In: Psychoanalytic Thinking in Mental Health Practice
Chapter Six: Therapeutic Work with Patients Borderline states of mind
https://www.routledge.com/Psychoanalytic-Thinking-in-Mental-Health-Settings/Evans/p/book/9780367567385
The presentation of patients with a diagnosis of borderline personality can fluctuate rapidly between integrated functioning and fragmented, psychotic states of mind. In a crisis, their fragmented states of mind are usually accompanied by actions designed to expel disturbing emotional states of mind. One patient I saw would carve abusive messages on her body, while another would threaten to throw herself in front of the traffic. These states of mind, which can be dismissed by some as attention-seeking, are alarming and cause severe management problems for psychiatric services, general practitioners, and others. Although this group of patients are, at times, capable at times of insightful and mature thinking, their mental functioning can deteriorate when faced with psychic conflict, as this causes them mental pain. When this happens, such patients may lose their capacity to digest and tolerate the frustrations of psychic reality and fall back on primitive defences. They split off aspects of their ego associated with perception and project these into the body or an external object. These projections, designed to externalise internal conflicts, are often accompanied by dramatic action (acting out).
Consequently, their perception of themselves and others is distorted, leading to difficulties differentiating between self and other. When their environment changes and/or they undergo separation from an object into whom they have projected a split-off part of their ego, their psychological equilibrium is upset. They often have a history of highly dependent, abusive personal relationships. The projection of important aspects of their internal world can leave them feeling empty and despairing. They can sometimes fill this emptiness with drugs, alcohol, self-harming or sadomasochist relationships. They seek excitement as a way of feeling alive and are often demanding service resources, especially when their self-destructive and chaotic behaviour raises anxiety among healthcare professionals.
It is common for these patients to have large numbers of health-care professionals involved at the same time since many of these patients are victims of varying kinds of abuse. Telling their painful history is a way to enlist professionals' sympathy, which can stimulate a wish in the professional to rescue them. Such patients seek intense, ‘special’ relationships in which they believe their dependency needs can be met, and they often push staff beyond the bounds of normal professional behaviour in an attempt to meet these needs. Self-harming behaviour can force carers into actions designed to protect the patient from themselves. For example, the staff may put a patient under close nursing observation. At times, this may be appropriate. However, it can become a malignant cycle, as the patient projects all responsibility for their well-being into the staff. Any attempts to reduce the level of observation lead to acting out, which puts pressure on the staff to increase observations once more. The clinical situation can become stuck, as any progress produces an adverse therapeutic reaction. Staff can then retreat into a moralistic state of mind in response to an understandably frustrating clinical situation. Planning for discharge from in-patient units may be clinically appropriate. Still, it is often accompanied by a ‘judgmental’ attitude as the discharge is accompanied by a justification which says that the patient ‘does not have a diagnosable mental illness’. This defensive attitude pushes all responsibility for treatment onto the patient as if they could control their disruptive actions and behaviours. Indeed, it is expected to hear staff describe patients as a ‘Borderline’ or ‘Personality disorder’ in a pejorative way that indicates the extent to which the patient has got under their skin. This sort of thinking is based on a false division between something called ‘personality disorder' and something called ‘mental illness.' The reality is that presentations of all psychiatric illnesses are derived from disorders in the patient’s personality.
When the patient feels blamed or rejected this way, it can increase the level of acting out and force staff to continue caring for them. I sometimes think that the label ‘Borderline’ indicates the extent to which the patient has been able to affect staff through the operation of the countertransference negatively.
So why do borderline patients have such a disturbing effect on mental health professionals? Using clinical examples to illustrate my ideas, I will outline some of the psychoanalytic thinking I have found helpful when trying to think about and work therapeutically with patients in borderline states of mind.
Paranoid Schizoid Position
Patients in borderline states of mind employ primitive defences by splitting and projecting aspects of their ego into the external world. Klein (1934, 1940, 1946) differentiated two significant types of psychic functioning. She coined the term ‘paranoid schizoid position’ to describe a state dominated by the primitive psychic defences of splitting and projection. These defences protect the ego from internal conflict and psychic pain. Anxieties in the paranoid schizoid position are related to a feeling of persecution and a preoccupation with the protection of the ego. As the ego develops some strength and capacity to bear psychic pain, the need for primitive defences reduces. The reduction in splitting and projection allows integration to take place, signalled by anxieties about loss and guilt rather than persecution, this more integrated form of psychic functioning Klein defined as the ‘depressive position’.
