I HATE YOU . . . PLEASE DON’T LEAVE ME!:THE BORDERLINE CLIENT AND PSYCHODRAMA
Perhaps some therapists have already had the experience of working with a client who becomes furious during the session, complaining about your ability as a professional, about something that was said or even the way it was done. In general, we therapists become very unsure of ourselves at these moments. We do not know how to act, on the one hand trying to find out what we did incorrectly and on the other being absolutely sure that it was more the client’s performance, which then causes us to be angry and sometimes afraid of him.
As therapists, we know it is not easy to admit that we may feel anger and fear toward our clients. However, in the specific case of the borderline client, these are the exact feelings that he commonly produces in the people who are the most intimate and dear to him. Therefore, it is essential that the therapist know this and decodify his own emotions without blame or shame, so as not to act in a complementary way and to be able to help the client understand the psychodynamic involved in the process.
Lineham (1993:3) estimates that 11% of the non-committed psychiatric clients, and 19% of the committed ones in the United States are borderline clients. Among those who are diagnosed with “personality disorders”, 33% of non-committed clients and 63% of committed ones are considered to be borderlines. This type of client is, therefore, frequent enough for one to believe that all therapists, in general, have had at least one case.
Besides this, they are also the ones who most commit suicide. It is estimated that 70 to 75% of borderline clients have at least one self-destructive episode or act, with approximately 9% of the cases being fatal (Lineham, 1993:3).
In Brazil, we do not know of any work concerning the prevalence of this pathology within mental diseases. However, considering our own clinics and the experiences of co-workers, we think that something similar must be taking place. What is intriguing is that besides the great danger of this condition, the available therapies fail without exception, and therapeutic advances are extremely insignificant and slow. The clients normally come to the clinics with a list of therapists whom they have already consulted, over medicated (as doctors try several psychiatric medicines to control the symptoms), and their families seem devastated and with no hope of attaining proper help.
BORDERLINE PERSONALITY CONCEPT 3
The term “borderline” was used for the first time by Adolf Stern in 1938 to describe a group of clients who appeared not to be benefiting from classical psychoanalysis, and who did not fit in the “neurotic” or “psychotic” categories. In reality, according to his classification they had a type of borderline neurosis.
In 1980, the condition was included in the Diagnosis and Statistics Manual – DSM III of the American Psychiatric Association4 which initially listed eight criteria (in the following revision, nine), five of which must be present to make the diagnosis of borderline disturbance:
- Pattern of unstable and intense interpersonal relationships, characterized by alternating between idealization and devaluation extremes.
The borderline client thinks in a dichotomous and radical way. His world, like the child’s, is full of heroes and villains, and not infrequently any slip-up or failure by the hero inevitably condemns him. He does not understand gray areas, inconsistencies or ambiguities. Good and evil do not mix: somebody is either totally good or totally evil. He idealizes and is disappointed all the time, appearing to be eternally searching for the perfect caregiver, the one who will always be correct.
- Impulsiveness in at least two areas5 potentially harmful to himself. (waste of money, sex, drug use, shoplifting, reckless driving, episodes of voracity).
The borderline lacks the ability to postpone gratification: his behavior results from intense momentary feelings and does not seem to learn from experience. He has an altered notion of time: “yesterday” and “tomorrow” are meaningless; only “today” seems to exist.
- Instability in showing affection due to accentuated mood reactiveness. (episodes of intense dysphoria, irritability, or anxiety usually lasting a few hours but rarely more than a few days).
The borderline client’s mood can vary greatly in only one day or even in a few hours. He is not usually calm and controlled but frequently hyperactive, pessimistic, and depressed. His reactions are generally very intense and inappropriate for the situation that produced them.
- Intense and inappropriate anger or difficulty in controlling it. (Frequently demonstrates irritation, constant anger, and reoccurring physical fights).
His fits of rage are unpredictable and disproportionate to the frustrations that produced them. Domestic scenes of the type: screaming, breaking objects, threatening with knives, and hitting/scratching people are typical of these clients. The anger appears after any trivial offense, but in reality seems to come from some underground arsenal, from the fear of being abandoned or disappointed.
The borderline’s anger is directed at those closest: relatives, therapists or doctors. It aims to test the bonds and commitments in an incessant search to find out how far he can push people. It seems to be an incompetent cry for help, as it ends up pushing away the people whom he needs most. For this reason, many therapists stop the treatment early or limit the number of borderline clients whom they treat.
5- Threats, gestures, or recurring suicidal and self-mutilating behavior.
This self-destructive behavior has a double meaning: firstly, it is witness to the depression and despair underlying these conditions: to feel physical pain is, in extreme cases, the only way of feeling alive and/or a very efficient way of distracting oneself from greater suffering; secondly, the para-suicidal6 behavior shows these client’s need to manipulate the people who take care of them in order to get more attention or love. In general, they do not want to die but only to communicate their suffering in a convincing way.
Paradoxically, because of being insistent and repetitive they end up driving people away, which makes them needier, more desperate, and with a greater desire to hurt themselves.
Many clients report feeling calm and relieved after such “accidents”, and some scientists try to explain this phenomenon attributing it to the release of endorphins, which are a kind of self-treatment by the organism when in pain. Effectively, both self-destructive behavior as well as the well being it leads to are not easily understood phenomena.
relation to psychotherapy, this symptom is what causes therapists their greatest problems: they pay a great amount of attention to these behaviors, running the risk of reinforcing them; on the other hand if they are ignored, the client can insist and go on in a progression of attempts to cause a stronger impact, which can result in suicide.
Self-mutilation, except when associated with psychosis, is a type of borderline disturbance trademark. There are many different ways for a person to self inflict harm: he can cut himself, smoke or eat in excess, obviously neglect his body, drive recklessly, etc.
- Identity disturbance; accentuated instability and resistance to self-image or the feeling of self.
The borderline person lacks a clear perception of the limits between himself and the other. In general, he needs to impress people to keep them around him, and his sense of identity and self-esteem are associated with getting this attention or not. Therefore, he has to always be proving this, but deep down he has a feeling of non-authenticity, of falseness. Even when he achieves success, the borderline gets upset, believing that he did not deserve it or that at any time they will find out he is a fraud and will be humiliated.
