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A Little Cream and Sugar: Psychotherapy With a Borderline Patient

1998; American Psychiatric Association; Volume: 155; Issue: 1 Linguagem: Inglês

10.1176/ajp.155.1.114

1535-7228

Joan Wheelis, John G. Gunderson,

Transactional Analysis in Psychotherapy

Back to table of contents Previous article Next article Clinical Case ConferenceFull AccessA Little Cream and Sugar: Psychotherapy With a Borderline PatientJoan Wheelis, M.D., and John G. Gunderson, M.D.Joan Wheelis, M.D., and John G. Gunderson, M.D.Published Online:1 Jan 1998https://doi.org/10.1176/ajp.155.1.114AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This case report describes selected parts of a psychotherapy with a patient diagnosed with borderline personality disorder. Although this report features aspects of psychodynamic psychotherapy, readers should recognize that this modality usually needs to be used selectively as part of a treatment program involving family, cognitive/behavioral, and psychopharmacological modalities (1). Process material has been chosen from the first year of a twice-weekly psychotherapy to highlight issues that are commonplace during the course of such therapies: establishing an alliance, managing boundaries, setting limits, and responding to rage and suicide threats. The clinical material examines how countertransference feelings arise and become enacted. Insofar as this case report documents the common, recurrent, and oft-feared problems in psychotherapy with borderline patients, the discussion is intended to offer a primer for how these problems can be effectively managed. Indeed, the testing, the combativeness, and the dangers characteristic of the borderline patient presented here provide a backdrop against which we hope to convey a larger thesis. While the depth and intensity of dependent and rageful feelings, technical challenges, and commitment inherent in such work are often seen as a reason to avoid such patients, the work can be, and with experience will be, an enriching and satisfying professional activity.CASE PRESENTATIONI, Dr. Wheelis, was a second-year resident on call when I first met Ms. A. At the time she was a psychiatric inpatient who had been admitted a week before for suicidality and increased alcohol abuse. I had been asked to meet with Ms. A and potentially take over her treatment, since she had recently terminated with her therapist. The inpatient psychiatrist in charge of the care of Ms. A, as well as an outpatient consultant, had recommended a confrontational dynamic psychotherapy. I had arranged a first appointment for the following morning, but as the doctor on call the evening before, I was asked to see her for medical attention. In a rage at having been put in a quiet room, Ms. A had hit her elbow on the wall and was complaining of great pain. I felt uneasy that my first contact should be under such circumstances and wondered if she knew I was the doctor on call that night. When I arrived to see her, I was met by a short, medium-built woman wearing jeans, sitting cross-legged on the floor, looking angrily at me. Before I'd had a chance to introduce myself, she snapped:Ms. A: You could be dying before you got any help around here! My arm is killing me! This place is crazy! Therapist: Ms. A, I would like to introduce myself. I am Dr. Wheelis. Ms. A: Oh, no kidding! I didn't expect you. You're a resident? Interesting. You must be either very good or very crazy to have taken me on. Therapist: I can't tell if that's an invitation, a warning, or both [she smiled at my comment], but we have an appointment tomorrow. Why don't we discuss it then. For now, perhaps I should take a look at your arm. Ms. A: No, it's okay, just a little bang. Therapist: Are you sure? You suggested that it was giving you considerable pain. Ms. A: No, it's fine, really. I'll see you tomorrow. By the way, I hate being called Ms. A. Therapist: How would you like to be called? Ms. A: Lotta. That's what everyone calls me. Therapist: Very well, as you wish. Already in this initial interaction with her therapist-to-be, harbingers of the therapeutic challenges are evident. Ms. A demonstrates a manipulative style that predates the first interaction by seeking help through the exaggeration of a minor physical complaint. There is also the hint that Ms. A may be taking pleasure in suggesting to the therapist-to-be that working with her will be more than a small challenge. Her final request, to be called Lotta, betrays her desire to bypass professional formality by requesting an immediate familiarity.Ms. A was a 35-year-old, single, white librarian when I met her as an inpatient. The hospitalization was her 10th psychiatric admission. Her past history was replete with self-destructive behavior including wrist slashing as a teenager, alcohol and benzodiazepine abuse, chronic dysthymia, and suicidality. She was diagnosed with borderline personality disorder following her first hospitalization at age 18, having met