Ms X. was a woman in her forties who was referred to a specialist psychotherapy service for personality-disordered patients at the Tavistock Clinic in London, UK. She felt she was a failure in all aspects of her life and was tormented by a belief that she was the cause of all her misfortunes. Although the patient complained that she was useless in a repetitive and circular way, she was also damning doctors and therapists who have failed to help or cure her over a twenty-year history of mental illness.
Ms. X.’s family were all members of a fundamentalist cult that believed that one day, God’s chosen people would be lifted into Heaven. She described her father as a difficult man who devoted his life to caring for others less fortunate than himself. Her mother supported her father despite her reservations about the implications of his fundamentalist beliefs on the family. She had an older sister and a brother who had died of cancer in his twenties. As a child, the patient used to fear that one day, she would wake up to find that her family had been taken up to heaven, leaving her behind. The patient went to college to train as a nurse, where she fell in love with another student who suddenly committed suicide. She believed she was responsible for him going to Purgatory, as he was an atheist and she had failed to convert him to the Faith.
Ms X. then fell in love with another student who had applied to medical school after qualifying as a nurse. The patient went against her father’s wishes and applied to medical school but was turned down. She was devastated when she visited the medical school and discovered he had another girlfriend. The failure to get into medical school and the hurt caused by the failed relationship precipitated a depressive breakdown and an overdose, which led to a hospital admission. Ms. X. was treated with medication, Electro Convulsive Treatment and Cognitive Behavioural Therapy.
After her discharge from the hospital, Ms X. had outpatient psychiatric support, medication and counselling over many years. The patient had had a long-standing affair with her ex-counsellor, a married man from the same church, who used to advise her on the phone when she was upset.
She believed the world was divided into top-class people and second-rate people. Top-class people win and are successful, while second-rate people go unnoticed. The patient would often bring examples of people getting on with their lives successfully while she is stuck in a hopeless pit of failure. In addition to tormenting the patient, these ideas were designed to guide me in a more tremendous effort. As if she were saying, “I am second-rate, and I am with a second-rate therapist, but if he did his job properly and cured me, he would become first-rate and then he would pull me up with him”.
The patient believed I should stop trying to understand her and start coaching her on living her life. She often put me under pressure to step outside my role by suddenly announcing that she was going to do something that might adversely affect either her life or her therapy. For example, she suddenly announced that she was going to leave her permanent job and take work as an agency nurse as they were introducing a duty rota that might interfere with her attendance at therapy. The patient did not discuss her attendance at therapy with work, as she was worried it would interfere with her prospects of promotion. I immediately felt concerned that she was doing something that might damage her career and leave her feeling even less satisfied with her working life. I resisted the temptation to respond to my countertransference by taking an advisory role. Instead, I tried to maintain an analytic response by interpreting our dynamic.
In some sessions, Ms. X would arrive at her session and sit with her head in her hands, crying and berating herself for being useless in all areas of her life. The patient was bullied by an internal figure that was always making her feel like she was second-best. She believed the cure to this situation was to find a therapist who would demonstrate their care and devotion by breaking their usual practices. However, my failure to help her sufficiently led to her going to A&E, complaining that she was feeling suicidal and needed to be admitted to the hospital.
As much as she felt bullied, she also became the bully in her attempt to get me to change my style or demonstrate my devotion to her. On one occasion, she placed a surgical knife on the table between us and threatened to cut herself if she did not get the help she needed. The treatment offered was often measured against the ‘ideal' relationship provided by the previous counsellor. The abusive and corrupt nature of this relationship was ignored as she sought a ‘special' relationship that ignored limits and professional boundaries. The theme of special relationships is reflected in the following dream:
Ms. X. is showing a friend her ex-counsellor’s beautiful gold office. They are waiting for him to arrive, but he does not show up.
The patient feels that ordinary therapeutic understanding leaves her exposed to the problems of life’s ordinary difficulties. She puts me under pressure to treat her like a special patient who breaks the bounds of ordinary psychotherapeutic treatment. This is a reenactment of the rapture in which a God-like figure pulls her into a God-like world, leaving ordinary human suffering and relationships below. Rosenfeld (1987) described how the borderline patient’s internal world functions like a well-organised gang which defends the patient from anxieties associated with fragmentation or integration. External relationships are often recruited in ways which support this internal psychic structure. The patient's defensive organisation can remain quite stable until something in the internal or external structure breaks down.