That is why these people go from job to job, not sticking to any of them: they always have the hope that the next one will be different and they will feel better there. Literally, they cannot “find themselves”. Many times questions of sexual identity are also included in this confusion, since in the same way that the borderline does not know whom he is, he is also not able to decide what he desires.
- Chronic feeling of emptiness or boredom.
The absence of a strong sense of identity must culminate in a feeling of existential emptiness. This is so painful that the borderline searches out impulsive and self-destructive behaviors to get rid of this sensation.
- Frenetic efforts to avoid real or imaginary abandonment.
In the same way that a child is not able to distinguish between the occasional absence of his mother or her death or disappearance, the borderline experiences occasional loneliness as a sensation of complete and eternal isolation.
He cannot tolerate loneliness, becoming gravely depressed with real or imaginary abandonment as he loses the sensation of being alive. His existential motto appears to be: “if others interact with me, than I exist.”
- Transitory paranoid ideation related to stressful situations or severe dissociative symptoms.
In high stress situations, the borderline can show temporary dissociations, confused and delirious thinking, and paranoid interpretation of the facts. In general, he presents himself as a victim of an unjust situation.
The differential diagnosis between the various personality disturbances is not an easy task, as mixed conditions with similar symptomatology are common. In reality, the borderline disturbance is compatible with various other pathologies, making it difficult to know what came before – for example, if the personality disturbance came before a period of depression or alcoholism or if it were secondary to these occurrences.
Many times the borderline client presents a paranoid and split ideation, only differentiating himself from paranoid schizophrenic clients because the crises are faster and do not cause acute after effects like in schizophrenia. Besides this, the schizophrenic ends up getting used to his deliriums and persecutions, being less disturbed by them than the borderline.
In relation to diseases of intimacy, mainly bipolar ones, there are similarities relative to sudden changes of mood. However, in the borderline these changes are faster and, even in the period between crisis, he has difficulty in adapting to reality. It is also possible to confuse a borderline with a chronic hypochondriac, as they both maintain intense physical complaints to achieve bonds of dependence with family members and/or doctors.
Many authors still believe that there is a high prevalence of borderline disturbance between clients who are diagnosed with multiple personalities or post-traumatic stress.
Herman (1992:123-129) studies survivors from various types of trauma (such as varied forms of child abuse, rape, war, etc.) suggesting the generic name of “Complex Post-Traumatic Stress Syndrome” to include all these conditions.
She correctly argues that the “borderline personality” diagnosis has caused more damage than benefit for the study of personality disturbances. Like the term “hysterical” whose negative and pejorative connotation ended up becoming psychiatric jargon, the word “borderline” has come to mean manipulator and troublemaker over the last few years. This makes it impossible for the clients to be viewed as heroic survivors of severe childhood drama, with all the respect that this fact requires. This author also shows that the psyche has and uses some defensive resources against limiting- situations that make an attempt against human dignity. Dissociation, intrusion, irritability, self-hypnosis, impulsiveness, intense mood swings, self-mutilation, etc. are some of the defensive tools that will later constitute the different conditions of personality disorders.
Another dysfunction that is often associated with the borderline personality is the narcissistic personality disturbance. It is especially noteworthy because of the presence of a hypersensitivity to criticism and that any failure can cause grave depression. The great difference here is that in the long term the narcissist ends up being, in general, professionally successful. He works very hard to construct and keep up his powerful public image, being deeply self-centered and not getting personally involved with others. The borderline, on the other hand, does not have staying power or discipline and destroys bonds of affection and professionalism. Besides this he is sleazy, insistent, and very vulnerable to others’ opinions.
As far as the diagnostic similarity to clients categorized as para-suicidal in the AXIS and DSM diagnostic manuals, there are in fact symptoms common to both conditions such as: accentuated emotional loss of control, irritability and hostility, serious interpersonal problems, patterns of behavioral loss of control, drug abuse, sexual promiscuity, and previous suicide attempts. The cognitive difficulties are also similar: stressed cognitive rigidity, dichotomous thought, little capacity for abstraction and problem resolution. Such cognitive difficulties are related to the episodic memory deficit. The individuals affirm that their behavior is to escape an unbearable life.
It seems certain that the behavior that most differentiates the borderline from other conditions of personality disturbance is the presence of self-destructive acts and suicide attempts. Among those who show the eight DSM-III-R criteria, 36% kill themselves, compared to 7% of those who show five to seven of these criteria.
Three types of causes come to mind when one tries to explain this disturbance: inappropriate emotional development, and constitutional and sociocultural factors.
INAPPROPRIATE EMOTIONAL DEVELOPMENT
The clinical history of borderline clients frequently shows that they come from highly disturbed families, with a high percentage of fights and separations. In general they were children who suffered a wide variety of childhood abuse, such as:
- Physical abuse — they were victims of physical violence or were present when family members were beaten.
- Sexual abuse — they experienced incestuous relationships and/or different forms of sexual insinuations on the part of adults near to them. Kroll, (1993:55-56) says: “Our unified point of view is that episodes of childhood sexual abuse have been the most frequent cause of problems that lead to the borderline personality.”
- Emotional abuse — they suffered neglect and lack of care on the parents’ part, where an inversion of dependence was frequent and the child began to take care of the parents rather than the opposite.
Self-destructive behavior in borderline clients would be unconscious ways of perpetuating abusive parents.
As far as development phases or at what moment in the client’s life this pathology takes root, the age of 18 to 30 months, shortly after learning how to walk is often mentioned in specialized literature (Mahler,1977:82-95; Erikson,1968:107-115). Parents in this period oscillate between controlling the child so that he does not hurt himself (since he recently began to walk), or becoming slightly absent – prematurely freed from caring for a child who now would rather explore the world than passively remain in the parents’ lap.
In reality, many parents cannot stand the children’s autonomy, become resentful and threaten them with abandonment. Malher describes this period as one of separation-individualization and believes that it is crucial to the development of a separate and secure self. He observes the children of mothers who either excessively abandon or overly possess them. These children develop an intense fear of abandonment or a premature omnipotence of the type “I don’t need anybody”, for fear of being suffocated.
