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"Psych 101 -
What you didn't learn in nursing school."


by Kathi Stringer
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ISBN-13: 978-0615193137
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The Responsibility of Change and the Individual with Borderline Personality Disorder

Written by Kathi Stringer

Change. It is a word that provokes anxiety in some of the healthiest clients. But to a person with borderline personality disorder (borderline) it can be terrifying. Imagine having a shaky sense of identity, and even that which is known, is about ready to be annihilated though the process of change. Change doesn’t go over well with a borderline that craves object constancy, a developmental level skipped over in childhood, because it seems they are now threaten with the aspect of giving up that which is familiar and compulsive for the apparent, aggressive dynamic of change.

The Roadways of Change

In metropolitan cities traffic usually runs smoother when using two-lane roads. It is the one-way streets that can get confusing. Imagine a city with only one-way streets and trying to navigate your way around. It seems understandable a two-lane street would be more efficient by providing a greater access for delivery. It is with this paper I hope to remind the treater that there are Two Executive Deliveries for Change.

Client-Induced Change

Goals are often established with the onset of therapy built on the foundation that the client needs to change. Simply, it’s not what happens to the client but rather how a client reacts to the event. Cognitive behavioral treaters usually approach change from examining the client’s cognitive structures and will then suggest modification in certain identified areas to address a client’s emotional anxiety to stimuli (Linehan-DBT). However, most Cognitive Behavioral Therapy (CBT) offers only a single technique for change and referred to as ‘Client-induced’ since it places the full weight of change onto the client. Client-induced change can be extremely frustrating for the client since regression and failures are viewed as the client’s responsibility… i.e. “you choose to feel this way.” The rest of this paper will now focus on the second avenue for change.

Treater-Induced Change

At the opposite end of the continuum is a method for change referred to as ‘Treater-induced ’. Treater-induced modus operandi centers on the artful skills of the treater as an agent of psychodynamic psychotherapy (Gabbard). Actively, it is the treaters’ holding environment and detoxification of the projected objects (anger in this example) that will bring about change in the client. Treater-induced because the treater is offering to the client material that was projected onto the treater that has been contained and modified (changed by the treater) and is now more manageable for the client and available for assimilation into the client’s closed internal system. (see more on introjective identification)

Analogy of the Blacksmith

The blacksmith must first heat the material before it can skillfully be reworked into a precious measurement of success. If the blacksmith were to attempt to shape cold metal his efforts would be a consuming and daunting process. In other words a bit of heat helps in the reshaping development. Using a procedure of gently challenging (triggering) the client, the work then becomes warm and provides access for the treater to rework and modify the closed internal system of the client.

When to Hold and When to Fold

As any successful poker player will tell you, winning the game depends on the strategy. How to play the hand depends on the strength of the cards. Similar to poker the degree of success from therapy would depend on when to use confrontation and when to use supportive measures. For example, if a treater triggers a client using confrontation and then the client’s emotions become intolerable, the client may threaten to duck out of therapy, which at this time the apparent move would be to fold and use a supportive stance.

Analogy of Gently Stirring the Pot

If a treater finds themselves wrapped around a client’s finger, with sessions that are dull, flat and unproductive, then the reason is more then likely the treater is failing to stir the pot. The unresolved conflicts of the client are usually lying at the bottom of the pot in the form of sludge. By stirring the pot a treater can see what comes up so that it may be identified and reworked. I would recommend using a wooden ladle, a metaphor for ego-detachment and countertransference management to protect the treater’s hands from getting burned.

Containment for Change

As one treater said, ‘this anger you are projecting is yours and not mine”, to which the client replied, “can you think of anything better to do with it?” This is what separates the amateurs from the professionals. A professional is able to, contain, metabolize, detoxify and modify the projected object (anger) and then offer a more manageable form to the client, a second avenue for change (Bion).

Effective Treatment in the Region of Rejection

I want to shift gears for a moment and touch on the issue of rejection. It stands to reason the client needs a safe place to project their anger in the presence of the all-good-object and will not be excommunicated from the family relationship of the patient-therapist dyad. Some treaters because of their own unresolved conflicts place counterproductive boundaries on the therapeutic relationship. Some are unable to contain the projected bad object (anger) of the client and threaten to ban the client from the practice. For the individual with borderline personality disorder, they may respond in much the same way an angry child would from being banned from the family relationship. It could have a devastating effect. A threat like this runs the risk of validating the unconscious belief that ‘I am not lovable and I can destroy the all-good-object” and rejection is always just around the corner. For a borderline personality with separation and abandonment issues, this may fixate therapy because no matter what the re-enactment, rejection is the precarious dreaded monster. It is advisable to be prudent when setting the execution boundary to mitigate rejection fears.

Summary

Working with the borderline personality is a challenge. It is helpful when we are able to identify two avenues for change, client-induced and treater-induced. Client-induced change maximizes the cognitive behavioral techniques, while treater-induced change is a skillful and artful technique of modifying the client’s internal closed objects. Client-induced change is usually more effective and available to the client when the client is challenged (triggered).