of the process.  The therapist's response to "intrusive, threatening or abusive behaviour can vary greatly.  Fear, anxiety, rage, hate and shame may be experienced accompanied by a desire to avoid, flee, control, reject or punish the patient" (Pollock, 2001, page 218).  The therapist may set strict and punitive boundaries as if the individual were an adversary or even the enemy, as opposed to being the client-in-need.  This becomes counter-therapeutic as such response mirrors the individual's historical experiences of betrayal, abandonment, and rejection, and confirms his or her negative life schemas.  The therapist needs to own his or her instinctive reactions rather than denying the effect of the threats, rationalizing, or otherwise act in ways that compromise sound therapeutic decisions.  "It is essential that therapists feel equipped to understand and conceptualize what is being enacted within the therapeutic frame and space, avoid the allure of colluding unwittingly with transference patterns emerging and employ pertinent therapeutic strategies that will contain and regulate potential ruptures of the therapist-to patient relationship" (Pollock, 2001, page 218).  When therapy includes the individual with borderline personality disorder, the therapist needs to own and recognize his or her surprise, hurt, anger, and resentment as the normal response to borderline assaults.

Successful therapy often depends on the therapist's ability to initially accept and honor the individual's behavior in order to form a therapeutic alliance.  Acceptance and honoring however differ from condoning any problematic behavior.  Although the individual may complain incessantly, bounce checks, cancel appointments late or no show occasionally, or criticize the therapist of abusive behavior, he or she may alternately come on time or be early for sessions, be vigilant about attending every session, and religiously comply with the therapeutic contract.  The different responses depend on how well the therapeutic alliance is working.  Negative non-compliant, defiant, or rebellious behavior "indicates that the working alliance is failing and represents an emergency situation in the treatment which must be attended to before any other interpretive work"  (Chessick, 1979, page 537).  It may be appropriate that therapy that includes the individual with borderline personality disorder is always in an emergency!  This reflects the existential experience of the individual that he or he is perpetually in crisis with imminent betrayal, abandonment, and rejection by important people, be it the partner or in therapy, the therapist.

The therapist may conceptualize therapy or the therapeutic environment as a safe, secure, and nurturing environment for clients in an otherwise hostile world.  The therapist may attempt to soothe the individual's distress.  Many clients welcome and thrive in such a holding environment.  However, for the individual with borderline personality disorder there is no such safe, secure, and nurturing environment.  He or she brings an intrinsic fundamental sense of psychic danger everywhere no matter what anyone does to create sane and caring relationship containers.  Within the caring therapeutic container, the therapist may offer insight about the individual's process.  However the therapist needs to take care since, "interpretive interventions with the borderline individual tend to resonate with the projection of the RORU (rewarding object relations unit), exerting a regressive, infantilizing, enabling effect and offering `insight as excuse' for continued failures to behave adaptively.  That is, the explanatory or genetic interpretation is likely to be experienced by borderline patients as an affirmation of their helplessness and their felt need for help from others" (Roberts, 1997, page 235).

Creating a therapeutic rapport with the individual with borderline personality disorder "as with all patients- is definitely not formed by some kind of deliberately seductive gracious, giving, or charitable behavior by the therapist.  Coaxing, urging, persuading, or seducing patients into forming a therapeutic alliance is always antitherapeutic and generates the demand for more and more primary-process behavior; it damages the patient's autonomy and renders him dependent forever on the gratification being offered by the therapist.  When the time comes that such gratification is withdrawn the consequences may prove disastrous to the therapist as well as to the patient.  Therapists with a need to coax, persuade, and seduce intensive-psychotherapy patients are simply manifesting gross countertransference" (Chessick, 1979, page 535-36).  The therapist cannot provide the soothing that the individual with borderline personality disorder needs.  Inevitably, the individual will be alone, feel lonely, become desperate, and become likely to make poor choices and act out.  The individual will resent the therapist or the partner who has promised or implied that he or she will "always be there" or act to restore and re-stabilize the individual.  The therapist or partner will inevitably fail, thus repeating the betrayal, abandonment, and rejection experience.