seven of the nine diagnostic criteria of DSM-IV. At other times she had been given additional axis I diagnoses including bipolar disorder. She had had several medication trials without benefit. Her dominant symptoms were emptiness and aloneness; although she was impulsive and labile as well, these symptoms were connected to interpersonal stressors and did not fit criteria for bipolar disorder. Her current admission was precipitated by increasing depression and suicidality, but without a suicide attempt, following the loss of her boyfriend of 8 years. Her psychiatrist of 10 years had terminated treatment because of a geographic relocation. She felt increasingly withdrawn from her family, especially her mother, with whom she had been particularly close. Ms. A was quite specific as to the goals of her current hospitalization. She wanted to find a new therapist and to become involved in Alcoholics Anonymous in order to stop drinking.After the initial meeting in the quiet room, I met with Ms. A for her first scheduled appointment the following day. She was waiting for me when I arrived on the inpatient unit. Ms. A: Could we go where I could smoke? You'll have to get the matches from the nurse. I'm on supervised flames. I proceeded to get the matches and found a room where smoking was permitted. I handed her the matches.Ms. A: You're going to trust me with these? Therapist: I'm going to see if I can. Ms. A: What if I try to set something on fire? [She said this sarcastically.] Therapist: Then I won't be able to trust you, and I'll ask for them back. Ms. A: Hm! You ask a simple question, you get a simple answer. Doesn't happen so commonly around here. Do you smoke? Therapist: On occasion. Ms. A: Two for two! Most shrinks don't answer my questions. Therapist: Let's not try to set a record. Ms. A: I feel much better now that I have a therapist. Therapist: I want to interrupt you; I've only a half an hour today and I wanted to speak with you about a few things. What I had in mind was to meet with you several times between now and when you're discharged and give ourselves the opportunity to see if you want to work with me and for me to see if I think I can be of help to you. If we decide we can work together, then we'll continue on an outpatient basis two or three times a week, which we can decide together. [Ms. A starts to shake her head.] Ms. A: Let me interrupt you a minute! I'm not a nine-to-fiver. Now, I know I have trouble with limit setting and you can tell me this is out of the question, but I have in mind five times a week, and I need to know I can call you, you know? Therapist: No, I don't know. Ms. A: Well, like if I get into trouble, I want to know that I can contact you. Therapist: If you feel in trouble and unable to wait until our next appointment, I would be available, but if this were to occur frequently it would not be all right. I would question the utility of the therapy and would want to reassess it. Ms. A: Well, I never called my last therapist, but it mattered that I knew I could. You know, I always imagined I'd be in treatment forever. Therapist: Is that a wish? Ms. A: I'd just assumed since I'd been in therapy this long already, I will continue to be in therapy forever. Therapist: Do you want to change? Ms. A: Well, of course. Therapist: Then I think it's a mistake to make that assumption without question. Ms. A: Well, are you saying I won't need therapy forever? Therapist: I cannot say that. Ms. A: Well, then, are you saying I'll need therapy for the rest of my life? Therapist: I can't say that, either. I don't know, but I am suggesting that if you leave the question open, your therapy might be more effective. Ms. A: You're also telling me that you're not sure you're going to be my therapist. Therapist: That's true. Ms. A: What does it depend on? Therapist: If I feel I can be of help to you. Ms. A: What? Do I have to prove myself a good patient? Therapist: I would think it more worthwhile for you to be thinking if you want to work with me. Ms. A: I never really thought about that kind of thing. Therapist: Well, time to start. Ms. A: You're something else. Therapist: How so? Ms. A: Well, nobody really talks to me the way you do. Therapist: How's that? Ms. A: I don't know. Like you treat me like an adult, no kid gloves. Therapist: Should I? Ms. A: No. I don't know. Therapist: You're not quite sure? Ms. A: Well, most people treat me with kid gloves, you know, Lotta the sick one, the one who can't deal with anything. It makes me mad, makes me feel like a cripple. But then I think, they're probably right, and I can't handle anything anyway. I was aware of the way in which Ms. A's style of engaging me was static and rigid. She wanted me to conform with what she deemed the appropriate treatment plan—my being actively available to nurture her without question. My efforts to encourage her capacity for critical thinking were met with resistance but not rejection. I felt that this session significantly shaped my initial treatment plan. The