**Author’s Note: Other than public figures or people identified in the media, all other persons in this book are either composites of individuals the author has worked with and/or have been given different names and had their personal identifying information altered to protect and respect their confidentiality.
I received a request for feedback from a fellow therapist who I had previously consulted for on some difficult cases. Selena was a very sharp and capable therapist who had worked well with a range of clients in her private practice. There was something about this couple however, that got on her nerves. Selena told me,
"I have been working for the last four months with a real difficult couple. Frieda, the wife is a fifty-something privileged white woman who self-described as bitter, twice divorced, entitled, angry, and menopausal. She has with three children by three different fathers. The youngest child is with her third husband, Cliff who is also white- his second marriage. She's as borderline as you can get. And very difficult as you may have guessed. Cliff is not the big challenge. He's kinda meek, especially when she gets going. He tries his best. He's very conscientious. He's getting worn down. My guess is that he's depressed. I feel more and more stuck in our sessions and feel… walking on eggshells… actually more like navigating an emotional minefield... like tiptoeing through the flowers with hidden mouse traps! It's probably what Cliff goes through all the time with Frieda. I get totally drained on every level each session with this couple. When I see them on my schedule book, my body fills with dread. I know it's not him- it's her! I am liking her less and less all the time. I have brought up this client and the couple several times with my normal consulting therapist and examined my counter-transference this way and that. I've judiciously done research reading about working with borderline personality disordered clients. I've done my homework.
I hate to admit it, but I'm wanting to terminate… I want to lose this client! I feel bad about abandoning Cliff, but she's violated so many interpersonal boundaries. I'm getting worn out. Her latest, is complaining loudly about jerks who making getting in and out of the office parking lot difficult. She does this on the way out of the office, so that the "jerk" who is my next client appointment can hear her. Cliff tries to discretely mutter apologies for her. I live in a small community, so she knows people that I know including some people in official or professional roles. She brings them up in sessions, asks me about their personal life, and then gossips about them. She asks if I see this person or that person in therapy.
Frieda doesn't follow through anymore with any reading or homework I suggest in therapy. She plops down and goes on and on about how horrible everything is with Cliff- basically, the same stuff every session. She dominates the sessions whether she's talking or not. When she's talking Cliff just defers. You can see he doesn't want to challenge her. He starts to a bit, but she just brings more heat to the battle and he gives up. Shuts down and hangs his head. But then there's other times when she's so loving and positive about Cliff and the relationship… and about therapy. Life and the relationship is like a bed of roses. In these times, I find I can really like her. It's like happy time in therapy... pretty flowers and butterflies and birds singing... with Cliff following her lead about how things are going well. She used to listen carefully, consider what I said, and then try to expand upon it. She said therapy was helping her a lot. It was helping Cliff a lot. When she first brought up something Cliff did, she seemed ok with processing it carefully with me. Frieda told me I had a good style that worked for her. Their first couple therapist hadn't been very helpful she said. Cliff had said the first therapist was OK.
Then, about the fourth or fifth session while we were talking about an argument they had, I said something or the other about looking at it from Cliff's perspective. Something flashed briefly in her eyes. The session was almost over so I didn't get to find out what that was about. Snap! I stepped on some hot spot...a trap. Ouch! She canceled the next two appointments… that is, she had Cliff call to cancel them. Where'd that come from!? I didn't realize it then, but we went through another "honeymoon" therapy period of several sessions before I provoked her again. I don't even remember what I said. The next session, she 'forgot' her checkbook. She forgot it for two more sessions. And then was pissy when I told her I needed payment before the next session. After a couple of more cycles, I started to recognize a pattern. There's more but basically, it's still the same while also having gotten worse! Therapy can be smooth and very cooperative- seemingly productive. Then suddenly, she'd get triggered and she would rip me. Ouch again! Whenever she does this, Cliff gives me a sympathetic look. It's what he goes through! Sometimes, she suspects anything I say has some ulterior motive… some roundabout way to put her down… especially, if I support Cliff in any manner. If I'm silent for any amount of time, she accuses me, 'So, now I'm boring you? Don't you have anything to say about my pathetic life?'
Despite all the tension and acrimony between them, I can tell they really care for each other. They love each other and want to stay together. I can't believe I'm doing any good work with her. I feel trapped. I want to refer her out, but I know I'd feel guilty for foisting her on another therapist! She's not so nice anymore. When she's likable, I don't trust it. And, I'm right because she does turn on me again. I can't stomach this woman anymore. But there are times I really like her! I can tell she has a really good heart- one that has been broken so many times. I feel so sorry for Cliff. He must feel trapped. I know that's not therapeutically healthy or appropriate, but it's what I feel! She makes me feel so bad… a failure as a therapist. I'm supposed to like my clients! Damn, writing this, I realize how much I can't stand seeing this woman anymore. What is happening? What should I do? Arrrgh!"
