Conclusion:ClinicalFlexibilityAdaptability - 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
CONCLUSION: CLINICAL FLEXIBILITY AND ADAPTABILITY


Successful therapy with the individual with borderline personality disorder alone or as a couple tends to be a long-term process.  It may be culturally challenging because in some societies there are expectations for a quick fix-it solution when coming to therapy.  In the opening vignette, where an astute but flummoxed therapist, Selena recognized Frieda's obvious borderline behavior, the couple should be immediately presented with the need for long term therapy- definitely, not short-term or brief therapy.  Getting the couple to stay committed to the process is critical.  It would not have been hard to gain Cliff's commitment.  Long-term depth couple therapy may involve a mindset- cross-cultural mindset change.  The therapist should present long-term work as necessary and perhaps, as a cross-cultural requirement for the therapy.  The initial work may be quite pleasant and seemingly productive- a walk in the therapeutic flowerbed.  This may go on for quite a while before... Snap!  Ouch!  The therapist steps onto a trap hidden amidst the congeniality and praise.  Where'd that come from?  From predictable borderline patterns of behavior.  On the other hand, the therapist can often recognize borderline tendencies fairly quickly- perhaps by the middle of the first session.  Once the therapist is aware of borderline issues, he or she should require an immediate commitment from the couple, but especially from the individual with borderline personality disorder for a specific number of sessions- at least several sessions (8-10 sessions, for example).  Some therapists may do this as matter of policy, but this is especially prudent when there is borderline energy present.  Someone such as Frieda, however may have been threatened by the sense of severity conveyed by the therapist advocating a longer commitment to therapy.  Due to typical borderline hypersensitivity, she could have interpreted it with as implying that there was something really wrong with her.  At the same time, her long history of relationship problems and previous failed quick fixes may have made her more receptive to a more substantial therapy process.

An additional requirement to present at the beginning of therapy would be for a specific in-session process for if either member of the couple wants to terminate therapy (no telephone terminations, or just not showing up).  For the individual with borderline personality disorder such as Frieda who is already hypersensitive to criticism and a history of bolting from difficult emotional relationships, killing the therapy or giving up is more likely than not.  The therapist such as Selena should ask as standard protocol in couple therapy, whether the couple had tried therapy together previously and what had been the results.  Revelation of failed couple therapy with overt or implicit criticism of the prior therapist may prime the therapist's ego to do a better job.  It should also however prompt suspicion and further assessment for borderline issues.  The therapist should explain that the commitment serves to avoid either member of the couple using the attendance at or the continuation or termination of therapy, as another weapon in the couple's battles.  The therapist should predict to both that one or both members may threaten to stop coming to therapy to manipulate or intimidate the other.  Of course, this is really directed towards the borderline partner.  The therapist is actually identifying and predicting the habitual pattern of the individual with borderline personality disorder, and possibly the therapy pattern of the couple.  One of the primary ways the individual with borderline personality disorder deals with anxiety is to run.  Running from therapy, running from the therapist is very likely.  Where do these interventions and strategies come from?  From understanding the borderline pattern.

By anticipating this and other forms of avoidance (metaphorically, identifying the traps in the flowerbed) and making the prediction, it becomes a paradoxical intervention to address borderline defensive-offensive behavior.  Paradox works to either reveal or expose the habitual dynamic, and thus facilitates insight, which can lead to change.  On the other hand, as the client resists the prediction, the paradoxical intervention can cause behavior to change.  Selena can ask Frieda directly, "If you get mad at me... actually, when you get mad at me, what will you do?  I'm concerned that you will terminate therapy as a way to avoid dealing with the difficult issues... including being hurt by me, feeling betrayed, abandoned, or rejected by me.  Or, you may punish me by leaving therapy without talking about it... or some other way like missed appointments or bounced checks even.  Sounds like it is something you've done before with other therapists... basically, a version of what you do with Cliff to avoid confrontation or to punish him.  I need you to commit to doing it differently when you're mad at or hurt by or disappointed in me.  That means committing to come talk about it.  That's not only ok to confront me, but absolutely necessary to not do the same old behaviors again."