Erikson describes this same phase, however, in terms of polarization between search for autonomy (attempt to impose their desires), and shame and doubt (in the face of failures). The child is still very dependent on the environment and his desire for self-affirmation, intense and violent, is greater than his ability of being able to impose himself. The borderline disturbance would be the consequence of an overly authoritarian upbringing, whose strict parents would always impose their desires on the child. With time, the attempts at self-affirmation succumb to the parents’ desires and the child ends up becoming used to always submitting himself, developing a feeling of doubt about his own capabilities and shame over his failures. Little by little, he stops trying to express his wishes.
What is found in literature only suggests the presence of constitutional or hereditary factors in this condition’s etiology. For example, we know that siblings raised in the same family react to conflicts in different ways and only a few become borderline. This shows that something specific is needed to create one type of disease and not another. However, the individual who will later develop a borderline disturbance condition is, from childhood, a hypersensitive child who asks too much from his environment; he is more vulnerable, his needs are already shown to be very intense, his threshold for frustration is less, and his reactions more exaggerated.
It is also known that anti-depressant drugs and even anti-convulsive ones have the effect of alleviating symptoms in some borderline clients, in spite of not producing changes in basic personality.
Some other studies (Stewart and Montgomery, 1987:260-266) suggest a relationship between impulsive actions and abnormalities in the serotonin metabolism. Paul Andrulois and contributors (1980:47-66) point out the prevalence of neurological disorders such as hyperactivity, attention deficit disorders, epilepsy, etc. in borderline adolescents.
Finally, the presence of borderline parents (one or both) is extremely relevant in clinical histories. However, it is impossible to determine at this moment if this signifies a biological or psychological inheritance.
Some authors correctly point out that there are sociocultural conditions contributing to the high incidence of narcissistic and borderline disturbances nowadays. The lack of a nuclear family structure composed of a mother and father who spend part of the day taking care of their children is one of the points most often cited in this type of analysis.
The change in the role of women over the last thirty years ended up radically changing the domestic routine: the famous “dad works and mom takes care of the kids” does not exist anymore, because now ”mom is also working outside of the home”. The children go to school early or remain in the care of others and old people are treated with disdain, which contributes to one losing the sense of pertinence and history, family closeness, and reference to consistent social roles.
Other factors like technological advances, especially in the computer area, contribute to people being more and more self-sufficient and having isolated work and study routines.
We live in a “borderland” where we stimulate assertiveness (which in extreme doses borders on aggressiveness), individualism (which favors loneliness and alienation) and self-preservation (“each one for himself, God for all”).
Our society needs consistency and reliability and is extremely alienating, favoring the appearance of a gamut of pathological behaviors, such as drug addiction, eating disorders, criminal behavior, etc.
Religious sects which try to organize reality in a very simple and polarized way – ”what is right and what is wrong” – gain popularity, perhaps as a reaction to a certain nostalgia for the old days when an organized family set up rules for how to live.
Kreisman (1991) makes an interesting comparison:
We quickly moved ourselves out of the explosive ‘We Decade’ of the 60’s into the narcissistic ‘I Decade’ of the 70’s, and from there to the materialistic and fast ‘Power Decade’ of the 80’s. Following these external changes, internal changes occurred in our values: from the ideology aimed towards others, the ‘peace, love, and brotherhood’ of the 60’s, to the ‘self-awareness’ of the 70’s, and from there to the ‘self-searching materialist’ of the 80’s.”
We know that many physical diseases like stress and all the disorders it produces, such as heart attacks, hypertension, etc., are closely related to lifestyle. Why not think the same about mental diseases? They are perhaps the psychological price we pay for our modernity.
PSYCHODYNAMIC – HOW BORDERLINE WORKS
Imagine a person who because of some congenital mistake is born without skin: any touch, even the lightest one would cause intense pain and reaction. This is the borderline; what he is missing is the “emotional skin”. Searching in a simplistic way for this pathology’s formula, we might think that an overly sensitive child in contact with an invalidating and multi-abusive environment which destroys his basic self-confidence, has a tendency to develop defensive behaviors which are going to make up the very characteristics of this disturbance.
An environment that offers little validation is one which does not teach the child how to adequately deal with his emotions. This learning process includes not only recognizing and naming the different emotions but also learning how to externalize them, hold them in, deal with frustrations, and above all to believe in one’s own emotional responses as a valid form of interpreting the facts (basic self-confidence). What is peculiar about this learning process is that it is in large part non-verbal: children learn not only through what adults say, but especially through subtly observing how they truly are and act.
These clients’ dysfunctional families tend to deal inconsistently with emotional manifestations: sometimes they ignore; sometimes they minimize and do not confirm; and in some extreme situations, they support and shelter. It is from this inconsistent performance that some children learn to focus their energy in accomplishing something “great”. This makes them feel noticed and valued, but detours the attention needed to adequately deal with reality away from routine matters. Little by little, they become less competent, more dependent, and less responsible than the other kids.
Because of this, the borderline as adult tries to keep himself close to a caregiver at all costs. His attitude is passive towards what he must do, but he is extremely active in seeking out someone that will do it for him. This is accomplished in many ways: for example, remaining chronically sick psychologically (depression, anorexia nervosa, alcoholism), or physically (colds that do not go away, general hypochondriac complaints); presenting himself as a very naive person without any maliciousness to then set up a manipulative relationship; creating a great amount of trouble in these relationships and being the eternal victim – never receiving justice and always fighting for his rights, etc.
The people who live around the borderline, therapists and family members, have the sensation that they are going around “walking on eggs”. They often say he is never satisfied and the situations that he creates do not seem to have a way out. He has to have something to complain about, perhaps, to keep someone close to him trying to satisfy him.
Besides this, as he comes from an environment that neglects the growing child’s basic dependence needs (Cukier, 1995:65-69), the borderline remains fixated on searching for a good caregiver, the “perfect” one. He idealizes and disappoints himself easily, becoming furious when noticing other’s imperfections. He is like a child who imagines that his mother knows and can do everything, and he does not admit the opposite hypothesis.
When he grows up, the borderline ends up reproducing the invalidating characteristics from his environment: he invalidates his own emotional experiences and looks for other interpretations of reality. He is incapable of solving routine problems and has generalized difficulties about “how to live”. He sets unrealistic goals for himself, does not value small achievements, and hates himself for his failures. The “shame” reaction, characteristic of these individuals, is the natural product of an environment that shames those who show emotional vulnerability. Besides this, his suffering and emotional reactions are extreme: what would be just embarrassing becomes deeply humiliating; displeasure can become hate; a slight fault becomes shame; apprehension becomes panic or terror.