primary task was to encourage her as an active participant in her treatment rather than as a passive recipient of her treatment. We clarified other goals of her treatment to include improving her relationship with her mother, friends, and lovers through the examination of her conflicted feelings of neediness and anger. I told her that much of the work that we could do together would depend upon her ability to examine such problems in the context of our relationship as we had in this first session. Although reluctant, Ms. A was intrigued.This initial session is illustrative of a couple of important issues regarding alliance building. The interactions are characterized by the therapist's repeated attempts to question Ms. A's unrelenting efforts to force an unquestioned relationship based on her needs alone. The therapist wisely sets a preliminary agenda of considering the viability of a treatment relationship. She sets the stage by underscoring that therapy is to be tied to forward progression and not to continuation of old ways. The implicit differentiation between therapist and patient suggested in this process material covertly indicates that ultimately, separation is the goal of treatment. Later in the session, specific goals of therapy were discussed. Together they agreed that their work would focus on managing her anger and impulsivity and improving her relationship with her mother.I met with Ms. A as we had planned for a total of six sessions while she was hospitalized. I obtained the following history from her and her old records.Ms. A was born in the Midwest and was the older of two children; she had one sister 3 years younger. Her parents both worked in the auto parts industry. She had little to say about either parent: she described her father as difficult, her mother as rigid, like herself, but her "best friend." She had always hated her sister. Her mother reported that Ms. A was the product of an unremarkable pregnancy and that her early development was normal. She also commented during one of Ms. A's hospitalizations that she had found the task of mothering to be difficult, finding it frustrating to be tied to the house and to be caring for a child.Ms. A's earliest memory, at age 3, was of offering her mother a picture she had carefully and painstakingly drawn for her upon her arrival home from the hospital with her new little sister. She remembers shredding the picture into little pieces as her mother reached to accept it. When Ms. A was 13, her father suffered a fall at work and was paralyzed from the waist down. Whereas before she had been an active, helpful, and good-humored child who was open and talkative, she became withdrawn, solemn, and uncommunicative. Around the same time she began a friendship with a friend, Susan. She described the relationship as intense and said that its breakup after 4 years was instigated by Susan, who found the closeness suffocating. Susan apparently felt so controlled by Ms. A that Susan's mother became concerned that this was interfering in her daughter's development and so urged her to end the relationship. After the breakup of the friendship, Ms. A, then age 16, became depressed and cut her wrists for the first time, telling no one. Subsequently her schoolwork in a local public high school deteriorated, and she went from being an A student to a D student.This history frames important issues for the subsequent treatment. Her earliest memory introduces the issue of exclusivity, rivalry, and spitefulness. Until this point, Ms. A had been the sole proprietor of the parental attention; the disillusionment occurred when she saw her mother giving attention to her sister. Ms. A's intense relationship with her friend Susan was so exclusive and controlling that Susan's mother became concerned and intervened. The immediate effect of this was that Ms. A cut her wrists for the first time. It is notable that like many people who subsequently become identified as borderline, Ms. A made the initial self-destructive gestures in private. Only later did the secondary gain (the attention drawn from family and therapists by such actions as wrist cutting) become conscious and manipulatively—even spitefully—exploited. Perhaps more telling than the cut wrists is the fact that Ms. A's schoolwork deteriorated. This might have been a signal to caretakers that she was in trouble and calling for help, but, in any event, it reflects the serious and sustained injury that the breakup of this friendship involved for Ms. A.The loss of an exclusive relationship, as these vignettes suggest, reveals a core vulnerability in borderline patients (2). The therapist can anticipate that the patient is likely to want to recreate an exclusive relationship and can expect that the inevitable disillusionment of such claims will be greeted with similarly spiteful actions.Ms. A skipped many classes and began taking street drugs including marijuana and barbiturates. During her junior year of high school she began shoplifting and missing school