In many ways, the preference for an erotised ‘special’ relationship with her previous therapist, which had broken ethical boundaries, had also caused considerable damage to my patient. It was like the glamorous dream of a golden therapeutic office with no therapy actually taking place. However, my patient felt that I rigidly kept to my boundaries in an attempt to avoid a repetition of the erotised relationship with her counsellor. She experienced this as a punitive rejection of her and her needs rather than an attempt to provide an appropriately caring treatment situation. Ms. X. believed that being specially chosen was the only solution to her feeling second-best and she was convinced that my attempts to avoid this sort of dynamic deprived her of the treatment she needed. The desperate search for an ideal relationship overrode concerns about corruption and perverse relationships. However, on reflection, I could see that my attempts to prevent a reenactment did leave the patient feeling uncared for and neglected. This dynamic is often the cause of inappropriate acting out by staff as they are caught up in believing they can be the patient’s ideal object and resolve all their difficulties – a seduction indeed!
Rey (1994) highlighted the way borderline patients search for powerful phallic solutions to repair their damaged internal worlds. Ms X. searched for an erotised relationship with a phallic figure as an attempt to cure an underlying feeling of depression and neglect. When I responded to her desire to be special by keeping her at a distance, she felt I failed to understand how much she also needed contact with a maternal figure who could respond to her feeling of neglect. Ms. X often nudged me into indicating what I thought she should and should not do. She would fit in with my expectations and hold me accountable for her decisions when this happened. On one occasion, she told me that she would be missing a couple of therapy sessions because she had just bought an expensive bike and was going to compete at an elite endurance event. If she won, the event would make her feel she was a success; if she lost, it would just confirm that she was a failure. This was driven by a wish to triumph over the demands of an ordinary treatment with an ordinary therapist. The patient picked up on the disapproval in my response and withdrew her application for the race. At the following session, she accused me of suggesting that she should give up everything she enjoyed doing and slavishly commit herself to her work and therapy. She pointed out that this was a betrayal, as I didn't give anything up for her since I stuck to my discipline of trying to understand her. The patient complained that I could not contact her during the weekends and evenings when she needed the most help. She made the point that she was forced to contact her ex-counsellor, which left her feeling humiliated.
The patient's relationship with the therapy mirrors the world of the rapturous ascent into Heaven, where she believes she will be taken up into an ideal position by a powerful God-like therapist if she devotes herself to the therapy. When I fail to promote her to a special position, she feels betrayed and gives examples of her sacrifice. Any questioning by me in the therapy of the drive to achieve the ideal state leads to a terrible fear of reprisal and punishment, just as God throws Adam and Eve out of the Garden of Eden as punishment for their disobedience.
This was a dilemma for the therapist because if the patient accepted her need for help with her difficulties, she believed she would be unloved and unlovable. This dilemma was exemplified in the following dream:
Ms. X. was applying for a course that she believed would help her with her low self-esteem, but she was alarmed to discover that her curriculum vitae had a brown stain on it.
I thought the dream represented a belief that she could apply for a role as my patient in the hope of becoming her own person. However, the role of being my patient left her feeling that she had difficulties and was, therefore, flawed, as in the curriculum vitae with the brown stain. Ms. X responded to my interpretations by saying that I had been critical of her wish to strive for the ideal. She thought I was encouraging her to accept failure since “I was just saying that she was a failure and should not strive to address her difficulties”.
Ms. X.’s mind was dominated by paranoid-schizoid thinking, and she was either the ideal with no imperfections or useless. There was no room in her mind for a mixed appraisal in which she might realistically accept her strengths and weaknesses. She also put pressure on me to provide ideal solutions or condemnation. Patients with borderline personalities often feel unloved or unlovable and seek ideal relationships with ideal objects. When the object inevitably shows evidence of human failings, this results in a blaming state of mind in which they believe that either they have failed the object or the object has failed them. The enormous pressure this puts on their relationships often results in their acrimonious breakdown. The power of the projections comes across as a concrete communication that tends to demand a concrete response. In this situation, it can be challenging to think about the underlying meaning of the transaction and communication. Segal (1981) differentiated between symbolic and concrete forms of communication. Symbolic communication conveys information about the subject’s feelings and invites the listener to empathize with the emotional experience. Concrete communication has the emotional meaning squeezed out and demands and tends to force action in response rather than an empathic response. Words are sometimes experienced as concrete things that have the properties of actions rather than thoughts. One patient told me that he did not want to talk about his murderous thoughts as he worried that they might come true. An expressed murderous feeling is undifferentiated from a murderous act.