A “prisoner” of his own emotions, he needs only a small motive to provoke strong reaction such as fits of rage and violence, which confuse and frighten the people around him and himself. He creates great tragedies which he complains about with increasing rage, blaming others for the situation which he finds himself in; the greater the fit of rage, the more the borderline convinces himself and tries to convince others that they are the ones responsible for his feelings. Along with that, his emotional responses are long lasting and take a long time to return to a more appropriate emotional level. This contributes to his being highly sensitive to the next emotional stimulus.
Having his emotional development stopped in the first phases, the borderline is a child in an adult’s body. And like all children he is impulsive, does not know how to wait, cannot stand being frustrated, has difficulty in symbolizing abstract concepts (like time for example), and is always trying to get everything that he wants, at any cost. Because of difficulty in making decisions and taking on responsibility, he tends to be more successful professionally in lesser positions, preferring well structured jobs that do not demand these abilities.
In short, the borderline has tremendous difficulty dealing appropriately with his emotions, and the therapist needs to find ways: first, not to allow himself to be destroyed by emotional macro-demonstrations; second, not to destroy the precarious emotional structure that these clients show (we must remember that they do not have “emotional skin”); and finally, he needs to find creative ways of performing small “skin grafts” and give these clients some covering so they can grow and develop with dignity.
BORDERLINE CLIENT PSYCHOTHERAPY
There are two fundamental difficulties in the therapeutic treatment of borderline clients:
The first is what we could call collision of objectives, which means those goals usually accepted as valid in therapy (understanding one’s own problems, “healing oneself”, undertaking constructive changes in one’s life, etc.) are not the client’s priority aims. Initially the client does not want to heal himself; to one extent, he is proud of the symptomatology he presents, as it is witness to the atrocities that he has gone through in life. What he is looking for in the therapeutic bond is exactly this witness function: someone who sees and disagrees with the injustices that were committed against him. And he also wants (it is there where the therapeutic job becomes much more complicated) the therapist to compensate him for everything that he has gone through; he wants to be gratified for his immediate needs, be taken care of and comforted. And even more, he wants an intense and special relationship to feel important. Apparently, these client’s implicit speech is always: “I cannot get better unless you, the therapist, demonstrate that you care about me personally.”
M., 16 years old; thinking about studying psychology and not being happy with her own appearance were what brought her to therapy. In the initial interview, her parents complained about her attempts to manipulate everyone in the family to get what she wanted.
From the start, she showed herself to be an extremely insecure person, anxious to please and full of anguish. She right away established an idealized bond with the therapist, not missing any opportunity to praise her (the therapist) or recommend her best friends for treatment with her.
To investigate the purpose of these recommendations and the exaggerated idealization, an internal psychodrama was proposed (since the client refused to dramatize). After the initial warm-up T (the therapist) suggested focusing on the therapeutic relationship using role reversals, so that she could experience the two sides of the bonds.
In her own role, M stated that she was fascinated by T and wanted to get her affection in a “special way”, because this therapist, unlike the previous one, seemed to be competent and capable of understanding her. In T’s role the client was unreachable, a person who did not need anything and was very appreciative of the client and her “presents” (recommendations), however, not to the point of allowing her into the so called “special place”.
Still in the internal psychodrama, using directions so that the client could distance herself from this relationship and observe it, T asked what other relationship in her life she had felt the same way, liking somebody so much that they seemed unattainable and that no matter how much she tried to please, she could not obtain what she most wanted.
The client then remembered a scene from her childhood when she was around 4 or 5 years old in which, being out with her real father, she did everything to seem unpleasant and deny his importance: she wanted to make it clear that she loved her stepfather more, recently married to her mother and who had assumed the position of full time father. M felt very grateful to her stepfather and could not stand the idea of displeasing him. Praising him in front of her real father constituted a way of paying him homage and simultaneously getting revenge for her father’s abandoning her.
Reviewing this scene led the client to notice several of her attempts throughout her life of feeling “special”; attempts which failed systematically without exception: she had not been special to her father, who rarely visited her; she was not special to her mother, who had many priorities; and she did not even remain special to her stepfather after the birth of the couple’s new children. Her performance in therapy was just one more attempt to reach this “special” place, unattainable.
The second great difficulty treating such clients in therapy is the relationship style that they try to establish with the therapist: at the same time that they try to gratify their needs, they do not believe that this can occur. Knowing that many of these people suffer distinct forms of child abuse from their caregivers, it is easy to imagine how any bond that implies personal care will soon be filled with distrust from the past. However, firmly establishing the therapeutic bond and the sensation of being understood and accepted is the first step for the borderline client to be able to throw himself into the painful attempt of looking at his difficulties and trying to change his life.
This sensation of being accepted and understood is unknown to the borderline, who will need to check it repeatedly. His movements will be ones of advance and retreat, and the therapist also needs to advance and retreat in order to maintain this balance: an exaggerated advance or a very great retreat on the therapist’s part could put the work already done in jeopardy. The client will be constantly testing how important he is to the therapist and at the slightest sign that could be interpreted as rejection, he can attack, sabotage, or interrupt the therapy.
I., 34 years old, with a history of many previous unsuccessful therapies, starts therapy deeply depressed, crying, and without hope. Since the beginning she has been very critical of everything that T says, the way she does it or the moment she does it; in short, she is always emphasizing disagreements and making T feel cornered, having to take a lot of care not to wound her.
No attempt at clearing up these misunderstandings was very successful because the client started a confrontation, opposing her version of the facts against T’s version. It always seemed that a judge would be necessary to decide what was right.
One day T, abstracting the client’s complaints from the verbal context, began to pay attention to how much she suffered from those episodes in which she was always crying a lot and seemed to feel anguished, and that she had been treated unjustly. She decided to apologize:
-I., somehow, some things I say or do unintentionally touch an old wound of yours. I want to apologize to you for this, because there is no way that I want to induce pain or harm on you. I believe that if we are patient together, we will discover where this very sensitive point is. For now, I would like you to accept my apology, even though I don’t know what I did to hurt you.