altogether. There was increased friction at home with her parents. Despite their attempt to set limits through insisting on a curfew and other rules of conduct, they were ineffectual at controlling their daughter's behavior. The same year, at age 17, Ms. A was hospitalized for the first time after cutting her wrists and, this time, showing them to her parents. She continued to cut her wrists superficially while in a general hospital; unable to abide by the limits set on this, she was transferred to a state hospital briefly. After returning to the general hospital, she continued to violate the rules and regulations, even once setting her hair on fire in anger at a staff member. This and other breaches of agreements that she not harm herself necessitated her return to a state hospital, where she stayed for 6 months.As expected, Ms. A learned the power that is associated with self-destructive acts. Her first hospitalization was precipitated by showing her cut wrists to her parents. Her parents, however, were in no position to assess the seriousness of such actions. Even for clinicians, judging potential lethality and the appropriate response is difficult. When inexperienced clinicians first encounter young adult patients who have slashed their wrists or otherwise have behaved in a self-destructive way, such as minor overdosing, they often respond instinctively by assuming suicidal intention, then take on responsibility for preventing any recurrence. This often takes the form of psychiatric hospitalization; motivations may include anxiety about distinguishing between true suicidal ideation and self-harming behavior without lethal intent or fear of the legal, administrative, and psychological consequences should a suicide occur. Often conscious and unconscious enthusiasm for taking such a role stems in part from the opportunity it represents to fulfill what is the most dramatic and perhaps the most alluring promise of becoming a caretaker, i.e., to save a life.Repeated self-destructive acts by any patient should alert clinicians to the fact that the acts may not be suicidally intended. Such self-destructive acts are usually done for self-punitive purposes (3) and are sometimes associated with an experience of relief from painful ("intolerable") affective states (4), but they are also done with progressively more awareness of the controlling effects that such acts have on significant others. Follow-up studies show that in fact, about 8%–9% of borderline patients commit suicide (5) and that the suicide rate is particularly high among those, like Ms. A, who have comorbid substance abuse (6). This rate is about 400 times the rate (about 0.01%) in the general population and more than 800 times the rate (0.005%) found in young female subjects (ages 15–34) (7). By itself, this vindicates those clinicians who attempt to preclude the opportunity for borderline patients to perform suicidal acts. This can mean involuntary hospitalizations but more often entails decisions such as giving prescriptions for only small quantities of medications, enlisting family members to help monitor the patients' suicidality, and encouraging patients to know of one's availability in crises. Despite the high frequency with which borderline patients perform multiple self-destructive acts, the comparative frequency of those which result in actual suicide is low (4, 6). From this perspective, the data vindicate those clinicians who are primarily concerned about the secondary gain and manipulative intentions related to borderline patients' self-destructive acts. Their interventions are typically directed toward diminishing the secondary gains from self-destructive acts by, for example, staying uninvolved with hospitalizations or being unavailable between sessions.On balance, these facts offer little comfort for clinicians. The painful truth is that borderline patients do commit suicide, often under circumstances that may have begun as a gesture but in which they have miscalculated the response of those from whom a "saving response" was expected. Thoughtful judgment must be employed that takes into consideration the complexity of the patients' motives, the expected lethality, the self-destructive mode, the nature of the patients' relationship to significant others, including oneself, and the past responses from those others, including oneself.Following her discharge Ms. A completed high school studies. As a graduation present she was given a trip to Cuba to work with other college-bound students on a sugar cane plantation. Although she had been looking forward to this trip, shortly after her arrival she found herself feeling increasingly isolated and suspicious that other people around her did not like her. After only 2 weeks there, she decided to come home and called her parents. Following her mother's reluctant agreement with her adamant wish to come home, she wrote her parents a letter in which she stated that she felt like a failure and proceeded to overdose on her antidepressant