What do many therapists do? They terminate, avoid, and run away from the individual with borderline personality disorder. Working with individuals with borderline personality disorder is often considered among the most difficult clinical work. Roberts (1997) offer an explanation from Masterson of the intrapsychic structure of the individual with borderline personality disorder that rings true for the therapist, yet may still be difficult to translate into the therapeutic process. "…the intrapsychic structure of the borderline personality disorder is characterized by a split ego and split object relations units… The particular developmental arrest of the borderline personality disorder results in an archaic ego governed by the pleasure principle and, as such, concerned principally with the maintenance of pleasure and the avoidance of pain and unaffected by any self-destructive ramifications of reality. Thus, primitive defences such as splitting, avoidance, denial, acting out, projection, and projective identification are employed, with no regard for their ultimately self-defeating consequences. And, predictably, ego defects in the areas of impulse control, frustration tolerance, reality orientation, and ego boundaries persist. At the same time, a reality ego, albeit underdeveloped, exists, but it is split off from the pleasure ego, so it has no corrective influence on the regressive and ultimately self-destructive urges of the more archaic pathological ego. Further, the individual with a borderline personality disorder operates, not with one, but with two distinct internal paradigms of relationships. These split object relations units are comprised of two emotionally polarized pairings of an internalized self representation and an internalized object representation. Forming the rewarding object relations unit (RORU) is a part object representation that is powerful and supportive of clinging, dependent, regressive behaviour, a part self representation that is good and compliant, and the pleasant effects of feeling good and taken care of linking the two. The parallel and split off withdrawing object relations unit (WORU) is comprised of a part object representation that withdraws or attacks in response to separation or individuation, a part self representation that is inadequate, bad, and unattractive, and an affective connection of anger, frustration, and worthlessness"(page 234).
When conducting individual therapy, the therapist is challenged to be the rewarding object relations unit (RORU)- "the good guy," also labeled by the client such as Frieda initially as "the best therapist I have ever had." At some point, however, the therapist becomes the withdrawing object relations unit (WORU)- the betrayer, also condemned by the client as "another trusted person who has screwed me!" Frieda also did this as she turned on her therapist Selena. Taking heed of a classic therapeutic maxim, the therapist should know that the client has made him or her feel what the client feels. As the therapist, Selena feels ambushed, disappointed, hurt, betrayed, saddened, anxious, and afraid, any sense of specialness or immunity can be shattered. The client has "an abandonment depression which is followed by defence against the experience of this dysphoric state. That is, self-activation leads to depression which leads to defence." The therapist feels Frieda's aggressive defensive reaction. He or she can easily be drawn into the client's world to try to offer emotional sustenance. "More precisely, the pathological ego of the borderline personality disorder forms an alliance with either or both the rewarding and withdrawing part object relations units (Masterson, 1981, pp. 133-135). This is manifested clinically when separation stresses, self-activation, or progress in psychotherapy disrupt the defences and stimulate the abandonment depression. To defend against the experience of these painful affects, one of these false self organizations with its corresponding constellation of defences is activated. When the alliance is with the RORU, self-activation and separation strivings are terminated, regressive and self-suppressing defences are re-employed, and the client is relieved of separation anxiety and abandonment depression."
This dynamic at less intensive levels is usually well within the therapeutic experience, expertise, and behavioral and interpersonal comfort level of the therapist. Many clients with emotional and psychological wounds find therapist care and attention validating and empowering. However, with the individual with borderline personality disorder, there comes another side to the relationship. "On the other hand, an alliance may be established with the WORU, in which case the source of the abandonment depression is projected onto the environment, thereby effectively externalizing it so as not to experience it. And in some cases the same person activates these two alliances alternately. These alliances with the two object relations part units may be evident from the patient's extra-therapy relationships, as others are invariably perceived as either supportive, enabling, and caregiving or as cold, uncaring, or punitive. They will also be observed in the `transference acting out' in the psychotherapy setting, wherein these alternating perceptions are imposed on the therapist, with no or limited awareness that they are the patient's projections (Masterson, 1976, p. 102, 1981, pp. 146-164)" (Roberts, 1997). The individual with borderline personality has no secure or integrated sense of self. Kernberg (1986) described it as "ego weakness," where the ego is in perpetual risk to fail apart. The individual will cling onto another, taking on the identity he or she is assigned. However, he or she will then "feel threatened and invaded by the other and have to violently withdraw. In order to preserve some sense of coherence and integrity the ego is driven to employ powerful and primitive defences, such as splitting off bad or persecutory experiences from good or idealizing ones" (Spurling, 2003, page 27). The individual with borderline personality disorder engages in projective identification, where parts of his or her ego are experienced as being inside of others. At the same time, he or she experiences parts of others being forced into him or herself. A pervasive confusion results between self and the other.