The client became completely bewildered by T’s attitude and crying, answered that T was not to blame and that she, the client, was always starting fights in all of her relationships and that a confrontational atmosphere was common in her life. T then asked her to create a character to represent this feeling of injustice that was always attacking her, and she produced a Medieval Crusader who defended the cause of the Holy Catholic Church. I. remained in therapy for four years in individual and group sessions; she never abandoned the Crusader as a reference for these confrontational states and could, through its inter-mediation, investigate several situations of domestic violence which she had suffered in childhood. She mentioned “that day when T apologized to her” several times throughout those four years, repeatedly assuring that that was the most important moment of the therapy, without which she could not have continued.
Besides these two fundamental difficulties there are many others throughout the therapeutic process: sometimes in the middle of some simple and unimportant speech, the client rapidly escalates to extremely controversial and confrontational themes. Others, on the contrary try to please the therapist, taking on his points of view and ways of thinking, and the therapist must be careful to prevent this from happening. Many borderline clients frankly try to seduce the therapist, probably showing the way they used to obtain consideration and perhaps even some kindness in the past. Many times the therapist is taken by surprise like in guerrilla warfare: very seductive forms of relationships alternating with very aggressive ones.
Lineham (1992) and Kroll (1994) call attention to the need for validation, support, and empathy for the borderline client exactly because he lived through childhood experiences that invalidated his right to exist, have personal limits, develop individuality, and confide in his own ability to perceive and judge reality.
To validate and affirm, give permission, and gratify are therapeutic actions that many times superimpose themselves, generating confusion crucial to the therapy going well. Validation and affirmation are actions which aim at helping the client to develop an intrinsic notion of personal value, through a therapeutic relationship of acceptance which tries to illuminate the client’s positive qualities, as few as they are. This is not always easy since clients bring a huge gamut of inadequate behaviors, and it is necessary to be careful not to artificially reinforce this, which in no way would contribute to therapy. The fact that the client has survived in extremely adverse circumstances and is seeking out therapy, already represents a praiseworthy action in itself, since it takes courage to confront this journey. Real affirmation and restraint also come out of the respect that the therapist has for the client, establishing limits that he, the therapist himself, respects such as: time, space, phone calls, etc.
P., 30 years old, gets home wanting attention from his wife, who at the same time is tired and busy with the couple’s two-year-old son. His wife’s attitude is immediately interpreted as rejection and P begins to attack her, first verbally and then physically. His discontentedness and frustration increase rapidly and he cannot contain himself.
In the session, starting from the described situation and following other scene associations, we get to a scene in which he is three years old and wants to be held by his mother, who is busy cooking. She abruptly pushes him away from her and he begins to kick her out of anger. T asks the client what he as an adult would do with the child in this situation, and he answers that he would hold him before he started kicking his mother. T asks him to do it (with a cushion in the place of the child) and he hugs the cushion and cries.
In the comments, T validates both the pain of the frustrated child in the scene as well as that of the needy man arriving home; the way of dealing with his frustration and the manner of expressing his needs are discussed. One of the themes is how to contain a hurt and angry man, and the client suggests various possibilities: take a bath, go out for a walk, write a letter, etc.
Another way of affirming is to confirm the perception that the client has of his own parents and what they did to him. The therapist would be a witness to this abuse, having to help the client cry his pain and suffering away, and refocus and better organize his anger. In most cases the client turns his anger against himself, which constitutes one of the reasons for the bizarre self-destructive behavior noticed in these cases. Caution is necessary here not to excessively criticize the childhood parents because this means criticizing parts of the client himself.
M., 17 years old, 2 years in therapy, has been wanting to tell T about a subject for one month, but it is very difficult for her to approach it. Finally, she is able to tell her a “secret” which she is ashamed of and happened when she was five years old: they were at a beach house with a group of children and relatives and she allowed herself to be sexually manipulated by a teenage cousin.
Her mother accidentally discovered what had happened and became furious, harshly criticizing her in front of everybody and telling the story in a very disrespectful way to all the adults present. From this experience M concluded that she had done something very ugly, that she herself was bad and wrong, and that she should be ashamed of herself forever.
T suggests a role reversal with the frightened and guilty five-year-old girl, asking her what could have helped her to better overcome that experience. M responds that if the mother had supported her and explained what she had done wrong, along with keeping the matter to themselves, everything would have been much easier. The way her mother did it only taught her disrespect, shame, and guilt.
T agrees with her assessment, witnesses her pain and enables her to express the anger she has for her mother. The next step is to review the shame and the consequences of that sexual experience. In childhood, everything seems very serious and definitive; as adults the perception becomes relative. M contains her own little girl and gives a new meaning to the effects of this experience: nothing is totally wrecked forever!
Frequently, the borderline client tries to make the other complement him pathologically and go beyond the limits of therapy. It is always good to remember that a client’s greatest desire is to be helped to overcome the difficulties he has lived through, and it is there that the therapist must base his procedure.
M frequently requested schedule changes, giving too much importance to daily obstacles and wanting time periods which were incompatible with those of T’s. Besides this, finishing up the session at the scheduled time was difficult, since M would always bring up a very important subject right at the end. At first T tried to work around her schedule, trying to make the therapy viable.
One day after almost one and a half years of working together M, when the session finished, refused to leave the room without any apparent justification, urging T to remove her by force. After some discussion T noticed that M was overlapping the next session’s time period. T decided to let her stay in the room as long as she “needed” and to go see the next client in another empty room in her office. M remained alone in the room and after some time went away. In the following session she arrived apologizing, saying that she did not know what had provoked her into that attitude. Investigating what had happened using role reversal, M realized that she had been observing the client who came after her and felt very jealous because she was more beautiful, and “T would certainly find her more interesting”.
These associations led back to her relationship with her half brothers and parents, who “never chose her” unless she did something out of the ordinary, positive or negative. M realized how difficult it was for her to feel validated if she just behaved normally and accepted the limits that were put on her.
Permission9 is a very complex concept, as it implies validating the right that the client has of feeling and expressing his own emotions (anger, love, selfishness) and of being respected as a human being. For example, it is normal for a client not to be able to cut himself off from people who in the past were abusive to him. The client needs to obtain this permission, therefore, in therapy.