Removing the threat of running from therapy for the therapist is vital for conducting therapy with integrity.  Otherwise, the therapist is disabled in his/her interventions if the thrust of therapy becomes always trying to keep the individual or couple in therapy.  "Therapy has the best chance of working for you if I can be honest with you and say the things and give the feedback I need to give.  If I have to worry that you'll get hurt or mad and stop therapy, that messes up the integrity of doing the best I can with you."  The implicit threat of therapy being terminated by the individual with borderline personality disorder can intimidate the therapist from giving challenging feedback or making provocative interventions.  By anticipating typical borderline reactions, the therapist can set the therapeutic contract in anticipation of borderline reactivity to later terminate therapy or punish the therapist.  The therapist would be able to invoke the individual with borderline personality disorder such as Frieda', his or her prior agreement at the onset of therapy to such requirements and commitments.  Selena would be prepared and empowered to confront Frieda on her any capricious behavior (that has been predicted) and bring it into therapeutic discussion.

Since this dynamic of hurt, anger, running, and punishment is so intrinsic to the borderline process, the therapist can regularly as a part of therapy ask the individual with borderline personality disorder, "Have I done or said anything that upsets you?  Any instinct to get out of here or to punish me?"  Perhaps, the therapist can check in on this near the end of each session.  When giving provocative feedback or upon observing some affect indicating upset, the therapist can be very direct or specific, "How was that for you?  I just pretty much agreed with Cliff and disagreed with you, Frieda.  I can tell that bothers you.  That's good.  You can be mad at or disappointed in me, and we can talk about it without really punishing or rejecting each other.  Let's talk about it. What are you feeling and thinking?"  If Frieda denies being angry or upset, the therapist can use the other partner for confirmation.  "Cliff, Frieda didn't like what I said, huh?  You recognize her facial expression?  Her body language?"  After getting confirmation, the therapist validates with C-I-A while overtly addressing B-A-R.  "That's what I thought.  Although I challenged you right there, it's because I care that you want to feel close and intimate with... to be accepted by me.  I'm not betraying our agreement to support you.  I won't abandon you or reject your feelings and needs.  What happened inside you when I did that?"  The therapist process of caring confrontation is simultaneously modeling for the partner how to confront with care as well.  A similar process is recommended after the individual with borderline personality disorder has acted out.  "I did something the other session that hurt you or made you mad.  And you more or less punished me for it.  Rather than just being mad at you and pushing you away... that is, betraying our agreement to work on these issues- to hang in there together through hard times, abandoning you or rejecting you, we need to talk about it.  It's ok to be mad at me, although is not ok to punish me, and it is really important to talk about it rather than pretend it didn't happen and have a lot of resentments to carry forward."  The traps in the flowers are retrieved for examination and consideration.  In doing so, borderline reactivity and behavior may be slowed down and reduced.

Recognizing borderline thinking, emotions, and behavior, applying conceptual knowledge, while anticipating and planning for borderline dynamics from the individual with borderline personality disorder sounds like extremely obvious therapeutic guidance.  However, the therapist who fails the individual and his or her partner often seems ambushed by borderline assaults and disruptions in the session.  Where'd that come from?  Everything that is a part of the disorder, syndrome, or tendencies may occur in therapy, and of course in the couple.  And, it will occur with the therapist as well because he or she is not "special."   Selena recognized the borderline cues yet hoped somehow against theoretical wisdom that Frieda would not "go borderline" on her.  Wrong!  Everyone and anyone who gets close to the individual with borderline personality disorder is a potential, probable, and eventual betrayer, abandoner, and rejecter... and Selena proved to be no exception.  The traps snap on everyone and Selena should know that she would trip one sooner or later.  And, then another... and then another.  Ouch and ouch again.  The therapist cannot "love" or "care for" the individual enough or be "good enough" professionally to heal the individual's attachment traumas.  Once the therapist accepts his or her lack of immunity from borderline projections and attacks, then he or she can prepare for the individual's, the partner's, and the couple's borderline driven processes.  While Selena did not prepare for Frieda's borderline reactions and behaviors or for the borderline dynamics between Frieda and Cliff, once she experienced them she could still reset the therapy.  Everything that she could have or should have done earlier in couple therapy, Selena could still do as long as they remained in therapy.  While it could have and probably would have better clinically, applying the principles proposed at any point in the therapy remains conceptually sound.  

