Pitfalls and Transference Rage
The first pitfall in dealing with the archaic transferences of these patients is the danger of the therapist's panic. Flamboyant acting out often stirs up countertransference anxiety and hatred manifested by fears of patient suicide or malpractice litigation. It looks as if the patient is exploding and unless the therapist has a dynamic grasp of what is going on, he or she can be stampeded into doing something radical or into getting rid of the patient. I have treated a number of borderline patients referred by the therapist in desperation because this happened.
The second pitfall is therapist impatience. The therapist must be willing to sit sometimes for years with a borderline patient while he or she gradually catalyzes the rebuilding of ego structure. Many therapists simply do not want to do this, as it is stressful, tedious, and painstaking work that can be ungratifying for long periods of time. Borderline patients tend to set up in external reality the kinds of situations they need to have occurring. Sometimes they are quite expert at this, and the therapist gets sucked into playing various kinds of roles, depending on the projection assigned to the therapist. This leads to serious chronic countertransference problems.
When the raging begins it is usually impossible to argue a borderline patient out of his or her accusations. If on careful objective assessment it turns out that the accusations are correct--and this sometimes happens--then the therapist needs to self-correct and sometimes apologize. If the accusations are based on distortions or projection, the proper approach to this is a calm, nonanxious and consistently nonretaliatory stance, with eventual interpretation of what is happening. It is this consistent stance that provides the basic ambience of the treatment. Any disruption of it vitiates the subliminal soothing that is always going on in a well-conducted treatment of a borderline patient. No matter how we may wish to get away from this in our theoretical conceptions, the ambience or subliminal soothing the therapist provides coming from consistency, reliability, and integrity--the ambience of the therapist's office; the therapist's personality; the deep inner attitude toward patients that cannot be faked--these provide the basic motor that permits the psychotherapy of the borderline to go forward.
Sometimes the rage of the borderline patient is stirred up directly by frustration of the need for omnipotent control of everything and sometimes the rage is a secondary phenomenon to paranoid projection or an intense transference. In a sense these patients are correct when they predict that all human relationships will end up badly for them, with disappointment and dislike coming from everyone around them. Elsewhere I have discussed this as externatization in the borderline patient. These patients respond selectively to the negative aspects of significant people and develop a case or dossier based on selective negative perceptions for expecting attack from all sides--which then justifies a preemptive strike. The chronic calculated attacks on the therapist's defects, if not interpreted, can easily lead to countertransference acting out on the part of the therapist, even to the point of directly or indirectly getting rid of the patient. This is quickly used as "proof" or confirmation by the patient of his or her expectation of apparently unprovoked betrayal and abandonment.
Psychotherapists of borderline patients painfully experience the intensity of the patient's effort to manipulate them into validating the patient's projections. The therapist feels the inner conflict as he or she struggles against this manipulation. The most benign therapist approaching the borderline patient in a raging archaic transference finds himself or herself transformed into a horrible monster very quickly by the patient's selective perception, and unless the therapist is aware of this danger the tendency is either to retaliate or to challenge the patient's extremely unflattering portrayal. This sudden transformation of the therapist into a horrible monster can occur at any time in the treatment, even when there seemed to be a good working alliance. It often leads to therapist discouragement and "burn-out," with a lingering sense of depression and injured self-esteem.
The clinical phenomena must be studied to see what the therapist is actually doing with the patient regardless of the theoretical model that the therapist professes to follow. For example, the technique of Kohut, in which the idealization of the therapist is permitted over a long period of time so that the full transference involving the search for the idealized parent imago is permitted to develop, may easily be used by an untrained or untreated therapist as an excuse to permit a flattering kind of worship and massage for the narcissism of the therapist. Conversely, the technique of Kernberg, in which more confrontation goes on, can be used by the therapist to act out hostility and aggressiveness and to produce chaos, or even a sort of counterprojective identification.