VULNERABLE POINTS OF BORDERLINE CLIENT THERAPISTS
Borderline therapy is very delicate and the therapeutic relationship itself is firmly included. As the borderline is an eternal unloved child in search of a good caregiver, he will try to make the therapist fulfill this role. It is the therapist’s task to accept and validate the client’s feelings without entering in collusion with the part that he performs, in reality trying not to become responsible for him. The therapist needs to believe that the client has inside himself all the necessary potential for change. He must also emphasize, therapeutically, that the client recognize his emotions and confidence in his own perceptions as valid ways of interpreting reality, instead of adopting emotions and opinions from others.
The question of gratifying needs is the most crucial one in borderline therapy. As we have already said, the client’s entire performance with the therapist looks to find a place of special importance for him.
Kroll (1993), studying a wide variety of cases, mentions therapeutic and legal complications that resulted from a lack of discussion about this topic in particular. For example, legal actions alleging sexual abuse or malpractice brought by clients against therapists, threats of suicide related to certain actions that the therapist must or must not undertake, etc.
Especially questions like having or not having bodily contact with clients (hugs at very tense moments, for example), changing appointments to special days and times, permitting long phone calls at inconvenient times, etc., are small concessions that the therapist begins making almost unconsciously and which commonly evolve to the point of invalidating the therapeutic setting.
One wonders why even experienced therapists usually respond to the borderline clients’ pleas in this way. Probably due to these clients’ extreme vulnerability and a certain dose of the all-powerful savior of the world10 counter-transference that all of us have.
The excess or lack of gratification damages and may even sabotage borderline client therapy. The borderline, probably like all psychotics, has the capacity of crossing the professional line as if needing to feel the therapist’s real person. Very professional and rigid asepsis rules do not work very well with these clients, since they feel devaluated, unconfirmed, and become furious.
It is very hard for a client who has lived through these difficulties to hear the truth. This “child inside an adult’s body” does everything not to notice that his childhood has already passed him by, and that the rules and privileges of the adult world are different. Because of this, support and empathy are constantly fundamental. Without them, the borderline does not listen to the therapist’s statements about reality because he feels misunderstood and fights with the therapist.
This therapy’s difficulties are innumerable: the borderline client lives in a state of intense suffering, and many times the situations advance and become so complicated that it becomes difficult to focus on the fact which produced them. The sensation is one of building a house in the middle of a hurricane, which can seem very discouraging to the therapist.
Besides this, as the borderline deals poorly with all of his emotions, he also deals poorly with anger, being frequently subject to aggressive and explosive behavior. The risk here is that the therapist ends up “over-interpreting” the anger, without noticing what it hides – an intense vulnerability.
Finally, it is necessary to warn of the danger Lineham (1993:97) calls “blaming the victim”. In the beginning of treatment the therapist sensitizes himself to the client’s intense suffering and tries to reverse it. However, little by little when he realizes that his efforts seem useless, he can start to blame the client for causing his own degradation (he is the one who does not change and is fighting the therapy).
What is happening here is that the therapist ends up observing the behavioral consequences (the client’s suffering and the suffering that he is inflicting on the therapist) and attributing this consequence to the client’s internal and deliberate motives. In this situation it becomes very easy for the therapist to resign himself to failure, blaming the client for interrupting the treatment and relieving himself of responsibility.
THE BORDERLINE CLIENT IN PSYCHODRAMATIC PSYCHOTHERAPY
“There seems to be nothing for which human beings are less prepared and the human brain less equipped than for surprise”.
Keeping in mind psychodrama’s relational character, it is easy to see its appropriateness for treating borderline clients in which the client-therapist relationship is the fundamental instrument.
Psychodrama, thanks to its technical resources, subtly manages to enter the client’s intrapsychic defense areas, enabling him to relate to separate parts of himself. Besides this, it is an intense therapeutic relationship that offers a chance for “live correction” of relationship forms.
It is a dialectic movement between entering the behind the scenes of psychic life where relationship wounds from the past are stored – creating armies of characterological l defense – and the return to the here and now from a validating and warm relationship which, besides being a witness to past pain, offers a new and repairing relational model.
The borderline client, used to defending himself verbally, surprises himself with psychodrama. He is not able to control or predict either the therapist’s actions or his own reactions and associations.
This represents a great advantage for the therapist, who must however be careful with the client’s timing and sensitiveness. Many times the client appears quite warmed-up, bringing up material of an intimate nature as if he were impulsively revealing all of his pain. Getting close too abruptly runs the risk of coming across a lack of prepared structure on the client’s part, who later will invariably feel harmed. Many times it is a matter of cooling the client down for him to slowly descend into the depth of his questions and act in a responsible way according to his self-exposure level.
N.L., 50 years old, two years in individual therapy, begins a therapeutic group session in which the people hardly know each other and appear careful and hesitant, being the last to introduce herself. She speaks aggressively, saying that she was not there to waste time that she had been raped as a child and still today was searching for dangerous experiences, such as having sex with anyone who appeared in front of her. The group becomes stupefied, nobody says anything, and the client becomes angry and initiates an argument.
T interferes, showing her that what she referred to as a “waste of time” was a normal way for the people to gradually get to know each other to be able to build up bonds of mutual trust, in which each one’s privacy could be respected. In the rape scene that she told about, her privacy had not been respected and the way that she presented herself to the group ended up being a type of self-rape, where she neither respected herself nor the group.
In the above-mentioned case, T just pointed out the speed and intensity that the client wanted to initiate the relationships. Other types of overly warmed-up clients demand a few technical resources to help them cool down. Carefully setting up scenes, asking for role reversals, using objects from the room, and carefully interviewing supporting characters are ways of strategically cooling down.
P, while setting up the scenes, would already start playing the roles and counter-roles speaking angrily, barely giving enough time to compose the scenery. She seemed that it was a waste of time to specify the space, as if she were always being pushed by an urgency to finish the job quickly. One day T asked her, after she had quickly described her bedroom, to switch places with the door key. She seemed completely surprised and said abruptly that she had never had a key in the door. Then T asked her to take on the role of this door without a key. All choked up, she said that the door did not protect her privacy and that through it a father came in during the night to look at her naked.