medication. Her family flew to Cuba to bring her home, and she was then hospitalized psychiatrically for 6 months. Subsequently, Ms. A, then 19, took a job and began at a local college. She saw a therapist intermittently, and her next psychiatric admission occurred 3 years later. The context of that hospitalization was related to her inability to make a contract for safety with her therapist before the latter's vacation. Found not to be actively suicidal, however, Ms. A was discharged after only 5 days.The phenomenology of borderline psychopathology needs to be evaluated in terms of the patient's relationships to primary caregivers. When a borderline patient feels in the presence of one who is supportive or holding, the depressive features become paramount. Borderline patients can work collaboratively within a therapy, and their complaints are usually of boredom, loneliness, or emptiness. When a borderline patient feels endangered regarding the potential loss of the supportive, holding relationship involving a person or institution, then manipulative, self-destructive acts are common. These acts, then, have angry motivations as well as conscious manipulative intentions of preventing the separation from occurring by enjoining the therapist (or any other needed person who might be leaving) to respond in ways that will provide ongoing holding and support to the borderline patient. In contrast to such secondary gain associated with self-destructive acts, primary gain is evident under circumstances in which borderline patients find themselves without a holding or caring object relationship. In such cases the intention of self-mutilation is not manipulative; rather, it serves to diminish the anxieties associated with deficient self-object differentiation, boundary delineation, and dissociative experiences. On an unconscious level it may serve the purpose of exculpating themselves from the sense of profound badness. Under these circumstances, paranoid ideas of reference such as Ms. A experienced in Cuba can occur. They serve to diminish the sense of aloneness. Potentially dangerous impulsive actions can also occur that are neither intentionally manipulative nor self-destructive, e.g., promiscuity or getting into fights, often in the context of substance abuse.At the age of 22 Ms. A began her one long-term psychotherapeutic treatment. She described this 10-year therapy as "friendly," commenting that the "boundaries were loose." She was often not billed if she was having financial difficulties, and she and her therapist occasionally met over a meal. She felt fondly toward him. She had several hospitalizations shortly into this treatment because of suicidal ideation, but for the 4 years before the index hospitalization, Ms. A was relatively stable. She was in a long-term romantic relationship and had a stable job in a small library.Ms. A's diminished self-destructiveness and ability to sustain employment during this earlier period are probably attributable to the stabilizing effect of this therapist's supportive availability, as well as that of her romantic relationship. As noted earlier, when borderline patients find themselves within supportive or holding relationships, their ability to work collaboratively emerges, and there is an absence of the self-destructive and impulsive behaviors that otherwise would characterize them. If these supportive relationships are sufficiently stabilizing, they allow borderline patients to find alternative stabilizing sources of support in their lives outside of their therapy. Such supportive therapy can consolidate some developmental gains, which later permits more exploratory, expressive, focused treatment around character structure and organization. The reemergence of Ms. A's full repertoire of borderline behaviors and feelings at the time of the index hospitalization for this report is a testimonial to the persistence of her basic character problems. Although it is likely that her prior therapy had an overall positive effect, the lax professional structures within the relationship may have had the unfortunate effect of making her less willing to conform and accept the boundaries of a usual therapy. They may also have robbed her of the potential benefits that more ambitious exploratory or expressive psychotherapies can sometimes offer in terms of bringing about character change (8, 9).While Ms. A was hospitalized, recommendations were made that she be transferred to an alcohol and drug treatment center. She was adamantly opposed to this and proceeded to make plans to leave the hospital without this transfer occurring. She insisted that she could not take any more time off from her job. I reminded her of her self-assigned task for this hospitalization and urged her to participate in the alcohol-related programs and to consider strongly the recommendation for a transfer. She refused, claiming that her drinking was "not a big deal anymore" and that her job was more important.If a borderline patient has a significant problem