This is complicated in the therapeutic relationship and can leave the patient and therapist at cross-purposes. While the therapist or mental health professional believes that it is important to talk about what is going on, the patient feels this is very dangerous and may lead to damage. One patient told me he could not speak about an incident because he then worried he had done the wrong thing by telling me.
The concrete nature of communication
The concrete nature of a patient’s communication tends to provoke a concrete response from the therapist. For example, Ms W. was convinced that all her problems would be solved if only she could escape from the flat where she had been humiliated and abused by a previous boyfriend and move into another one. She pressured me to write to the housing office demanding a change in her housing and became furious when I commented on her fantasy that she could leave her problems behind in the old flat. She punched the wall, leaving a dent in the plaster and screamed: "What you do not get, Mr. Evans, is that all this ‘mumbo jumbo' is making me feel worse about myself. What I need is someone who is going to help me move out of that bloody flat."
In this instance, the patient feels she is trying to eliminate memories that make her feel bad about herself. I then try to push my understanding of what she is doing back into her. This enrages her as rather than offering a home for the unmanageable aspects of herself, I am forcing depressing and humiliating memories back into her. This makes her feel worse rather than better, and I do not seem to care about “The effect my therapy is having on her mental state”. She then had to demonstrate that she could not get through to me by punching the wall and screaming.
The patient puts pressure on me to relinquish my role as a therapist who offers understanding, which, as she puts it, “Is about as much use as a chocolate fire guard,” in preference for someone that does something useful, “Like a real mother”. This is a common issue in the treatment of patients in borderline states of mind, as they put pressure on the therapist to provide concrete solutions. However, when the therapist does respond to concrete demands or pressures, the patient can feel that the therapist has momentarily lost their bearings or even their mind. After one of these enactments, it is common for the patient to remind the therapist that they were only exchanging ideas rather than demanding concrete action. One very disturbed patient suddenly said to me, "You started to talk as if we needed to do something about my mind. However, that is not your role, your role is to help me think about my mind". This situation is complicated when dealing with patients in psychotic states of mind as the risk of serious acting out means that we do have to consider acting on, as well as thinking about, the symbolic meaning of actions and concrete communications.
When this happens, I think it is helpful to differentiate between the active role one might perform as a psychiatric nurse or psychiatrist and the role of a psychotherapist whose job is to understand the meaning of the patient’s thoughts and behaviours (Steiner, personal communication). Sometimes, these roles can be helpfully performed by different people in a psychiatric team. However, when this is not possible, the individual therapist or mental health professional has to monitor the relationship between their role as a therapist and their role as a mental health professional.
orderline patients live on the borderline between psychosis and neurosis, or put another way, they oscillate in their psychic functioning between the paranoid schizoid and depressive positions. They often exist on the edge of the depressive position and quickly retreat into a paranoid, schizoid one at the point they experience psychic pain (Steiner, 1979). In treatment, it is sometimes possible to trace the causes of a patient's shift from the depressive to paranoid schizoid position, but this is usually done in hindsight.
Ms W. communicated her difficulties in managing any humiliating thoughts about her relationship with an abusive figure. She wanted me to support her in developing a new picture of who she was and who she could become. This is a view of therapy as a magical transformation that helps the patient escape from their damaged internal object relations. While I did not believe the therapy could transform her personality, I did sympathise with the patient’s difficulty in facing her damaged internal world. Pushing the patient to face depressing realities before she was ready threatened to overwhelm her fragile ego with feelings of guilt and humiliation. Faced with a fragmented ego, she was then driven to seek manic solutions employing more splitting and projection. In many ways, I had to start by helping her understand that her mind was intolerant of shortcomings and failings. The therapy could then help her moderate her internal world and develop a mind that could manage depressing realities about herself, thus reducing the reliance on primitive and manic defences.
Klein (1946) highlighted the need for the infant to internalize the primary object as a good object, forming the basis of the infant's ego. Borderline patients have often had abusive relationships with parental figures so damaged and fragile internal relationships populate their internal worlds. Borderline patients need to find supportive but boundaries figures who can help them manage their harsh internal worlds.
The search for a supportive relationship
A primary nurse from a PICU? Presented an incident that had occurred the previous week. Ms A. had come to the ward under the Section on account of her unmanageable self-destructive behaviour. She presented herself as the victim of various abusive relationships, including with her previous psychiatric ward staff, who she accused of maltreating her. The patient's care on the unit was divided between the primary nurse, who concerned herself with the patient's deliberate self-harming behaviour, and an assistant clinical psychologist who offered 'abuse counselling.'