Meticulous attention to the phenomenological details of the interaction is the best starting point in dealing with patients who are subject to explosions of rage in the treatment. What is important is not the therapist's minor empathic failures per se, but the way in which they are experienced by the patient. The patient uses these minor empathic failures to relive a dreadful interpersonal experience in a protective effort to further demonstrate the need for distancing in interpersonal relationships. What we are listening for in the psychotherapy is how the patient is experiencing the interaction with the therapist and in what context these experiences are being placed within the patient's pre-existing patterns. It is only after we have been able to establish this information with the patient that we can begin asking why these experiences are placed in a particular context.
The most common fantasies we see emerging from the unconscious of the borderline patient are not oedipal fantasies as we move along in the treatment but narcissistic fantasies and fantasies of rage and of world and self-destruction, covering a deep fear of penetration and annihilation. The acting out of conscious derivatives of such rage and of world and self-destruction fantasies endangers the patients' very lives; the acting out of disavowed narcissistic fantasies often renders them poorly adapted and causes great difficulties in interpersonal relationships.
At the deepest point of the treatment these core narcissistic and destructive fantasies emerge and are worked through, not by giving the patient a. metapsychological explanation, but by allowing such fantasies to emerge into the light, studying their genesis and showing the patient how the acting out of such fantasies interferes with aims and goals in life. The borderline disorder is similar to the narcissistic disorder in that narcissistic transferences and fantasies often appear, but is different than the narcissistic personality disorder in that the intensity of the raging, fear, mistrust, and annihilation fantasies is much greater.
Kramer points out that the patient's speech, associations, or even behavioral flow, are best understood as compromise formations, essentially ambiguous and metaphorical. He emphasizes Arlow's concept that the patient unwittingly speaks metaphorically to the analyst and the analyst listens metaphorically because metaphor is used to ward off anxiety by means of the mechanism of displacement, "one of the sources of ambiguity in language and in metaphor" (p. 28). He summarizes Arlow's view as follows:
The sources of much adult psychopathology are the universal passions of childhood . . . when intrapsychic conflict does occur a pathogenic compromise formation may follow. The manifestation of this is a fantasy--or rather a core group of fantasies because there may be several overlapping editions of the fantasy as development progresses--centering around the conflictual wishes. This core of fantasies may become largely unconscious, but its derivatives pervade the structure and functioning of each individual--some pathologically, some nonpathologically (p. 31).
The specific understanding of core unconscious fantasies that govern the patient's life is the eventual aim of the psychoanalytic therapy of all patients, including borderline patients. Arlow and his group also contend that theories of pathogenesis related to specific preoedipal phases are quite speculative. As far as Arlow is concerned, such theories cannot be validated and are essentially doctrinaire.
Arlow and his group also object to preoedipal models that emphasize failure of adequate parenting and structural defects rather than conflict. Borderline patients seem to present a combination of structural defects and conflicts. The conflict areas are more amenable to an eventual psychoanalytic approach, but the structural defects sometimes have to be dealt with by techniques "beyond interpretation" that Gedo advocates. Failure to help borderline patients with structural defects by deliberate after-education, according to Gedo, simply represents another failure of parental empathy. This would be a parameter in the treatment of borderline patients and should not be undertaken unless the therapist is convinced that the defect exists and is not an apparent defect as the consequence of a structural conflict, a clinical judgment that is often quite difficult to make.
If one must err, in my experience it is best to err on the side of mistaking a defect for a conflict-related problem because in due time this error can be corrected: approaching a conflict-related problem as a defect by direct after-education produces a therapist-patient collusion that tends to drive the conflict out of sight and make it no longer amenable to the uncovering process. A therapist should also be very cautious in offering any patient after-education, for this is a common manifestation of countertransference acting out when the therapist's narcissistic equilibrium is wounded because the patient is not responding to analytically based interpretations.
- Chessick, Richard, The Outpatient Psychotherapy of the Borderline Patient, American Journal of Psychotherapy, Spring 1993, Vol. 47, Issue 2.
Reflection Exercise #3
The preceding section contained information
about rage and the BPD client. Write
three case study examples regarding how you might use the content of this section
in your practice.
According to Chessick, what technique may easily be used with a borderline client by an untrained therapist as an excuse to permit a flattering kind of worship and massage for the narcissism of the therapist? Record the letter of the correct answer