8. ExperientialTrinity-ResponseTrinity - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Therapist Resources > Therapy Books > Ouch Borderline in Couples

Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy
Chapter 8: EXPERIENTIAL TRINITY & RESPONSE TRINITY


The therapist may misdiagnosis the individual with borderline personality disorder for a variety of reasons.  The therapist may be theoretically averse to diagnostic labels without having sufficient sophistication to understand and respond clinically non-diagnostically.  When the individual presents in couple therapy, the therapist may formulate his or her theoretical assessment and treatment in terms of a variety of couple therapy orientations.  This may not adequately incorporate understanding for differential treatment when there is an individual with borderline personality disorder in the couple.  Diagnosis may focus on the couple's dynamics, implicit or explicit models of healthy relationships, improved communication between partners, or improving cognitive processing and reducing emotional reactivity, without diagnosis of member's emotional, attachment, or psychological functioning for potential problems or disorders.  The therapist may not recognize the individual's presentation as indicative of borderline personality disorder or borderline tendencies.  "The patient often presents with a diffuse, depressed affect.  The source of his affect is often a mystery to the therapist until typical marital behavior and interactions are examined.  Often, intrapsychic dynamics in the patient are explored in futile attempt to explain symptoms apart from the dyadic relationship.  It may only gradually become apparent that the symptoms are reactive in nature and an attempt to cope with an individual who vacillates between perceiving the spouse as a idealized object versus a bad, devalued object."  The partner may wonder if he or she causes the negative behavior.  "Self-doubt and recrimination are prevalent..."  (Weddige, 1986, page 55-56).  The partner may believe he or she has responded and changed significantly to better meet the individual's needs only to be slaughtered in an unexpected burst of rage for some perceived transgression.  The partner who is not clinically knowledgeable may continue to blame him or herself.  This is no surprise since the individual has often relentlessly blamed the partner for the problems.  A diagnosis of borderline personality disorder may relieve everyone's confusion.  The therapist may use a formal diagnosis and identify the borderline personality disorder.  Or, the therapist may explain that he or she recognizes a characteristic syndrome of behaviors that imply certain origins and point to various strategies for change.

B-A-R: BETRAYAL, ABANDONMENT, & REJECTION
The therapist may be initially alerted to the possibility of borderline personality disorder or borderline tendencies by recognizing a simplified borderline emotional and behavior diagnostic pattern.  The pattern is noted with the mnemonic, B-A-R which stands for "betrayal, abandonment, and rejection."  These three emotional/cognitive experiences comprise the experiential trinity of the individual with borderline personality disorder.  Fear of being abandoned and thus, of being alone can be overwhelming.  "Several clinical theorists have posited intolerance of aloneness as a defining characteristic for BPD that provides coherence to the DSM's descriptive criteria.  Gunderson subsequently suggested that this intolerance reflects early attachment failures, noting that individuals with BPD are unable to invoke a 'soothing introject' in times of distress because of inconsistent and unstable attachments to early caregivers or, in Bowlby's terms, because of insecure attachment.  Gunderson observed that descriptions of certain insecure patterns of attachment—specifically, pleas for attention and help, clinging, and checking for proximity that often alternate with a denial of, and fearfulness about, dependency needs—closely parallel the behavior of borderline patients" (Agrawal et al., 2003, page 95).  In addition, "Downey and Feldman's (1996) description of the rejection-sensitive individual fits well with the preoccupied prototype. The rejection-sensitive is hypervigilant to rejection, exaggerate partners' dissatisfaction and lack of commitment, and behave in ways that are counterproductive to healthy relationship functioning. In a study of undergraduates, these researchers found that rejection sensitive women reacted to perceived partner rejection with hostility and withdrawal of emotional support, whereas rejection sensitive men reacted with jealousy and controlling behaviors. Such social construals and reactions may facilitate and maintain mutually destructive interpersonal dynamics. Consistent with this hypothesis, rejection sensitive men who were highly invested in intimate relationships showed an increased risk of partner violence (Downey et al., 2000)" (Henderson et al, 2005, page 227).

