Borderline Personality Disorder
Written by John M Rathbun M.D. To assist the therapist in maintaining appropriate engagement with borderline patients, a psychologist at Columbia named Jeffrey Young has developed an interesting way of categorizing the ego states commonly seen in borderlines. In his experience, the borderline patient will normally present four ego states, which he calls MODES:
1. The patient normally presents for therapy in an ego state which Young calls The Vulnerable Child Mode - in this mode, the patient is compliant and seeking assistance. This is a continuation into adulthood of behavior patterns used by most children to secure caring and assistance from powerful adults. The therapist will be idealized by the patient in this mode, often leading to a breakdown in normal therapeutic boundaries if the therapist's grandiosity or guilt can be hooked by the patient. Since the borderline's need for emotional nurturance exceeds the capacity of even the most giving therapist to satisfy, the therapist who lacks good professional boundaries will often begin to experience anxiety and resentment about the patient's escalating demands. This will cause a failure of empathy on the therapist's part, leading to the emergence of
2. The Angry Child Mode - in which the therapist is harshly devalued by the patient. If the therapist reacts defensively, an even more dysfunctional ego state will emerge:
3. The Punitive Parent Mode - since the child was punished for expressing normal needs and emotions, the adult knows that she is wrong to have these needs and emotions, and deserves punishment for expressing her feelings. Because she has internalized her parents' dysfunctional attitudes and behaviors, she will begin to punish herself for having needed the therapist so much, and for having expressed her anger at the therapist for not satisfying those needs. In the punitive parent mode, the patient will derogate herself during internal dialogues, will experience herself as defective, worthless, and contemptible, and will often punish herself through self-mutilating or self-poisoning. Her attempt to regain a position of emotional equilibrium will often lead to the fourth and last of the common ego states seen in borderlines:
4. The Detached Protector Mode - in which feelings are disavowed, and the patient appears passively compliant and placid. This particular ego state is often overvalued by naive therapists whose personal insecurity leads them to prefer the appearance of calm to the turbulence of the patient's other ego states.
The Detached Protector Mode is actually the least workable of the four ego states commonly seen in borderline patients; the only appropriate therapeutic technique for this mode is to encourage the Vulnerable Child mode to reemerge. One can do this by reminding the patient how she felt in a previous session.
You may then have to work through eruptions of the Punitive Parent Mode by assuring the patient that her need for nurturance is normal and acceptable. In general, your goal is to extinguish the Punitive Parent Mode by presenting yourself as a more accepting and appropriate parent for the patient.
The Angry Child needs help learning how to express that emotion in nondestructive ways. A therapist who is personally secure will encourage the patient to verbalize even more anger at the therapist, but actual verbal abuse should be redirected into more authentic emotional expressions. In this regard, the patient can be helped to use "I" statements rather than "you" statements - "I felt abandoned by you" rather than "You're a cold, uncaring, heartless bastard". You may have to assist the patient to understand that "I think you're a cold, uncaring, heartless bastard" is really a "you" statement disguised as an "I" statement. The payoff for the patient in learning how to verbalize anger more appropriately is that the patient can then be angry without sacrificing connection with potential sources of emotional nurturance.
The Vulnerable Child Mode is the most workable ego state in borderline patients. Young suggests four basic techniques for this ego state:
1. Cognitive interventions - using journaling, you can teach the patient to examine her dysfunctional thoughts and decide for herself if they are valid. Some common dysfunctional assumptions in borderlines are
a. The world is dangerous and wants to hurt me
b. I am powerless in this world
c. I am hopelessly defectived. Things are good or bad, choices are all or nothing
2. Experiential techniques - such as gestalt, imagery, and inner-child work
3. Therapeutic relationship - giving the patient a good example to imitate
4. Behavioral pattern breaking - finding new and more effective ways to get legitimate needs met
Some basic therapeutic techniques to use with borderlines:
1. validate needs and feelings; avoid problem-solving for the patient
2. be reliable and caring and real
3. strongly praise any improvement in behavior
4. re-attribute parental rejection to parental defects
5. teach the patient to recognize the various ego-states or modes of behavior as they emerge in the sessions, and to understand how their dysfunctional assumptions arose naturally from their suboptimal early experiences
6. attribute any patient failures to the patient's excusable misunderstandings and help the patient to analyze these
7. using the empty chair technique, teach the patient how to talk back to the punitive parent
8. acknowledge your mistakes and model forgiveness of yourself and others
Most therapists who write about treatment of post-traumatic syndromes emphasize that treatment must proceed in stages. The first stage is always focused on the development of a therapeutic relationship based on mutual understanding and respect. Young suggests this stage will be facilitated if the therapist can always think of the patient as a needy, primitive child rather than as a greedy, manipulative opportunist. Emergence of such negative attitudes in the therapist is associated with poor treatment outcomes, as the patient's original experience with a punitive parent is repeated in the therapy.
It is important that patient and therapist agree on goals for the treatment in language that makes sense to the patient. It will also be necessary for the therapist to make clear the limits of therapist availability. Most patients with Borderline Personality Disorder have daily and nightly emotional crises, and will need frequent reassurance by phone or in extra sessions, at least until they learn how to manage their emotions better. It's legitimate to tell the patient that daily phone calls are not OK, and that late night calls make you cranky the next day. You can also mention that learning self-soothing is one of the important goals of therapy.
If the patient is doing something that you can't tolerate, it's important to discuss this in session before you reach the point of resenting the patient. It's appropriate to tell the patient that frequent phone calls disrupt your personal time, and that you may begin to feel resentful if it continues. Borderline patients have usually grown up around people with poor conflict resolution skills and poor interpersonal boundaries, so you want to show the patient how two adults can discuss and resolve a conflict without becoming abusive or withdrawn from each other.
When your practice situation permits, it's appropriate to inform the patient that you charge for after hours phone contacts as well as for extended phone contacts during office hours. These are professional services which the patient should expect to pay for, just as you would expect to pay for the furnace man to come and relight your burner on a cold winter's night. Offering unlimited free support at all hours of the day or night is a recipe for therapist burnout and for a major betrayal of the patient's trust, because you will not be able to keep it up, and a burned-out therapist is both unhappy and dangerous.
Since many of you work for not-for-profit agencies, let me take a moment here to disparage certain dysfunctional attitudes that seem to pervade such organizations. You probably went into this sort of work because you enjoy helping people, and you feel real compassion for those less fortunate. These traits make you willing to work long hours for low pay, and your professional reputation depends on your willingness to go the extra mile for your clients. When an entire organization is staffed from top to bottom with professionals who share the value of self-sacrifice, there's an opportunity for the best intentions to lead to the worst outcomes.
Not only does your borderline patient need to see that relationships can have limits and still be rewarding, she also needs to believe that she can survive on her own adult resources in this world. The therapist who can't limit the patient in her quest for constant reassurance is saying, "Yes, you really are just as incompetent as you feel!"
The most challenging aspect of therapy with Borderline Personality Disorder is knowing how to set and enforce limits. This is a matter of therapeutic art, and cannot be taught in a lecture or manual. We all make errors in judgement when it comes to enforcing limits and providing optimal levels of support in therapy. More experienced therapists are less likely to make these errors, and should be sought as mentors by less experienced therapists. Therapeutic technique is not perfectible, only subject to endless improvement. Borderlines are those patients who show us where we have room to grow in our technical skills.
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