The relationship between the therapist and the individual should not be based on a condescending stance in either direction.  The therapist should not "buy" rapport by acquiescing to the individual's emotionally stunted or immature requirements.  The therapist should also not dominate the individual as an authoritarian parental figure.  While the therapist may take an authoritative role- leadership as a wise and experienced but sensitive facilitator, the relationship must be essentially adult, rational, and a partnership.  Merely gratifying intense but dysfunctional needs will not serve the development of the individual or the couple's growth.  Gratifying any narcissistic needs of the therapist will also not serve the individual or the couple.  "Obviously treatment of such patients requires considerable tact and rests on a thorough working through in the personal psychotherapy of the therapist of his own narcissistic problems.  Thus, the unanalyzed acting out, angry, or narcissistic therapist… soon stirs up a veritable storm of trouble and emotion in borderline patients" (Chessick, 1979, page 537-38).  The dynamics of therapy will be practice and a model for the real life of the individual and couple, but the "clear emphasis is that rewards come to the patient as a consequence of his maturation and enhanced capacity to achieve gratification in interpersonal relations with people outside of the therapy.  Indeed, the ultimate test of any psychotherapy is the evidence of the patient's increasing capacity for reason, love, and productive work as well as an improved sense of the joy of living" (Chessick, 1979, page 536).

The therapist can get caught up focusing on the harmony of therapist-client relationship as a goal within itself.  How well the individual with borderline personality gets along with the therapist is not the goal of therapy!  The goal is the intrapsychic well being of the individual and healthy functioning with his or her partner.  The therapist needs to be willing to risk disharmony- in fact, to lose harmony in order to provoke the growth of the individual and of the couple.  Change and growth requires and includes getting into conflict in therapy (rather than avoiding conflict) and working through it successfully.  This provides the practice and model to get into conflict outside of therapy in life and working through it successfully.  The therapist must realize that despite hopefully providing personal and professional wisdom and actions, those experiences will not enable the individual to transcend him or herself.  The quality of the therapist also will not enable the individual to transcend his or her borderline personality disorder.  He or she will interact and react to the therapist as he or she has reacted to other intimate persons, including getting into borderline induced conflict.  The therapist who fails to realize this and does not structure therapy for dealing with inevitable borderline behaviors will fail the individual and the couple.

THERAPIST-CLIENT RAPPORT
The therapist needs to be aware of differences in the therapist-client relationship in working with the individual with borderline personality disorder alone or in couple therapy.  "With the more neurotic client a sense of mutuality about the aims and value of the counseling can develop.  The counselor can rely on the work being a shared enterprise when the going gets tough.  Consequently, the ability of the client to cooperate in the work means that acting out by the client is likely to be limited and recoverable.  But all of this presupposes the client's ability to negotiate the degree of involvement with the counselor, to be affected without feeling taken over or invaded, or to feel separate without feeling abandoned and discarded (Spurling, 2003, page 28-29).  The therapist needs to be aware that the therapeutic assumption of mutual investment and trust may be fundamentally missing with the individual with borderline personality disorder.  While the individual seems to agree with clinical interpretations and cooperate with therapeutic guidance, the compliance may be compelled from fear of abandonment by the therapist for failing to agree or cooperate.  "Where more genuine contact is made, this is likely to provoke fear and hatred in the client, fear of the counselor getting inside and taking over and hatred of the counselor for being separate and not available all the time."  These are the same experiences that the partner has: apparent agreement and compliance hiding deep resentment, and closeness igniting fear and anger.  Therapy just like the intimate couple's relationship becomes much more complex.  The therapeutic rapport or relationship, which is foundational to most theoretical processes may not become securely stable for a long time- if ever.

Other clients may experience uncertainty about the therapist as normal transference to be worked through.  "With the borderline or psychotic clients the danger is that the transference will lose its symbolic, or 'as if' quality, and be experienced by the client as real.  A transference psychosis will develop involving a breakdown of ego boundaries and a loss of reality testing in a previously non-psychotic client.  This confusion between fantasy and reality is a feature of the transference with any client.  But with the neurotic client it is likely to be a transient and partial experience, whereas for someone functioning at a borderline level this quality of the transference can become its dominant and overwhelming feature" (Spurling, 2003, page 29).  The partner has already experienced unreal and distorted perception in the eyes of the individual with borderline personality disorder.  The therapist will wonder who and what the individual has seen and experienced from the therapist's actions to justify such high negative intensity.  Reality checking or reassurance works effectively for a neurotic client who is not as invested or not terrified with the negative projective assertions of the individual with borderline personality disorder.  Invoking the boundaries of the therapeutic relationship enables the therapist to challenge neurotic misinterpretations.  This tends to aid the therapy immensely.  However, with the individual with borderline personality, the inability to sustain a stable healthy intimate relationship can be seen as his or her essential disability.  Thus the foundation of therapy available with most other clients- establishing and maintaining an intimate and trusting relationship (therapeutic rapport) is extremely difficult to form for the individual.  Borderline anxiety makes such rapport for the individual ordinarily almost impossible to achieve with anyone.