Relevant insecure attachment styles leading to borderline personality disorder also reflect the betrayal, abandonment, and rejection trinity.  "The fearful pattern concerns development of a negative self-worth, chronic anxiety about rejection and abandonment, affective instability and intimacy anger (Dutton et al., 1994). The individual is caught between pervasive distrust of others and a desire for intimacy coupled with an extreme sensitivity to rejection and chronic frustration of attachment needs. The fearfully attached individual vacillates between care seeking and self-reliance without resolution to this dilemma. The preoccupied attachment pattern refers to an individual with a negative self-image who seeks approval and validation from idealized others. This pattern is also associated with high intimacy anger and features of borderline personality organization, including unstable affects, denial, idealization/devaluation, projective identification and obsessional thinking…" (Pollock, 2001, page 216).  The therapist should be alerted when hearing the individual describe his or her relationship (current and/or past) by reciting how the partner has time after time betrayed, abandoned, and rejected him or her (which occurred almost weekly with Frieda about Cliff).  The complaint pattern reflects how the individual with borderline personality disorder experiences his or her life of relationships.  For each of the experiential trinity, there will be characteristic complaints made about the partner to the therapist, the partner, and anyone else willing (unwillingly!) to hear.

Betrayal:

That the individual's partner did not fulfill expectations, including ones that may have never been verbalized.

"You promised!" Often "promises" were not explicit, very vague, or extremely subjectively interpreted.

The individual talks about being disappointed in the partner.

That the partner broke his or her word.

That the partner lied.

"I depended on him (her)."

That the partner failed to follow-though.

That the partner is not dependable.

Interrogation about partner's time spent and activities with other people, whether or not there is potential romance (for example, questioning partner's time spent with football fan buddies).

"I can't trust him (her) anymore."

High demanding expectations of the partner (and therapist)- a pre-emptive strategy to avoid betrayal.

Hyper or excessive focus, time, money, and energy spent on partner, including denying own needs (to "enforce" or create debt/duty of partner to comply with expectations/demands).

Frequent covert and overt "scorekeeping" behaviors affecting the balance of relationship equity ("I did that for you… You need to do this for me").

Abandonment:

Complaints about the partner being late.

Upset about not knowing where the partner is.

Wanting and demanding to know where the partner is, was, will be, with whom, why, and for how long.

Frequent phone calls or texts to or messages left for the partner.

Anger about the partner not agreeing (not being on his (her) side) when complaining about something that happened.

Jealousy or anger about the partner spending time with other people.

Fury that the partner forgot him (her) (or something he (she) wanted or needed).

Complaints about the partner not listening, understanding, or relating to him (her) (emotional or intellectual abandonment).

Frequent comments and fear about being empty, alone, or lonely.

Centering life on the partner (to force partner's reciprocal centering life around him (her) in order to preclude abandonment).

Rejection:

Complaints about the partner disagreeing with the individual with borderline personality disorder.

Complaints about the partner not spending enough time or wanting to spend time with him (her).

Complaints about the partner preferring someone or something other than him (her).

Anxiety about not being good enough (sexually, physically, socially, intellectually, emotionally, economically, etc.).

Feeling hurt that the partner disagrees with him (her).

Anxiety and complaints that the partner does not care about his (her) feelings, needs, desires, and so forth.

Long lists of partner transgressions against him (her).

Constantly retrieving and replaying old complaints against partner.

Reliving pain and hurt of past events.

Bringing up the partner's old boyfriends (girlfriends) as being favored over him (her).

B-A-R-T: BETRAYAL, ABANDONMENT, & REJECTION AND TERRORISM
While the individual with borderline personality disorder may bring up any topic: work, dinner, the children, watching television, socializing with others, family, and so on, betrayal, abandonment, and rejection will be the frequent underlying themes.  While the individual in many if not most couple therapy may communicate similar issues, it would be the intensity and consistency of these complaints dominating therapy and the relationship that should alert the therapist.  When the therapist notes a strong pattern of communications about the relationship reflecting B-A-R: betrayal, abandonment, and rejection, he or she should further investigate of the possibility of a diagnosis of borderline personality disorder.  Adding the letter "T" for the concept of "terrorist" to the mnemonic B-A-R to create another mnemonic, B-A-R-T.  The behavioral outcome of betrayal, abandonment, and rejection experiences is the individual with borderline personality disorder assuming the role of a relationship "terrorist."  A terrorist is a person who believes that the force he or she faces is overwhelmingly powerful, morally repugnant, and not amenable to reasonable persuasion or negotiation.  Functional analysis about Frieda's power and control in her life would not find her particularly vulnerable, but deeper emotional and psychological examination revealed her identity of being victimized and ineffectual.  Since the terrorist believes in his or her self-righteous moral stance, feels he or she has suffered outrageous abuse, and cannot engage in "civilized" exchange or battle with the powerful entity, the terrorist takes entitlement to attack without regard to any rules of engagement.  The geo-political terrorist assumes the right to bomb civilian population and targets not directly involved in oppression.  The civilian population is deemed culpable and deserving of punishment by virtue of perceived association or benefit of some sort.

