2. Insight,Holding,DialecticalBeh Ther - 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 2: INSIGHT-ORIENTED, HOLDING, & DIALECTICAL BEHAVOR THERAPY


In individual therapy with the individual with borderline personality disorder, the therapist often eventually becomes the betrayer who is "punished" by canceled appointments, no shows, etc.  Some therapists recommend remaining as consistent, accepting, and nurturing as possible, letting the client work through the transference with the therapists.  These, however, are often the same therapists that say the individual with borderline personality disorder drives them crazy!  Johnson (1991) described three orientations for working with the individual with borderline personality disorder: insight-oriented counseling, therapy that provides a supportive holding environment, and dialectical behavior therapy (DBT).  "Proponents of insight-oriented individual counseling believe that the therapist should interpret the client's behavior and feelings early in the treatment process (Kernberg, 1975; Masterson, 1981).  This approach is derived from a theory that borderline pathology arises from malformed psychic structures that require undoing (Waldinger, 1987)" (page 168).  The therapist may find that interpretations offering insight to the underlying motivations for behaviors can be highly transformative for some individuals.  With understanding of family-of-origin experiences, cultural training, and neurosis-inducing stresses, the individual may be able to cognitively, emotionally, and finally behaviorally interrupt previously dysfunctional choices and actions.  Or, the partner of the individual with borderline personality disorder may be able to empathize, judge him or her less harshly, react less negatively, and help the individual reality check and then change behavior.  This process works well for emotions, schemas, and behaviors that are not deeply embedded in the psychic fabric of the individual.  However, the individual with borderline personality disorder can have very good insight to the origins of his or her sensitivity, reactive emotions, and dysfunctional behaviors, but remain unable to alter behaviors to be more functional in relationships.  Frieda is one such individual who may be able to diagnose him or herself with borderline personality disorder (especially, if experienced in therapy) or describe his or her dysfunctional process very accurately, including how he or she unfairly lashes out against the partner regularly.  Unfortunately, Frieda's hypersensitivity and quick and intense reactivity override insight and borderline behaviors explode upon the partner Cliff or the therapist nevertheless.  If insight works well, it may be because the individual does not have borderline personality disorder or has less intense borderline tendencies.  He or she may be emotionally high strung and temperamentally intense but without early attachment injuries.  Thus, acquiring insight may be sufficient to promote change.
 
"Other theorists advocate for the creation of a holding environment rather than interpretation (Buiie & Adler, 1982; Chessick, 1982; Volkan, 1986).  According to this view, borderline pathology is not caused by malformed psychic structures but rather by a deficit in the ability to hold or soothe oneself, arising from early developmental failure.  According to the deficit view, the therapist must be a 'holding self-object' (Kohut, 1978), which means that the therapist must perform the holding and soothing functions for the borderline patients that they cannot perform for themselves (Waldinger, 1987)… the therapist must function in reality as a stable holding person" (Johnson, 1991, page 168-69).  Chessick (1979) described the atmosphere for the individual with borderline personality disorder in therapy as "good enough holding."  The salient points are:

1. A consistent and frequent being at the service of the patient, at a time arranged to suit mutual convenience.

2. Being reliably there, usually on time.

3. For a contracted-for period, keeping awake and becoming professionally preoccupied with the patient and nothing else (such as telephone calls, tape recorders, etc.)

4. The expression of love by the positive interest taken and "hate" (as Winnicott sees it) in the strict start and finish and in the matter of fees.

communicate this understanding by interpretation.

6. Use of a method stressing a nonanxious approach of objective observation and scientific study, with a sense of physicianly vocation.

7. Work done in a room that is quiet and not liable to sudden unpredictable sounds and yet not dead quiet; proper lighting of a room, not by a light staring in the face and not a variable light.

8. Keeping out of the relationship both moral judgment as well as any uncontrollable need on the part of the therapist to introduce details of his personal life and ideas.

9. Staying, on the whole, free from temper tantrums, free from compulsive falling in love, and so on, and in general being neither hostile and retaliatory nor exploitative toward the patient.

10. Maintaining a consistent, clear distinction between fact and fantasy, so that the therapist is not hurt or offended by an aggressive dream or fantasy; in general eliminating any "talion reaction" and insuring that both the therapist and the patient consistently survive their interaction.

Winnicott feels that this setting reproduces the earliest mothering techniques and invites regression.  If it is consistently offered. An "unfreezing of introjects" takes place as a natural consequence of the regression that occurs (page 536-37).
Chessick believes these guidelines essentially require the therapist functioning as a stable mature individual that is realistically dedicated to therapy.  Johnson (1991) cites Waldinger (1987) as recommending support would include hospitalization, extra therapy sessions, and phone conversations between sessions, availability and contact with the therapist when he or she is away (including vacations and off-hours).  A person who seeks out therapy individually or in a couple may be characterized as someone who has problems with boundaries.  The boundaries may be too rigid and block out needed or desired intimacy, communication, and mutuality.  Or, the boundaries are too diffuse such that emotional, spiritual, intellectual, physical, sexual, and psychological intrusions contaminate autonomy.  Or, boundaries are inconsistent and unpredictable resulting in pervasive anxiety.  Or, all three problems with boundaries manifest at different times.  The lack of consistent boundaries that allow for intimacy and other positive connections while also keeping out harmful factors make life and relationships difficult and unfulfilling.  Therapy therefore may be conceptualized as helping the individual (and the couple) develop healthy and appropriate boundaries.