, having reassured the primary nurse that she would not visit her ex-boyfriend, who was known to be violent. She was brought back by the police the next day, having been severely assaulted by her boyfriend. The primary nurse described how she had to sit in the clinical examination with the patient while the doctor examined her beaten body. She described the patient’s cold, cut-off and matter-of-fact way of presenting herself for assessment after the physical assault. She commented on how detached the patient seemed from her body and from the events that led up to her being so badly beaten. The nurse was visibly shaken by this experience and finished by saying she was disgusted by the damage and did not know if she was cut out for this type of work.
In the discussion, several problems with Ms. A.'s management emerged. Her self-destructive behaviour had encouraged previous institutions to take responsibility for keeping her alive by putting her on continuing close observations under Section. This became an unhelpful, malignant pattern whereby she projected all responsibility for her well-being onto the staff. When the patient was admitted to the current Unit, they hoped to reverse the trend by encouraging her to act more adultly and responsibly. She gave the impression of being insightful, articulate, and motivated to co-operate with the plan.
Ms. A. was taken off her Section due to her apparent progress and was in preparation for discharge. The assistant clinical psychologist thought the therapeutic work was going very well and described the patient as a likeable woman who showed tremendous potential as an artist. The primary nurse was more reticent about Ms. A.'s progress and mentioned that the deliberate self-harming behaviour had continued regularly and increasingly frequently. She felt that Ms A. was more fragile than she presented to the assistant psychologist and worried that her self-harm would increase as the discharge plan was implemented.
Ms. A.’s improvement was sustainable as long as the ward staff continued to care for her. The moment they decided to remove the Section order and plan a discharge, the destructive aspects of her personality, located in the acting-out behaviour, increased in violence. In addition to punishing the ward, her actions can be seen as an attempt to show staff that she needed to feel they understood her difficulties. The patient had minimal capacity for tolerating frustration or metabolising her psychological state and used action to evacuate undigested psychological experiences. In the example above, different parts of the patient were communicated to different parts of the team. The assistant clinical psychologist was in touch with the patient’s abilities and resources, while the primary nurse was more in tune with the underlying fragility and damage.
Ms A. presented herself as a victim of historically abusive relationships. The clinical team’s approach was based on the idea that they needed to support the patient in separating from these abusive external figures. This approach denied the patient's ongoing involvement with abusive internal figures and the way these internal relationships become re-enacted in the transference with staff. The meaning of the patient's acting out was ignored to avoid malignant cycles of care. However, the acting out indicated a serious problem in the patient's relationship with herself and her internal objects. In many ways, they are like a message that says, ‘I may look OK on the outside, but I’m damaged inside’.
In his paper, On Arrogance, Bion (1958) describes a group of ‘Borderline Psychotic’ patients who experienced a catastrophic breakdown in their maternal relationship as infants. The breakdown of this relationship leads to a deficit in the ego, as the infant fails to internalize the mother as a good object, able to help him or her digest emotional experiences. The infant internalizes an ‘ego destructive superego’ instead of an internal good object. This superego demands ideals in the infant’s self and objects.
On further discussion, it emerged that Ms. A. had a voice in her head that demanded she harm herself whenever she experienced anxiety or concern about her future. She hated the dependent aspects of herself, which exposed her to knowing about her feelings of vulnerability and need. These experiences were then projected into her body and attacked by a highly critical internal figure, who acted as if anxieties or vulnerabilities could be burnt or cut out. The visit to the abusive boyfriend externalized this internal dynamic, as he attacked her and treated her in an abusive and dismissive way.
This action shifts the attention from the patient’s internal relationship with a bullying figure who attacks her to an external relationship with the abusive man. The patient’s apparent cooperation with the planned discharge does not consider her anxieties about being left on her own with her abusive internal voices. Anxiety about her ability to cope without the ward's support is expressed through acting out. This forces the team to look at the extent of the patient’s damaged relationship with herself, expressed through her beaten body. It is interesting to note that the primary nurse is sickened by the sight of the patient’s damaged body. Still, to a degree, that prevents her from being able to think about the seriousness of this abusive internal relationship. Patients with borderline features often describe a part of the self that passively watches on while they abuse themselves or allow themselves to be abused. One patient said that she watched herself attack herself through cutting but did nothing to stop it.