The individual such as Frieda with borderline personality disorder becomes an emotional terrorist who self-righteously lashes out at his or her partner- Cliff for example, for any number of betrayal, abandonment, and rejection (B-A-R) transgressions that he or she may or may not be aware of.  The partner (or the therapist, Selena for example) is held accountable for perceived negative intention or for gaining some imagined benefit.  The experiential trinity of betrayal, abandonment, and rejection (B-A-R) creates the emotional/behavioral terrorist to form the new mnemonic, B-A-R-T.  The therapist when noting the B-A-R trinity should then evaluate the individual in the relationship acting as an emotional/behavioral terrorist who lashes out self-righteously at his or her partner.  Betrayal, abandonment, and rejection may be important themes for the individual in the relationship, but he or she may not act as a terrorist lashing out at the partner.  The therapist should assess for covert attacks- for example, passive aggressive behavior, which could still be indicative of borderline personality disorder.  However, if there are neither overt nor covert attacks on the partner, the diagnosis of borderline personality disorder would probably not be indicated and couple therapy should follow other routes.  "A patient reacting with rage to a gross empathetic failure on the part of the therapist is showing neither a 'transference' nor a 'borderline personality.' He is responding appropriately to a deep disappointment" (Chessick, 1976, page 544).  The emotional reaction is very human, of lesser intensity, and most important, not followed by toxic borderline behavior.  Therapy then would find dealing with and promoting change around each theme or issue to provoke less highly intensive reactivity than is characteristic of borderline personality disorder.  It is not only the intensity of enduring the experiential trinity of B-A-R that is problematic in a couple with an individual with borderline personality disorder, but also the destructive impact of the borderline/terrorist behaviors.

C-I-A: CARING CONTRACT COMPLIANCE-INTIMACY-ACCEPTANCE
Using the concept of an emotional/behavioral terrorist as a metaphor for the individual with borderline personality disorder leads also to a mnemonic for partner response and therapist strategies for intervention.  The partner and the therapist should activate C-I-A: Caring contract compliance, Intimacy, and Acceptance.  Frieda and other individuals with borderline personality disorder crave and need these three responses or need to feel these three things are happening.  In actually, most people need as sense of Caring contract compliance, Intimacy, and Acceptance from their intimate partners, and in most close relationships.  These comprise the secure attachment response trinity to deal with the borderline behavior- that is, the emotional/behavioral terrorism.  Each element of the secure attachment response trinity relates directly to its counterpart in the borderline experiential trinity.  First, since the individual with borderline personality disorder is terrified of being betrayed (Betrayal is the "B" of B-A-R), the partner or the therapist needs to consciously demonstrate caring contract compliance (the "C" of C-I-A).  Cliff for example should verbally express and show that he or she cares by complying with the contracts of the relationship- the agreements, expectations, and covenants between the two members.  For the therapist such as Selena, this starts with setting up an explicit therapeutic contract for the goals, process, roles, and relationships in therapy. "The function of the contract is to define the responsibilities of patient and therapist, protecting the therapist's ability to think clearly and reflect, provide a safe place for the patient's dynamics to unfold, set the stage for interpreting the meaning of deviations from the contract as they occur later in therapy, and provide an organizing therapeutic frame that permits therapy to become an anchor in the patient's life. The contract specifies the patient responsibilities, such as attendance and participation, paying of fees, and reporting of thoughts and feelings without censoring. The contract also specifies the therapist's responsibilities, including attending to the schedule; making every effort to understand and, when useful, comment; clarifying the limits of his or her involvement; and predicting threats to the treatment. Essentially, the treatment contract makes the expectations of the therapy explicit (Clarkin, 1996)" (Levy et al., 2006, page 490).

Clarity with the therapeutic contract models for the relationship contract between partners.  Verbally expressing contractual expectations- that is, relationship expectations are especially important since the individual with borderline personality disorder often holds unarticulated, implicit, unanticipated, and unexpected expectations.  He or she holds secret contractual clauses that no one- not the partner, not an unsophisticated therapist, or the individual him or herself is aware of until activated.  The partner and the therapist must confront the individual with borderline personality disorder when he or she ambushes them with such a clause.  In the confrontation that denies the accusation of betrayal, the partner or therapist also must spend words and energy to express caring about the individual.  The partner or therapist will articulate the overt contract with affection and integrity.  He or she will re-commit to it and to the individual but not accept retaliatory ambush as reasonable.  The partner or therapist will re-affirm that he or she has and will continue to comply with the contract of the relationship, but not to the borderline ignited demands.  Frieda needs to hear that Cliff and Selena refuse to be abused and refuse to be labeled as horrible people, and that with these boundaries that Cliff and Selena still care for her as agreed according to the relationship expectations or contract.

