I Hate You--Don't Leave Me - Jerold J. Kreisman [73]
The borderline may need to be frequently reminded of the parameters of therapy. He should understand the ground rules, including the doctor’s availability and limitations, the time and resource constraints, and the agreed-upon mutual goals.
The patient must not lose sight of the fact that he is bravely committing himself, his time, and his resources to the frightening task of trying to understand himself better and to effect alterations in his life pattern. Honesty in therapy is therefore of paramount importance for the patient’s sake. He must not conceal painful areas or play games with the therapist to whom he has entrusted his care. He should abandon his need to control, or wish to be liked by, the therapist. In the borderline’s quest to satisfy a presumed role, he may lose sight of the fact that it is not his obligation to please the therapist but to work with him as a partner.
Most important, the patient should always feel that he is actively collaborating in his treatment. He should avoid either the extreme of assuming a totally passive role, deferring completely to the doctor, or that of becoming a competitive, contentious rival, unwilling to listen to contributions from the therapist. Molding a viable relationship with the therapist becomes the borderline’s first and, initially, most important task in embarking on a journey toward mental health.
Therapeutic Approaches
Many clinicians divide therapy orientations into exploratory and supportive treatments. Though both styles overlap, they are distinguished by the intensity of therapy and the techniques utilized. As we will see in the next chapter, a number of therapy strategies are used for the treatment of BPD. Some employ one style or the other; some combine elements of both.
Exploratory Therapy
Exploratory psychotherapy is a modification of classical psychoanalysis. Sessions are usually conducted two or more times per week. This form of therapy is more intensive than supportive therapy (see page 161), and has a more ambitious goal—to alter personality structure. The therapist provides little direct guidance to the patient, utilizing confrontation instead to point out the destructiveness of specific behaviors and to interpret unconscious precedents in the hopes of eradicating them.
As in less intensive forms of therapy, a primary focus is on here-and-now issues. Genetic reconstruction, with its concentration on childhood and developmental issues, is important, but emphasized less than in classical psychoanalysis. The major goals in the early, overlapping stages of treatment are to diminish behaviors that are self-destructive and disruptive to the treatment process (including prematurely terminating therapy), to solidify the patient’s commitment to change, and to establish a trusting, reliable relationship between patient and doctor. Later stages emphasize the processes of formulating a separate, self-accepting sense of identity, establishing constant and trusting relationships, and tolerating aloneness and separations (including those from the therapist) adaptively.2 ,3
Transference in exploratory therapy is more intense and prominent than in supportive therapy. Dependency on the therapist, together with idealization and devaluation, are experienced more passionately, as in classical psychoanalysis.
Supportive Therapy
Supportive psychotherapy is usually conducted on a once-weekly basis. Direct advice, education, and reassurance replace the confrontation and interpretation of unconscious material typically used in exploratory therapy.
This approach is meant to be less intense and to bolster more adaptive defenses than exploratory therapy. In supportive psychotherapy the doctor may reinforce suppression, discouraging discussion of painful memories that cannot be resolved. Rather than question the roots of minor obsessive concerns, the therapist may encourage