I Hate You--Don't Leave Me - Jerold J. Kreisman [69]
Therapy may be interrupted. It is not unusual for borderlines to engage in several separate rounds of therapy, with different therapists and different techniques. Breaks in therapy may be useful to solidify ideas, or to try out new insights, or merely to catch up with life and allow time to grow and mature. Financial limitations, significant life changes, or just a need for a respite from the intensity of treatment may mandate a time-out. Sometimes years of therapy may be necessary to achieve substantive changes in functioning. When the changes come slowly, it can be difficult to determine whether more work should proceed, or if “this is as good as it gets.” The therapist must consider both the borderline’s propensity to run from confrontations with his unhealthy behaviors and his tendency to cling dependently to the therapist (and others).
For some borderlines, therapy may never formally end. They may derive great benefit from continuing intermittent contacts with a trusted therapist. Such arrangements would be considered “refueling stops” on the road to greater independence, provided the patient does not rely on these contacts to drive his life.
How Psychotherapy Works
As we shall see later in this and the next chapter, there are several established therapeutic approaches for the treatment of BPD. They may proceed in individual, group, or family settings. Most of these are derived from two primary orientations: psychodynamic psychotherapy and cognitive-behavioral therapy. In the former, discussion of the past and present are utilized to discover patterns that may forge a more productive future. This form of therapy is more intensive, with sessions conducted several times a week and usually continuing for a longer period. Effective therapy must employ a structured, consistent format with clear goals. Yet there must also be flexibility to adapt to changing needs. Cognitive-behavioral approaches focus on changing current thinking processes and repetitive behaviors that are disabling; this type of therapy is less concerned about the past. Treatment is more problem-focused and often time-limited. Some therapy programs combine both orientations.
Whatever the structure, the therapist tries to guide clients to examine their experience and serves as a touchstone for experimenting with new behaviors. Ultimately, the patient begins to accept his own choices in life and to change his self-image as a helpless pawn moved by forces beyond his control. Much of this process emerges from the primary relationship between therapist and patient. Often, in any therapy, both develop intense feelings, called transference and countertransference.
Transference
Transference refers to the patient’s unrealistic projections onto the therapist of feelings and attitudes previously experienced from other important persons in the patient’s life. For example, a patient may get very angry with the doctor, based not on the doctor’s communications, but on feelings that the doctor is much like his mother, who in the past elicited much anger from him. Or, a patient may feel she has fallen in love with her therapist, who represents a fantasied, all-powerful, protective father figure. By itself, transference is neither negative nor positive, but it is always a distortion, a projection of past emotions onto current objects.
Borderline transference is likely to be extremely inconsistent, just like other aspects of the patient’s life. The borderline will see the therapist as caring, capable, and honest one moment, deceitful, devious, and unfeeling the next. These distortions make the establishment of an alliance with the therapist most difficult. Yet establishing and sustaining this alliance is the most important part of any treatment.
In the beginning stages of therapy, the borderline both craves and fears closeness to the therapist. He wants to be taken care of but fears being overwhelmed and controlled. He attempts to seduce the