THERAPIST AS BETRAYER
The therapist takes on a special and critical role in the life journey of the individual or couple.  "In a crisis individuals, of any age, can make attachments to strangers who are perceived as more capable of solving the problem, or stronger and wiser.  Therapists can be seen in this way and so can provide a temporary secure base within therapy that enables clients to explore new solutions to their problems" (Byng-Hall, 2001, page 31).  The therapist may be seen less as a helper and more of a savior.  He or she is to somehow create a safe and secure foundation for each member to become healthy and skilled internally and interpersonally.  "The very nature of the benevolent, attentive and unconditional relationship with another human being cultivated within the therapeutic situation represents the substrate for potential unrequited affection between patient and therapist.  Discrepancies in perceptions of the shared intimacy can, of course, occur in either direction or in a dysfunctional reciprocal fashion.  Therapist and patient are comparatively vulnerable to each other and a complex variety of interactions are often exhibited.  Thoughtful clinical analysis and conceptualization of the nature of the emerging emotional attachment is necessary to avoid stagnation, rupture or even dissolution of the relationship entirely" (Pollock, 2001, page 215).  The intensity of intimacy between the individual and the therapist can duplicate the romantic relationship in the parent-child dyad and the couple's relationship.  The therapist must carefully manage his or her counter-transference dealing with possible adulation.  "The patient clings to the therapist or the therapy as a kind of magical protection and security against the hardships of the external world" (Chessick, 1979, page 539).  The individual may have the habit of projecting onto significant others (in particular, a cross-gender projection by a heterosexual individual)- in this case, the therapist the capacity and responsibility to be emotionally rewarding.

"Borderline patients recreate the early archaic awareness of the omnipotent caring object in their transference.  The therapist, like the mother of symbiosis, is called upon to provide the structure and substance of the patient's sense of self.  When the patient experiences an actualization of this 'we-self,' self and object are fused and share a common omnipotence (silently).  When the patient, however, feels uncared for or uncompleted in psychotherapy, the early differentiation experience is revived and the therapist is imbued with powerful ominpotentialities.  Assumptions about the therapist's omnipotence may surface through the borderline patient's extreme 'intolerance' of mistakes on the therapist's part, or a conviction that the therapist never errs" (McGlashan, 1983, page 51).  The individual may believe the therapist understands his or her deeper feelings and thinking whether it is expressed or not.  He or she may think everything the therapist says has some deep purpose or hidden message for control or manipulation.  As a result, the individual becomes angered and accusatory over any perceived slight or misunderstanding.  On the other hand, the individual may seek acceptance by being overly compliant to the point of being against his or her self-interests.  With extensive deference, the individual may tolerate or excuse abusive treatment from the intimate other.  Or, interpret the therapist's behavior as abusive, while minimizing how hurt he or she feels and simultaneously accruing resentment.  As the individual begins to benefit from confrontation and adapt to healthier behaviors, intense fear of abandonment can revive.  The individual's fear that self-care in the intimate relationship will cause the partner to reject him or her, and clinging and compliant behaviors may increase.  The therapist needs to anticipate this regressed reaction to tentative growth.  The therapist should be prepared as a therapist within therapy and prepare the individual and the partner to reassert productive processes.

The therapist should monitor the individual's transference for aggressive versus passive or compliant borderline reactions.  The powerful role of the therapist and the attachment injuries of the individual make for an intense relationship and also for intense reactions.  The "nature of the involvement can range from appropriate dependency to benign infatuation to morbid or obsessional emotional engagement" (Pollock, 2001, page 215).  Obsessional emotional engagement can lead to threatening behaviors, undesired contact and stalking, and in extreme cases shift from emotional over-involvement to overtly physical violent behavior.  The individual may compulsively act out with or without cognitive awareness of his or her emotional triggering and the dysfunctionality of his or her behavior.  "A preoccupied attachment pattern and borderline personality organization allied to social incompetence, loneliness and isolation are further markers for the development of erotomanic behaviour.  Evans et al. (1982) proposed that erotomania could be conceived as a variant of abnormal or pathological mourning for the lost object" and Goldberg (1994) conceptualized erotomania as an expression of 'lovesickness'.  The sufferer yearns for and fails to mourn for the lost object, denial impinging upon reality testing, often displaying 'paradoxical conduct' (Segal, 1989) by interpreting disavowal of any emotional bond by the object (no matter how strongly conveyed) to be secret affirmation of love designed to 'test' the patient's perseverance" (page 217).