The double technique is valuable but dangerous to be used with the borderline. Caution should be shown mainly in the question of timing, as was pointed out earlier, because the client easily denies the double if it is not synchronized with his vulnerability. As a matter of fact, the best double for an infuriated client is the one which points out the sadness, the hurt, and the deception that led to the defensive response. Many times feelings of humiliation and shame are also involved.
A double that points out the manipulative character of a client’s aggressive behavior needs to be carefully introduced, and only after the affirmation of his weakened aspects.
R 30 years old, two years in bipersonal therapy and six months in group therapy. Comes to the group session angry at the other group members, who had agreed to call each other and go out during the week, but nobody called her. She tells the group:
-You really can’t trust anybody! You guys are all talk, but deep down you are as irresponsible and stupid as everybody else! I don’t know if it is worthwhile having therapy if the people are so set in their ways and don’t care about other people’s feelings. I will never make plans with you again!
Various people in the group tried to justify their absences, but R replied to them all with growing fury, not accepting excuses and invalidating any conciliatory attempts. T made a double of the group telling R how the group felt impotent since she did not accept anything they were offering her.
R became even angrier, saying that now the group was the poor one and she the villain, when in truth the situation was the reverse. Then T placed herself at her side and, imitating the same bodily position, said in a low voice:
– I would like so much to be understood, not accused . . . I feel so sad . . . I would like so much to have been with you guys during the week . . . everything got screwed up! And now . . . everything is getting even worse . . . I don’t know how to fix it . . . I am feeling more and more alone!
The client began to cry a lot after finishing the double and was able to change her attitude towards the group which, at the same time, managed finally to get closer and talk to her.
The mirroring technique is very useful for permitting a view away from the power struggles involved in the interactions, as well as the Psychodynamic produced. The therapist in this situation can formulate a synthesis of what the scene shows, accentuating parts that the client probably still does not realize. It would be like a reinterpretation, in loco, of facts that the client had interpreted differently.
L..,20 years old, is becoming an alcoholic, getting more and more involved with hard drugs. She says that she is not capable of resisting drugs when she knows that there is the possibility of getting them. However, after using them, she feels very bad and regrets allowing herself to take them.
Starting from the scene in which she gives in to drug use, L gets to a scene where she is four years old, alone in the house, feeling sad and abandoned. While she plays with a big ball all alone, she thinks that if she hurt herself, her parents would have to come home and take care of her. In continuum, she throws herself against the wall with all her might, injuring her head which begins to bleed.
Her parents are called and immediately return home to help her. Although in pain, L is happy: her parents are worried about her and together with her. It was not such a bad price that she paid!
T, leaving the positions marked off by the cushions, asks her to leave and observe the scene from outside it. T stimulates the client to observe what is happening to that little girl from her present adult role.
– Look at what is happening to that little girl. She is learning to hurt herself; attacking herself is a good way to get attention, and this is what she is going to continue doing in her life. Her capacity for self-destruction will continue growing: she will get involved in car accidents, consume great quantities of alcohol, begin to take harder and harder drugs . . .Do you think that is what she really wants? Before she started to hurt herself, what do you think that she needed?
L. sadly observes the little girl, saying that she needs love and affection, but that those parents were incapable of spontaneously giving that to her. T then asks her as an adult to hold her needy little girl and see if together they would like to maintain the self-aggression and self-destruction pact, if they keep on thinking that it is a reasonable price to get love and attention.
L., holding in her arms the cushion that represents the little girl, speaks to her affectionately, saying that this was not what she wanted and that it would be necessary to find another way, but that it would take time because she did not have any idea how she could do it differently.
Mirroring is therefore a privileged place of insights for the client and therapist, but it is important that the therapist be faithful to what the client brought, not adding personal content or theories.
The technique of Supplementary Reality becomes a valuable resource to be used in borderline client therapy, since it permits him to catch a glimpse, even though in a fantasy, of the necessary solutions for the various dead end situations which are frequently proposed.
B., 27 years old, four years in individual and group therapy. Complains of professional dissatisfaction, because he always ends up having to take on greater responsibility than his partner in the firm. He feels incapable of discussing this matter with his partner without becoming internally resentful and aggressive, since his apparent attitude is one of submission and impotence.
In a scene in which he was presenting this reaction in front of his partner, T asks in what other situation from his life he had felt that same way.
Promptly, B brings up an old scene, which is already well known by T, in which after the suicide of his mother he desperately tries to please his father, even though feeling a lack of justice.
The six-year-old child, weak and helpless, does not have any alternative without anybody who could care or trust in him.
Invent the parents that you would like to have, T suggests.
B, visibly fascinated, chooses two people from the group, whom he likes a lot, to play the role of these ideal parents – caring, affectionate, and encouraging.
He spends a lot of time “enjoying” and perfecting his parents until he is satisfied.
Let’s go back to the scene with your partner except this time you will have these “good parents” behind you, who are going to cheer for you.
B looks at his partner, looks at his “parents”, who stare at him with tenderness; his posture becomes more erect and he talks calmly with his partner:
I have been very unhappy for a long time with the way things are going in the company. I think it is important that we discuss the matter in depth, because I have considered breaking up the partnership.
In the following session B tells us that the “false parental couple” seems to have injected him with an energy that is helping him to solve not only the partnership situation but also other unsolved situations in his life.
A very useful technique for working with the client’s aggressive aspects is a combination of anger concretization with the interpolation of a metaphor, which can symbolize the concretized product.
Cukier (1995:101-107) describes this character interpolation technique well. She shows how, through the relaxation of the client’s interpsychic area, experiencing reactive and defensive roles is made possible, highlighting them from the rest of the personality.
A., 43 years old, two years in bipersonal therapy, complains of debilitating jealousy of her husband and frequent crises of aggressiveness triggered by situations in which she feels insecure as a woman.
On one of these occasions, she sets up the scene of her husband getting home early in the morning. T suggests:
Show me with your body. . . without talking . . . how you are feeling.
Force the tension even more, T suggests. The client tenses up completely and seems like a monster twisted in rage.
T allows her to experience this bodily tension for some time, and after assertively suggests:
I want you to find a character now . . . from history . . . movies . . . any character who could feel like this.
The client lifts her arms and draws back her lips, exposing her teeth like fangs and forms her hands into claws as if she were as a beast.
Anything . . . the client asks.
Yes . . . the first thing that comes to your mind . . .don’t censor anything.