with substance abuse, his or her involvement in treatment for that condition should usually be insisted upon before individual psychotherapy begins. If an individual therapist does not insist upon such involvement at the beginning of therapy, it becomes extremely unlikely that the patient will enlist in it voluntarily. Self-help groups, such as Alcoholics Anonymous, like employment, are the best "co-therapies" one could have; they both structure the patient's time and offer support while providing added resources for the patient to deal with the issues raised within individual therapy.In a session shortly before the decision would be finalized regarding our working together, Ms. A spoke of her anxiety regarding that issue.Ms. A: I like you. If you tell me on Thursday that you will not be my therapist, I am going to be very, very upset! Therapist: That sounds like a threat. Ms. A: No, I am just telling you. Therapist: Have you been thinking about your needs? Ms. A: I really like what you said about maybe not being in therapy for the rest of my life. I've been afraid to ask you how much you charge. I won't be able to afford it when I leave. Therapist: If we continue, you would be transferred to the outpatient clinic. The fee there is $28. Ms. A: What? [She sounds disappointed.] I thought it was going to be about $100.Ms. A's positive attitudes toward the desired therapist-to-be should be noted. In saying that she really likes the notion that she does not have to be in therapy for the rest of her life, does she really mean this? If she does, is it because it is a relief from the fear of being trapped and controlled by her therapist? One would hope that it means that she is truly interested in changing and making that therapy obsolete in time, but that would involve a loss which we can predict already that she is likely to dread. It is thus prudent to listen to such complimentary remarks with some skepticism. As Ms. A goes on to suggest that she thought the fee would be $100 and that she would not have been able to afford this, she may be hinting at her ambivalence even as she flatters the therapist-to-be. She would like her therapist to begin feeling very much needed and special.The final meeting while Ms. A was an inpatient occurred a couple of days later.Ms. A: So today's the day. You know, I never thought that you would need to make a decision, too. I thought that if I wanted to see you and could agree to the terms, it would be all right. Are we hearing echoes from Ms. A's childhood? Is this a small child speaking to her mother before her sibling arrived? Did she believe that if she wanted to be with her mother, that would be sufficient to ensure its actualization? Ms. A did not and probably still does not accept the idea that her relationships can be worthwhile if they are not exclusive.Therapist: Did you think I might not have some impression, too? Ms. A: [nervous] I never thought about those things before. Therapist: You seem nervous. Ms. A: I am because I want to know what your decision is. Therapist: You're worried that I might say no. Ms. A: I'd be very upset. Therapist: What are your thoughts? Ms. A: I don't want to talk about it. But I'd be very upset! I feel like the only thing I might get out of this hospitalization is finding a therapist, and since I am leaving in a couple of days, if you don't see me, I'll be very unhappy! Therapist: You sound like you're hoping I'll feel guilty. Ms. A: No, I'm not. I've nothing more to say. Therapist: You say you don't want to talk about your thoughts and feelings that upset you. That is one of the many things I was talking about the other day, when we spoke of making a contract for therapy. You're going to have to try to explore those different feelings and thoughts if I'm going to be of any help to you. Ms. A: Listen, I'll do the work. You haven't even told me yet if you're going to work with me. Christ almighty, this is like torture! Therapist: I am curious to know why you find yourself so confident that you can work with me when it sounds like your previous therapist had such a different style. Ms. A: Well, just because I stay with something doesn't mean it's a good thing. Therapist: So what kept you in that treatment for so long if you felt it wasn't a good thing? Ms. A: I liked him. He was a friend and he cared about me, but I also knew I didn't do any work, certainly later on. I like you; I want to work. I'll tell you now, I'll get angry and fuss when you ask me to work, but I'll do it. I really was intrigued with the idea you put in my head that maybe I don't have to be in therapy for the rest of my life. Therapist: Well, I have decided to work with you. These are my conditions: that we begin with meeting twice a week, that I am available in between appointments only in emergencies, and that you work, meaning paying attention to your feelings and that you pay your bill in a timely fashion. Ms. A: I won't miss work to come to my appointments. I need a 7:00 a.m. or 7:00 p.m. appointment. Therapis