Second, since the individual with borderline personality disorder is terrified of being abandoned (the "A" of B-A-R), the partner or therapist needs to verbally re-commit to the intimacy (the "I" of C-I-A) between them.  Previous painful experiences sensitize the individual to anticipate a loss of intimacy from being abandoned… again.  "…a traumatic experience induces a basic sense of existential anxiety by shattering once–held assumptions.  For example, one of the most basic assumptions of any relationship is the expectation that a partner will be both accessible and responsive during times of need.  When an exigency is imminent, attachment needs become prominent, which induce real or perceived threat, danger, loss, or uncertainty (Bowlby, 1969).  If a partner fails to respond with the expected reassurance and comfort, the entire relationship becomes defined as unsafe.  This violation calls into question the significance of oneself to the other partner. A s previously mentioned, clients will often describe these incidents in an intensely emotional manner, and self–worth is often called into question" (Naaman et al., 2005, page 60).  The partner such as Cliff may feel that the individual with borderline personality disorder should know that the partner would not abandon him or her.  Or, the therapist such as Selena may assume that Frieda is clear that taking a vacation or canceling an appointment because of illness is also not abandonment.  However in the moment, Frieda with her borderline anxieties cannot feel or hold such confidence.  The partner needs to clarify that separation whether it is for a few hours, temporary for the workday or a visit, financial budgeting, or laundry (or a therapist illness or short vacation) is not abandoning the individual.  Physical and other separations or disagreements are clearly identified as not being emotional separation.  Disagreement or failing to be in complete cosmic sync with each other is not indicative of abandonment of the intimate relationship. The partner or therapist should verbally reaffirm intimacy whether or not the individual has explicitly expressed his or her abandonment fears.  "Frieda, even when I disagree with you I still want to be close to you.  What I just said or what I want to do, doesn't mean I want to abandon you."  Often, the individual with borderline personality disorder may deny or does not initially or easily verbally express abandonment fears, yet is soothed when intimacy is affirmed by the words or action of the partner or therapist.

Third, since the individual with borderline personality disorder is terrified of being rejected (whether or not he or she is conscious of the fear or willing to admit it)- Rejection is the "R" of B-A-R, the partner or therapist needs to verbally express acceptance (the "A" of C-I-A) of the individual.  The partner or therapist needs to clarify that although he or she may disagree with the individual's thoughts or interpretation, the partner continues to accept the essence of the individual as the bonded romantic intimate.  The therapist commits to continuing to accept the individual as a cared for and invested in client.  The therapist including Selena cannot accept the individual acting out unless he or she understands and has compassion for the vulnerability of the individual that underlie caustic behavior.  The individual will often complain and accuse the partner or therapist from any number of perspectives and ways without expressing that his or her core fear is of rejection.  The individual will try to force the partner or therapist to accept his or her interpretation or opinion to avoid anticipated rejection.  The partner or therapist will feel him or herself and his or her thoughts, feelings, and essence rejected by the individual.  The therapist will experience his or her professionalism and ethics questioned and condemned.  Selena was tempted to reject Frieda, which would have confirmed Frieda's fears.  These types of behavior should cue the partner or therapist that rejection is what the individual with borderline personality disorder is feeling and fearing.  

Feedback such as "I disagree about that, and I still like you, care about you, and love you!" (or from the therapist, "…and I'm going to keep working with you!") sound clichéd, but speak to the individual's core anxiety.  As the partner or therapist reminds him or herself with the mnemonic C-I-A to show and express caring contract compliance, intimacy, and acceptance, he or she will respond to the individual with borderline personality disorder's anxieties around B-A-R: betrayal, abandonment, and rejection.  That is what Frieda needs and what she fears.  By doing so, the "T" of the B-A-R-T, emotional/behavioral terrorism or borderline behavior may be reduced and mitigated.  The therapist's and the partner's ability to respond to the individual's emotional distress also can facilitate the individual becoming more proficient in managing his or her emotions.  Both the therapist and the partner also need to be aware that betrayal, abandonment, and rejection fears will not be assuaged by one or two expressions or reassurances of caring, intimacy, and acceptance.  The depth of vulnerability of the individual with borderline personality disorder is too great for normal soothing or validation to suffice.  As a result, Cliff and Selena need to be prepared to repeatedly face B-A-R and to repeatedly respond with C-I-A.

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