A tellurian woman . . . she answers firmly.
What are you like, tellurian woman? asks T curiously.
I am half woman . . . even sensual . . . and half beast . . . like a jaguar with its fangs ready to rip its prey apart.
From then on, T interviews this tellurian woman quite a bit. She tries to find out its background, when it first appeared, where its power comes from, if it even has any, etc. After this warm-up in the role, T asks the client to return to her own role, to be herself and tell her when and why she needed to create this tellurian woman inside of herself.
The client quickly brings up a scene in which, at five years old, she was taken to a psychologist’s office against her will. As soon as she got there, she began to kick, scream, and one time broke an office window. Her tellurian woman was a form of childhood defense that she had created against the impotence she felt being treated as crazy. She became “crazy” for revenge against being considered “crazy”.
In many other sessions the “Tellurian Woman” metaphor was used and even a collage was made to concretize it more. It ended up being a type of jargon between T and the client each time they wanted to refer to these aggressive defense reactions, which deep down denigrated her more than they defended her.
We believe that when a borderline client begins to understand the defensive nature of his aggressive parts, they acquire dignity and he can already stop identifying with them. He can now actively search for a more skillful way of defending himself, and this technique — the adding together of concretization with interpolation of metaphors — is extremely useful for this purpose.
Finally, we would like to comment briefly on the basic psychodramatic technique — role reversal. Experiencing the role of the other allows the client to absorb aspects of the relationship that he had not imagined. It also enables the therapist to have a more global view of the process’s psychodynamic.
Frequently, when we are investigating childhood scenes with borderline clients, we come across an “Other”, an abusive adult. It is important that the client has confirmed his abuse experience, but it is equally important that from time to time he can rescue some positive aspect from these primary relationships, without however denying the abuse suffered and the consequent emotion.
S., 28 years old, who was systematically beaten with a rod during his childhood. He tells T, when T interviews him in the mother’s role, that the mother herself was beaten during childhood with a copper wire. Her intention, when beating her son with the rod, was to give him the same education but hurting him less.
Asking questions about the abusive adult’s real intention could save, in this case, even a kind aspect from the mother, which in some way comforted the client.
Treating borderline clients presents a constant challenge for the therapist. The pain of a childhood lacking in basic care and validation saturates the possible forms of relationships for these clients, making them suspicious, demanding, scheming, and forever dissatisfied. Reaching a balance between attitudes of acceptance, support and validation on one hand, and the placing of structured limits on reality on the other, presents a difficult task for the therapist.
The seductive role of “savior”, trying to fill the client’s enormous needs, or the one of “blaming the victim”, making the client responsible for the therapy’s failure, are constant traps in the way of this task.
The creation of an “emotional skin” that can help the client to contain and organize his emotions, happens in a creative therapeutic relationship by way of small “skin grafts”, which allow us to give these clients some covering so they can grow and develop with dignity.
- American Psychiatric Association (1995) – “Manual de Diagnóstico e Estatístico de Transtornos Mentais” – 4 ° edição. Editora Artes Médicas, Porto Alegre DSM IV pp. 617
- Cukier, R.(1995) -” Como sobrevivem emocionalmente os seres humanos?” Revista Brasileira de Psicodrama, vol.3 Fascículo II, São Paulo.
- Cukier , R.(1992) – “ Psicodrama Bipessoal – sua técnica, seu paciente e seu terapeuta “ Editora Ágora, São Paulo.
- Erikson, Erik ( 1968) – “ Identidade, Juventude e Crise”, Zahar Editores, Rio de Jáneiro.
- Falivene,L.(1995) – “Jogo: Imaginário autorizado e exteriorizado” ” in “O jogo no Psicodrama” Júlia Mota, Editora Ágora, São Paulo.
- Lineham, M. Marsha (1993).- “Cognitive Behavioral Treatment of Borderline Personality Disorder “ Guilford Press.
- Herman , J.L (1992)- “ Trauma and Recovery” Basic Books, NY,
- Kreisman, J and Strauss,H. (1989)- “I hate you don’t live me- Understanding the Borderline Personality”. Avon Books, N.Y.
- Kroll, Jerome (1993)- “ PTSD/ Borderlines in Therapy: finding the balance ” W. W. Norton and Company Inc.
- Mahler, M. (1977)- “ O Nascimento Psicológico Humano”, Zahar Editores, Rio de Janeiro.
- Miller, Alice ( 1979) – “ O drama da criança bem dotada ”. Editora Summus,1997.
- Millon, T. (1987) – “ On the genesis and prevalence of the borderline personality disorder: A social learning thesis “ , Journal of Personality Disorders 1 in Marsha Lineham (1993) em “Cognitive Behavioral Treatment of Borderline Personality Disorder “. Guilford Press.
- Paul ª Andrulois and col. (1980)- “Organic Brain Dysfunction and the Borderline Syndrome” Psychiatric Clinics of North America 4. In Kreisman ,J. ( 1991).
- Stewart ª Montgomery (1987) – “The Psychopharmacology of Borderline Disorders”. Acta of Psychiatry of Belgium 87 .in Kreisman, J. (1991)
4 Diagnosis and Statistics Manual of Mental Disturbances – 3rd edition – DSM-III Magazine – R, São Paulo, Manole, 1989 pp 366-367.
5 Does not include suicidal or self-mutilating behavior, described in item 5.
6 Kreisman introduced the term para-suicidal behavior in 1977 to mean intentional, non-fatal, self-destructive behavior (self-mutilation, taking drugs, burning, suicidal thoughts). It includes suicidal gestures and manipulations. Para-suicidal however is a better and less pejorative term than manipulator. The difficulty in treating these individuals makes one frequently blame the clients, which obviously does not help them.
9 Alves Falivene (1994) shows that in every group (family, for example) there are sociometric conditions that constitute “external authorization” for individual behavior. Each person who is exposed to this power will develop a corresponding “internal authorization”. In extremely hurt clients the internal authorization is so fragile that the demand will be a repeated dependence on the external permission. The equilibrium between an external and internal authority will be the base of a true authority. The therapist, upon permitting and validating emotions and behaviors, functions as a new external authority who looks to reinforce the client’s internal authority.
10 Miller (1979) skillfully shows how a good part of therapists come from families in which they had been asked to be the “good kids” who helped their parents.