I Hate You--Don't Leave Me - Jerold J. Kreisman [71]
The Patient-Therapist “Fit”
All of the treatments described in this book can be productive approaches to the borderline patient, though no therapeutic techniques have been shown to be uniformly curative in all cases. The only factor that seems to correlate consistently with improvement is a positive, mutually respectful relationship between patient and therapist.
Even when a doctor is successful in treating one or many borderline patients, this does not guarantee automatic success in treating others. The primary determining factor of success is usually a positive, optimistic feeling shared between the participants—a kind of patient-therapist “fit.”
A good fit is difficult to define precisely, but refers to the abilities of both the patient and therapist to tolerate the predictable turbulence of therapy, while maintaining a sturdy alliance as therapy proceeds.
The Therapist’s Role
Because treatment of BPD may entail a combination of several therapies—individual, group, and family psychotherapies, medications, and hospitalization—the therapist’s role in treatment may be as varied as the different therapies available. The doctor may be confrontational or nondirective; he may either spontaneously exhort and suggest or initiate fewer exchanges and expect the patient to assume a heavier burden for the therapy process. More important than the particular doctor or treatment method is the feeling of comfort and trust experienced by both patient and therapist. Both must perceive commitment, reliability, and true partnership from the other.
To achieve this feeling of mutual comfort, both patient and doctor must understand and share common objectives. They should agree upon methods and have compatible styles. Most important, the therapist must recognize when he is treating a borderline patient.
The therapist should suspect that he is dealing with BPD when he takes on a patient whose past psychiatric history includes contradictory diagnoses, multiple past hospitalizations, or trials of many medications. The patient may report being “kicked out” of previous therapies and becoming persona non grata in the local emergency room, having frequented the ER enough times to have earned a nickname (such as “Overdose Eddie”) from the medical staff.
The experienced doctor will also be able to trust his countertransference reactions to the patient. Borderlines usually elicit very strong emotional reactions from others, including therapists. If early on in the evaluation, the therapist experiences strong feelings of wanting to protect or rescue the patient, of responsibility for the patient, or of extreme anger toward the patient, he should recognize that his intense responses may signify reactions to a borderline personality.
Choosing a Therapist
Therapists with differing styles may perform equally well with borderlines. Conversely, doctors who possess special expertise or interest in BPD and who generally do well with borderline patients cannot guarantee success with every patient.
A patient can choose from a variety of mental health professionals. Though psychiatrists, following their medical training, have years of exposure to psychotherapy techniques (and, as physicians, are the only professionals capable of dealing with concurrent medical illnesses, prescribing medications, and arranging hospitalization), other skilled professionals—psychologists, social workers, counselors, psychiatric nurse-clinicians—may also attain expertise in psychotherapy with borderline patients.
In general, a therapist who works well with BPD possesses certain qualities that a prospective patient can usually recognize. He should be experienced in the treatment of BPD and remain tolerant and accepting in order to help the patient develop object constancy (see chapter 2). He should be flexible and innovative, in order to adapt to the contortions through which therapy with a borderline may twist him. He should possess a sense of humor, or at least a