Britton built on Bion’s ideas in a 1989 paper called The Missing Link. In this paper, he describes how patients deal with a breakdown in the mother-infant relationship. The infant splits off and projects the mother's unavailability, creating an illusion of an ideal relationship, which they cling to and control. Any separation or breakdown in understanding between the infant and the mother is projected outward into the father, who is now experienced as a threatening, disruptive presence. Borderline patients try to establish an ideal relationship with an ideally supportive object. Any break in the ideal situation can be split-off and denied in the initial stages. But when things reach a critical point, there is an explosion of acting out or verbal outbursts.
Planning for her discharge home left Ms. A. to deal with her adverse internal and external relationships without the support of the nursing team. She tried to maintain an ideal relationship with the unit by denying her anxieties and feelings about discharge. These are projected into her body. Then, when they reach a particular pitch, she acts out by visiting her boyfriend, who is known to be violent. This externalizes the internal conflict so that he is the one who attacks her body. The body, which carries the evidence of her hatred for the part of her that depended on the unit for care and attention, is attacked. While the patient remains detached and uninvolved in the examination of her body, the nurse is filled with horror at the extent of the damage (Evans, 2016). Borderline patients need help in separating from the influence of tyrannical, internal figures that tend to dominate their internal world. Ms. A. found it hard to acknowledge the degree of her dependence on staff to help her with feelings of self-hatred and loathing. Her actions communicated anxiety about being left on her own with a tyrannical internal figure that attacked her for any perceived weakness or failure. She visits the boyfriend to be beaten by him so that her internal and external scenarios will match. Why? Because there is relief from her psychic conflict when it is externalized.
Separation from a tyrannical internal figure.
Mr. Y. was a man in his late twenties who came into therapy at the Fitzjohn’s Unit at the Tavistock Clinic in London, UK, in a crisis and suffering from what he called depression. He was promiscuous and led a manic lifestyle, throwing himself into different relationships. These would often end in him feeling mistreated, rejected and suicidal. The patient's father died at an early age, and his mother brought him up. The patient returned home to visit his mother most weekends despite describing her as critical and disapproving of him. This intensely critical relationship was repeated in the treatment, where I felt under intense critical scrutiny.
Mr. Y.'s mother would often become the voice for this harsh and critical internal object, as he would often quote her saying what a disappointment he was. He told me how he often thought he would fall onto the railway tracks on the way to sessions and lose the use of his legs. This represented a reprisal by his tyrannical superego that could not stand any admission of weakness or dependence upon help. The patient felt that attending therapy and getting help in thinking about the severity of his internal world exposed him to retaliation from this possessive and murderous internal figure. Indeed, he feared that this murderous figure would rather push him onto the train tracks than be exposed in therapy sessions.
At other times, Mr. Y.’s internal world changed as he moved from being the victim of a murderous superego to becoming a tyrannical figure himself. Any shortcomings in understanding or emotional attunement were immediately pointed out in a highly critical way. Moreover, I often had the feeling of being on a knife-edge, as the patient wanted attention to his mental disorder. Still, any phrase or comment that upset him could produce a violent, verbal response. If he thought that I did not take my responsibilities for his condition seriously, he would increase the volume and veracity of the complaint, with the desire to get through to me.
The tyrannical superego demands that the ego evacuates anything that causes psychological pain or conflict. Bion described patients like this as developing minds that act like muscles to project psychic problems into the external world rather than digest them. Mr. Y. would push a serious problem into me, but if I tried to talk to him about the problem, he responded by saying that he was bored with that issue and wanted to move on and talk about something else.
Rey (1994) used to say that these patients lacked an internal spine and had no clear identity. He thought they were looking for a marsupial pouch to project a part of their internal world. They project so powerfully and concretely that the interactions often profoundly affect the therapist's mind. Consequently, their projections are often accompanied by a fear that the therapist will retaliate by pushing the projection back into them.
Having projected unwanted aspects of themselves, they then want to control the object, as they fear losing touch with the elements of themselves that have been projected into the object. Rey (1994) described the claustro-agoraphobic nature of borderline patients' relationships with their object. If they are too close, they fear being overwhelmed, but if the object is too far away, they fear feeling detached from a precious aspect of themselves. Hence, Mr. Y. would often get into a panic approaching breaks, fearing that I would die. He then feared being overwhelmed by all the aspects of himself that had been projected into me for safekeeping. Borderline patients often use their eyes to control the object. In the case of Mr Y., I had the experience of being watched like a hawk and my reactions and responses were carefully monitored. He was always worried that I would be driven to act out or do something unpredictable due to the amount of unmanageable, unwanted psychic debris projected onto me. If I moved around or looked uncomfortable, he worried that I was being made ill by his projections.