An individual such as Frieda develops borderline personality disorder often from intensely difficult childhood experiences. "The childhood of the borderline patient is marked by profound disappointment in the natural hopes and expectations of phase-appropriate soothing and stimulation and appreciation from the parents, interference with phase-appropriate idealization of the parents, and lack of a generally reasonable and empathic response from the parents. This disappointment, repeated over a period of years, produces a profound rage in the patient, a deep mistrust of human relationships, as well as a literal fear of annihilation. The deep mistrust and early disappointment make it impossible to integrate primitive phase-appropriate narcissistic structures of the grandiose self and the idealized parent imago, which then persist in an unaltered form to adult life, producing the narcissistic aspect of the clinical picture. The enormous rage consequent to the disappointment and also often fired by hostile unempathetic enemalike intrusions by the parents, produces a whole new set of problems for the patient that is not faced by an individual in ordinary development. A variety of fluctuating ways are found to deal with this rage, ranging from depression to schizoid withdrawal to somatization to acting out producing the borderline clinical picture" (Chessick, 1976, page 541). While the childhood experiences may be clearly linked to current functioning, the individual often is unaware of it. The therapeutic challenge becomes how to elicit awareness and insight. An individual may have deep denial or a lack of memory about childhood experiences. It may require major transference experiences, crises, and work to bring these horrific memories into consciousness. This often takes quite a while during which the individual may be going through a series of relationship disasters with accompanying distress and despair… and acting out. For some individuals, childhood memories are available, but the intensity of pain, fear, and loss may be minimized. This may be difficult work as well.
"The syndrome of borderline ego-integration has been described as early as the 1680s when Sydenham described a group of patients who 'love without measure those whom they will soon hate'" (Weddige, 1986, page 52). From being good guy to bad guy… from rescuer to assassin… the therapist finds that the interpersonal and relationship dysfunction of the individual often manifests in the client and therapist relationship. Working with a couple with a borderline partner or using couple therapy as a treatment modality for borderline issues may not be considered by the therapist, since problematic borderline issues tend to interfere with partner intimacy, successful marriages and relationships. "Stone, in his follow-up study of patients with BPD, found that 52% of the women and only 29% of the men were married at follow-up. By comparison, 80 to 90% of men and women from the general population are married by their late thirties or forties. Other research has suggested that borderline subjects did better on follow-up if they avoided intimate relationships" (Links and Stockwell, 2001, page 492). Yet, partner intimacy or relationship problems may be the predominant presenting issue of the individual with borderline issues, and borderline issues also being the core instigators of couple's dysfunction. "Labonte and Paris (1993) found that people diagnosed with borderline personality disorder were more likely to experience the termination of important relationships than were other psychiatric patients and normal people. Other researchers have examined the association between the number of borderline symptoms (as opposed to a diagnosis) and family functioning. For example, poor self-reported family interactions were related to the number of borderline symptoms an eating disorder patient endorsed (Waller, 1994). Likewise, Trull, Useda, Conforti, and Doan (1997) found that being classified as borderline (subclinically by endorsing a set number of borderline features) added to the prediction of interpersonal problems above and beyond gender and other Axis I disorders in a nonclinical sample" (Gutman, 2006, page 1276-77).
The intimate partner relationship is a fundamental healing force- possibly by virtue of facilitating empathetic connections. Positive partner relationships have been seen to stimulate emotional and psychological healing in individuals with very difficult disturbances or disorders. "Quinton and colleagues studied behaviorally disturbed, institutionally raised girls and observed that good outcomes in young adulthood were associated with having a stable marriage. Paris and Braverman noted that older, caretaking husbands could attenuate borderline psychopathology in their young wives" (page 492). Individual therapy with individuals with borderline personality disorder is often- virtually always complicated by alternating intense positive and negative transference. The therapist becomes the idealized intimate and nurturing parental figure or object only to morph into the viciously betraying abuser. "Couple therapy, similar to group therapy, can dilute the intensity of the transference relationship that is rapidly formed in therapy with BPD patients. The negative transferential aspects are typically projected onto the spouse while the therapist receives the positive projected aspects of the transferential relationship. As long as the therapist can avoid reacting based on these projections, the engagement in therapy can be enhanced" (Links and Stockwell, 2001, page 494). Avoiding or appropriately dealing with the positive projections about the therapist and managing and intervening in the negative projections against the partner remain significant therapeutic challenges. Poorly handled, the individual with borderline personality disorder can and will shift to negative projections of the therapist as well as Frieda had done with her couple therapist Selena. However, the therapist's interventions can lower the negative intensity of the activated individual with borderline personality disorder and perhaps, prevent major crises… or manage the crises. The couple often has repetitious cycling of uproar and crisis followed by stabilization into security and comfort, to be followed by another triggering event and subsequent crisis. The crises can lead to extreme negative behavior, including self-harm (suicidality, risk taking, etc.).