The individual is extremely predictable within a spectrum of behaviors in the disorder.  Experiencing failure by intimate others (now the therapist) is not new to the individual with borderline personality disorder.  Selena's therapeutic "failure" so to speak not to take a more assertive strategy at the beginning of therapy is an opportunity to have a reparative shift in therapy.  Reframing the process of therapy, admitting mistaken or misguided therapy, and owning negative thoughts and feelings may be a remarkable and unprecedented gift from therapist to the individual who is used to being betrayed, abandoned, and rejected.  Others who have "erred" dealing with someone like Frieda, either tried to appease her such as Cliff does or pathologized and found justification to leave her.  When Selena as the therapist recognizes and accepts the "logic" of the borderline world, he or she can accept the individual Frieda as an emotionally injured person trying to survive according to his or her borderline experiential reality.  Therapist acceptance leads to the individual and subsequently, the partner accepting the logical dysfunction.  The therapist gives a form of "radical acceptance" to the individual with borderline personality disorder much as the individual needs to give him or herself "radical acceptance."  Acceptance yet confrontation, caring yet boundaries...this process thus includes principles from the holding environment orientation for treatment.  Distinct from condoning behavior, this acceptance of the underlying compulsion leading to behavior is unconditional and completely honors the individual's right to survive.

Therapy however also has to address the illogic of dysfunctional acting out for acceptance to be genuine.  Attempts to survive and resultant embedded reactivity and behaviors become logical when temperament, attachment injuries, family-of-origin models, and other psychodynamic, cultural, and cognitive experiences are examined.  Frieda is driven to survive by the means she has available.  How she came to her strategies and tactics will make sense with sufficient investigative work into her family-of-origin, culture, attachment style, trauma, and so on.  Borderline reactivity and thinking makes sense finally through insight work, which reflects insight-oriented therapy.  A holding therapeutic environment where insight is gained, however does not guarantee anything is better at home or in the relationship.  Establishing the therapeutic contract and relationship among Selena the therapist, Frieda, and Cliff is a monumental first step.  Understanding the logical origins of borderline behavior is another huge step.  Change in behavior, possibly first in couple therapy between Frieda and the therapist and then, between Frieda and Cliff as facilitated by the therapist is essential.  However, the ultimate steps are behavior change at home between Frieda and Cliff.  Thus, a coherent therapeutic plan for working with the individual with borderline personality disorder alone or in a couple should draw heavily from the behavioral aspects of dialectical behavioral therapy.  When the therapist such as Selena accepts that anything can and almost will happen, then he or she may be better able to accept the challenge of working with the individual with borderline personality disorder in his or her most critical circumstance- as partner in a couple.

The therapist cannot pick a singular orientation or therapy and expect it to be applicable with the individual with borderline personality disorder, especially in couple therapy.  There are far too many variables, far too many boundary problems, and far too much intensity and reactivity.  Frieda and Cliff were but one set of partners where borderline issues shaped the relationship.  Other partners combine in a variety of manners depending on the style and degree of borderline tendencies and behaviors and the ability and resources of the partners.  Clinical flexibility and adaptability while maintaining a clear conceptual coherence becomes essential to the adventure of working with the couple that includes the individual with borderline personality disorder.  Such therapy may be among the most challenging and difficult clinical work, but also is the most fundamental mission of the therapist.  The therapist has the opportunity to help someone be a fulfilled member of something greater- the couple.  He or she has the opportunity to help the couple be fulfilling for both its members, and the family it may head.  The couple is one of the most elemental of relationships.  As functionality as a child in the family-of-origin, functionality as a member in the couple may predict functionality in all other relationships.  Betrayal, abandonment, and rejection issues versus caring contractual compliance, intimacy, and acceptance behaviors are the most basic work of being in a relationship, and therefore of therapy and the therapist.

Both individuals often can and do provide for one another despite their dysfunctionality.  A longing for attachment and intimacy that manifests in dysfunctional behavior drives the individual with borderline personality.  His or her partner seeks attachment and intimacy as well and offers it in exchange.  The therapist must recognize that the driving force for borderline dysfunction can become the driving force for confronting relationship dysfunction.  The individual has often suffered multiple failures, been desperately lonely, and fears imminent loss of the current relationship.  Life as he or she has lived it has not worked.  As a result, therapy can be empowered despite and against borderline instincts to take more confrontational and provocative strategies.  Couple therapy first provides the individual with borderline personality disorder and his or her partner hope for changing their dynamics and for a better life together.  Couple therapy can provide assistance to minimize or remove some of the traps, to lessen their impact, and allow for the partners to traipse more connected and fulfilled in a relationship flowerbed of caring, intimacy, and mutual acceptance.  Less or more of relevant quantitative changes that can lead to qualitative changes of more nurturing, connection, security, respect, and care are the what couple therapy can offer.  That is what couple therapy can offer if the couple therapist tries not to be special, but theoretically sound and therapeutically skilled.  There are inevitably traps in the borderline flowers, so do not be surprised when they inevitably snap!  Be prepared.

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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