The loved therapist becomes the hated persecuting intimate.  Positive engagement becomes angry, hostile and the individual acts out victimization.  The abrupt change in how the therapist is seen as a betrayer represents "the defensive process of splitting and a reflection of idealization and devaluation of the same object" (page 218).  The individual with borderline personality disorder loses control frequently at home and does this to the partner and corrupts, if not destroy the relationship.  The therapist needs to anticipate and plan for individual losing control and/or becoming hostile and punitive in therapy and with the partner.  A major therapeutic and theoretical error comes from the therapist assuming immunity from the borderline projections.  That is virtually identical to the mistake the partner makes thinking he or she can "love" the individual into change.  Since it would not be a surprise for the individual with borderline personality disorder to run away (terminate therapy) or punish the therapist (missed appointments, bounced checks, etc.) when hurt, sound therapy prepares for such inevitable behavior.  In couple therapy, the therapist has the advantage of collaborating with the partner on how to handle the borderline acting out against the therapy.

In general, as a client feels out of control or the couple or family is coming apart, therapy is initiated and the therapist is enlisted to arrest decay and fix everything.  There is a conscious awareness of being out of control.  The theme or schema of helplessness or being the victim results in self-harming choices and failure to care for oneself.  The individual may not only act helpless but also assert to the therapist that he or she is helpless in therapy.  Therapy may be conceptualized as empowering a person, couple, or family to become more in control, more productive, and healthier.  Assertion of inability, lack of control, and hopelessness are antithetical to the core principles of therapy.  The therapist is there to help, and the clients must accept help… must be helped!  Sometimes, the individual with borderline personality disorder may not be sufficiently self-aware to know he or she is or has gotten out of control.  The individual may become passive in therapy- for example, being late or missing appointments.  He or she may offer a litany of excuses why he or she has avoided or cannot activate positive behaviors. If the therapist confronts the victim stance as dysfunctional "early in treatment such an intervention might be expected to elicit the patient's protestations of the therapist's failure to appreciate his/her plight and accusations of coldness and uncaring on the part of the therapist"(Roberts, 1997, page 235).

The essence of many therapeutic approaches often requires the confronting the individual's, the partner's, the couple's, or the family's problematic personal perceptions, thinking, and behavior in therapy.  Through confrontation, the client may identify and then alter or stop dysfunctional behavior, leading to happier and more fulfilling life and relationships.  The specific problematic behavior of acting out against the therapist should be anticipated and named at the beginning of therapy, with a contract for confrontation and discussion once it arises.  The theoretical framework to the couple is that confrontation of therapeutic acting out is critical to successful therapy.  When the therapist confronts a problematic choice or behavior, the client may examine or re-examine values and expectations that had been assumed to be sacrosanct.  Upon closer inspection the client or couple may realize how some values and expectations disserve success and inhibit growth.  With insight of personal and couple's processes and for outcomes gained from therapist confrontation, the individual or couple makes changes or adjustments.  The therapeutic process is empowered by client acceptance and trust of the therapist's confrontation coming from good will and integrity.

Confrontation of the individual with borderline personality disorder is likely to ignite his or her betrayal, abandonment, and rejection fears.  "It has been demonstrated clinically that borderline patients will in time accept and integrate a confrontation, demonstrated by recognition of the self-destructiveness of the defence, its consequent containment, and the emergence of genuine self-activation and autonomous activity.  However, it is precisely such self-activation and autonomy, which will evoke the abandonment depression and separation anxiety, necessitating the re-activation of the alliance with the pathological ego and the use again of the maladaptive defences (the disorders of the self triad).  In this way, effective psychotherapy results in a cyclical process in which confrontation of self-defeating defences frees the real self for expression and autonomous action, which, in turn, stimulates the abandonment depression and its related affects.  Defences against this affective experience are then re-mobilized, this requiring additional confrontation, containment of defences, further self-activation, deepened affect, and so on (Masterson, 1976, pp. 63-65; 1981, pp. 150-152).  This cyclical process leads to the client's enhanced capacity to contain maladaptive defences, to utilize more adaptive defences to manage the underlying anxiety and depression, and, in some instances, to work through the abandonment depression with intrapsychic restructuralization" (Roberts, 1997, page 235-36).  In the couple that eventually breaks down, the individual usually has a partner who gets caught up in his or her maladaptive defences.  The partner is unable to encourage more adaptive ways to deal with embedded anxiety and depression.  The partner, who attempts to confront the individual's reactive emotions and behaviors as unproductive and damaging, is seen as an abandoning and rejecting betrayer. The therapist supporting the partner's perspective more effectively reinforces confrontation of the individual.  Therapy must facilitate the individual being able to work through his or her intense reactive emotions, become less defensive-aggressive, and make better choices.  The therapist needs to be ready for the individual experiencing this process as making him or her "wrong."

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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