Without significant qualification, the holding environment theory and strategy may promote rather than eliminate poor boundaries.  Therapy that mandates that the therapist function as the stable holding person for the individual with borderline personality disorder appear to require that the therapist give up consistent personal and professional boundaries.  Erratic demands for a perfect holding environment would require the therapist to provide diffuse boundaries or no boundaries for the individual.  Such advice for a parent would be considered tantamount to asking the parent to spoil the child.  The 100% availability implied by a purist holding philosophy confirms to the individual that he or she cannot suffer and survive on his or her own… that the individual cannot provide his or her own holding container.  The therapist who tries to provide the individual such as Frieda a perfect holding environment will experience violations of his or her boundaries and likely develop resentment towards the individual- both consequences that arose for Selena as Frieda's couple therapist.  In reaction to an impossible and fruitless therapeutic and a personally destructive strategy, Selena like many therapists working with a borderline resort or am tempted to setting harsh and punitive boundaries (including termination) and/or personal and professional guilt.

Dialectical behavior therapy offers guidance that may assist the therapist in balancing the borderline demands.  DBT "combines intensive behaviorally oriented psychotherapy with psychoeducational group treatment (Linehan, 1987).  DBT has shown considerable promise in reducing borderline clients' self-destructive behavior (Linehan et al., 1989).  This variant of behavior therapy is dialectical because it deals with multiple tensions, notably the necessity of accepting clients for what they are while attempting to try to teach them to change (Linehan, 1987).  The treatment is approach is behavioral because it focuses on skills training, collaborative problem solving, contingency clarification, and management, and the observable present (Linehan, 1987).  It is directive and intervention oriented" (Johnson, 1991, page 169).  The therapist consistently verbalizes empathy for the individual's intense pain and desperation.  This creates a validating therapeutic environment while accepting existence of the individual's self-destructive behaviors without judgment or surprise.  In an article in the New York Times (Carey, 2011) Linehan, the founder of DBT revealed that her own process of healing from the desperation of her younger years (including being diagnosed with borderline personality disorder) came from being able to accept herself as she was.  "She had tried to kill herself so many times because the gulf between the person she wanted to be and the person she was left her desperate, hopeless, deeply homesick for a life she would never know. That gulf was real, and unbridgeable."

From disliking and hating herself, she came to accept herself totally: her feelings, thoughts, and behaviors.  Radical acceptance was accompanied or followed by believing that real change is possible.  Behaviorism asserts that the individual can learn new behaviors, "and that acting differently can in time alter underlying emotions from the top down."  Rather than working from a theoretical stance that change in cognition, awareness, or emotions lead to change in behavior, therapy can work on change in behavior that lead to change in cognition, awareness, or emotions.  Acceptance of oneself and of behaviors intrinsic to oneself does not condone them as welcome or viable- nor does it mean accepting behaviors as permanent.  Instead, dysfunctional behaviors are revealed and named as the individual's attempts to problem-solve extraordinary stress.  Therapy works from "two seemingly opposed principles that could form the basis of a treatment: acceptance of life as it is, not as it is supposed to be; and the need to change, despite that reality and because of it."  The inefficiency and ineffectiveness of the behaviors to actually manage life demands is noted to direct the individual towards developing better strategies.  The therapist actively teach:

Emotion regulation,

Interpersonal effectiveness,

Distress tolerance, and

Self-management skills.

The therapist specifically supports positive behaviors for emotional and functional stability.  In contrast to a pure holding environment (which Selena, for example could not sustain with Frieda), the therapist establishes clear boundaries regarding availability outside of regular appointments.  In anticipation of continued self-destructive behavior, the therapist establishes contingency plans to promote positive behaviors and eliminate self-destructive behaviors.  DBT "emphasizes building and maintaining a positive, interpersonal, collaborative relationship in which the… role is that of consultant to the client" (page 169). The individual with borderline personality disorder often stays in crisis and thus, stays focused on immediate issues.  DBT augments individual therapy by utilizing group treatment to teach specific behavioral, cognitive, and emotional skills that are not obvious to the individual as relevant to a current crisis.  DBT is currently considered among the most effective- if not most effect therapy for helping the individual with borderline personality disorder.  Its basic principles and strategies may be applicable to couple therapy that includes the individual with borderline personality disorder.  Therapist-client and group process-client goals offer guidance for couple therapy. In couple therapy, using the therapist and couple as a three-person group to teach important relationship skills can duplicate the function of DBT GROUP treatment.   The mini-group of the two members of the couple with or without the therapist can provide feedback to the individual.  The couple can be trained to be the individual's group treatment at home, if the individual with borderline personality disorder empowers the partner in such a role.

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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