In the scenario described above, the therapist is involved in an intense transference relationship requiring absolute emotional attunement. Pressure is put on the therapist to act like an ideal figure and any separation between patient and therapist causes violent emotional storms. It is as if the therapist becomes the failed mother who has dropped the infant in favour of their relationship with the father. The infant then nags, cajoles, and criticises the mother for leaving the father and turning his attention back to the infant. This can become part of a grievance against the mother for failing to provide ideal and continuous care. Any separation is attacked as an impediment to the ideal relationship the infant relies on to survive.
In his paper, Subjectivity and Objectivity, Britton (1989) describes the patient’s difficulty in connecting his subjective self with an objective view. Borderline patients fear the integration of subjective experience with objective thought as this heralds painful realizations about reality that interfere with their psychic equilibrium. Patients in borderline states of mind are sensitive to any communication that contains an objective assessment of the patient's behaviour, as this is felt to threaten the patient's subjective experience. Mr. Y. once said, “If you say that I want you to be an ideal therapist one more time I am going to hit you. I feel like you are saying you are not the right therapist for me and you’re trying to get me to go to someone else”. In this instance, the patient felt I was trying to get away from him by suggesting I could not fit in with his demand to be the ideal. He attacks me by threatening to hit me in an attempt to get me to behave in an ideal way. Joseph (1985) describes how patients behave in ways that nudge the analyst into behaviour that fits their expectations and defensive needs. On many occasions, Mr Y. said that I was banned from talking about separation as if we could live in a bubble which excluded the reality of loss. However, if I were influenced by these threats and failed to pre-empt the significance of breaks or separations, it would precipitate some dramatic acting out, as reality suddenly hit in a traumatic way.
Mr. Y. was very sensitive to my voice and whether he felt I was engaged. He would often ask whether I was bored or tired. He also hated intellectual comments and would say he had wasted his time coming if I could not be empathic or authentic. In these situations, I had to take in his perception of me. If I said anything that contradicted his perception, he would become more insistent, saying that I was accusing him of lying and threatening to throw a brick through the window of the building with a note attached saying what “A ******* job’s worth I was". The patient was also sensitive to any interpretation or comment that lacked authenticity or a feeling of my being unengaged. Again, if he felt I was pushing the problem back at him or failing to take his perception seriously, he would threaten to contact the complaints department and lodge a complaint. If we had an unsatisfactory session, he would phone the secretary’s office to leave a message saying I had left him with suicidal feelings. The patient sometimes used to collapse into states of self-hatred and self-loathing. He would accuse me of pushing my responsibilities back onto him if he picked up anything slightly judgmental in my comments. Mr Y. would respond by saying he did not think Nazis were allowed to train as therapists.
Technical Challenges
This brings us to some of the technical problems of treating borderline patients. First, we must listen to their words and get on their wavelength. The most helpful way of thinking about the patient’s clinical material is that, in some way, they are always trying to tell us something, and we have to understand where they are coming from. Borderline patients are persecuted by the ideal of what they should have or would like to have been. This dynamic gets re-enacted in the relationship with the therapist.
Mr. Y. once told me that he had spent the weekend with his mother, who talked about how marvellously his cousin was doing with his new child. She then said to the patient that she had given up waiting for him to produce grandchildren, as he was hopeless with women. The patient drew breath and then asked, “Are you bored? Why aren’t you saying anything? Perhaps you agree with her that I’m a waste of time.”
We can see here how the breakdown in the relationship between the patient and his object is repeated in the therapy. The patient tells me a problem and when I don't immediately reply, he feels I am disinterested or unavailable. In this way, I become like the object that won't take anything about his mind. Another patient used to open the door, sit in the chair, and say aggressively, “Oh thanks very much! I come all this way, and you can’t even be bothered to say hello.” The strength of the accusation can provoke either an apologetic or defensive response in the therapist. This affects the therapist’s ability to maintain an analytic stance. Thus, professionals can get into a cycle of acting out with the patient. With Mr. Y., when he says that he lives in a very cruel world, meaning his internal world, he starts to cry. Then, the next second, he retreats into a position of mocking himself. “Oh, I hate this winging ‘oh poor me’”. In this state, he descends into self-hatred and mockery.
In my experience, it helps to take the complaints seriously and always see things from the patient’s point of view in the first instance, assuming they are trying to tell us something. This can be very difficult when you feel that their view of you is grossly unfair, but it does not help to push it back into the patient as this is responding defensively rather than analytically. It does help to consider what they are saying. Steiner (1993) outlined the difference between what he described as ‘analyst-centered’ and ‘patient-centered interpretations’. The analyst-centred interpretation involves viewing how the patient views the analyst, while the patient-centred interpretation focuses on the patient.
Patients who lack a good internal object need to feel that the external object understands their feelings and how they think. They need to feel they are with a therapist who can take in the patient’s view of the therapist. They must also feel they are with someone empathic and sympathetic. The countertransference is unconscious, and we are prone to respond without being fully aware of our motives. Borderline patients are susceptible to the therapist’s tone of voice and use of language. These patients pick up on any hint of criticism or lack of warmth in their voices. The problem is that some patients are tyrannical in their control and provoke the therapist into a defensive position. These patients are susceptible to this and react badly as they quickly feel they are being given cold charity or patronized. As one patient used to say, ‘You are as engaged as a wall'. This is a technical problem with borderline patients, as any hint of feedback that has not been digested and thought through is experienced as an assault. This sort of response can lead to a rapid deterioration in their mental state, as the patient tries to force the message home by escalating the strength of their communication and by acting out.
Borderline patients live on a mental knife edge as their perception of themselves oscillates between ideas of triumphant success and catastrophic failure. The superego governs this state of mind. Lucas (2009) thought the therapy process was to provide support and help build perspective so the patient's ego can separate from the influence of the superego. Thus, the therapist aims to turn the patient's ego from a knife edge to something broader - a gymnastics bar would be good enough!
DISCUSSION
Many patients come into therapy or treatment expecting to be restored to an ideal state and they put pressure on the therapist to act as an omnipotent God who can remove all problems. Ms X. believed she had an ideal relationship with her previous counsellor, who demonstrated his devotion by breaking his ethical boundaries and developing a corrupt relationship with the patient.
This is an example of a difference in the expectations between the therapist and the patient. Whereas I took the view that the relationship with the ‘ideal’ interfered with her development and capacity to engage with life, the patient believed this relationship saved her life. The difference in expectations between the therapist and the patient can lead to conflict and frustration. The patient believes the therapy will restore them to an ideal state, while the therapist is trying to help the patient come to terms with their imperfections and difficulties. Pressure is applied through the countertransference on the therapist to provide omnipotent solutions. The patient fears that the extent of their difficulties cannot be solved by ordinary means and hence they seek magical solutions. However, when a patient senses the therapist is omnipotent in response to the pressure, he/she may also become wary, feeling that the therapist has become corrupt or lost his/her mind.
The countertransference provides valuable information about the patient's state of mind. Borderline patients have difficulties dealing with the psychic contents of their minds and tend to evacuate undigested elements of their minds through action. They also put considerable pressure on mental health practitioners to act rather than think. Ideally, the function of the mental health practitioner with these patients is to use their verbal capacity to reverse the process and turn the action and pressure towards action back into words. However, if mental health professionals or therapists push insight back to the patient prematurely or rush the patient's development, it can cause rapid fragmentation. Progress is often dependent upon supportive relationships, even if the patient plays down the significance of these relationships. Borderline patients do not like being reminded of their underlying fragility and dependence upon others - yet hate it to be forgotten.
Steiner describes the process of therapy as involving two stages. The first stage consists of a sense of being understood, while the second stage involves giving the patient insight into their behaviour. Borderline patients rely on relationships with people who understand them to support them in managing their damaged internal world. However, the second stage can easily overwhelm the patient with guilt about the damage done, leading to fragmentation. The patient must feel that the therapist cares about them and their lives. Patients get anxious if they feel that they are with a therapist who is emotionally cut off or oblivious to their suffering. The patient often requires the therapist to combine objective thought with empathy. You could say that these patients need to feel that they are being cared for by a therapist that contains a parental couple that can come together to treat and care for a troubled infant. Helping the therapist maintain their internal couple will depend on many things, including an opportunity to discuss the inevitable obstacles that arise in treatment. Understanding these obstacles to development can deepen the therapist's clinical understanding of the patient and their difficulties, allowing the therapist to support the patient while helping them integrate projected aspects of themselves. This, in turn, helps the patient reduce their reliance on violent projection as a means of dealing with psychic pain.
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