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Avoid rigidity: Many beginning therapists who are well aware of the literature on boundary problems with borderline patients (Gabbard & Wilkinson, 1994; Gutheil, 1989) become excessively rigid in their psychotherapeutic stance. Patients with BPD may experience this unyielding posture as cold and remote and end up quitting the therapy because they do not feel understood by or connected to the therapist. A more clinically useful strategy is to strive for a spontaneous and flexible position in which boundaries are observed, but the patient is allowed to actualize certain patterns of internal object relations with the therapist (Gabbard, 1998; Sandier, 1981). As in all human relationships, the borderline patient tries to impose on others a particular way of experiencing and responding. Therapists must be sufficiently flexible to join in this "dance" evoked by the patient so that the characteristic pattern of relatedness can be observed and understood.
Establish conditions that make psychotherapy viable: The inherent instability of the borderline patient demands that structure must be imposed from external sources. Before psychotherapy is started, several points should be thoroughly discussed with the patient: (1) what therapy is and what it is not, (2) the need to end sessions on time, (3) expectations about payment, (4) regular appointment times, (5) a missed appointments policy, and (6) the therapist's expectation that the patient must be a collaborator in the psychotherapy process and work actively with the therapist in defining goals and working toward them.
The approach to suicidality in BPD is somewhat controversial. Some clinicians (Clarkin, Yeomans, & Kernberg, 1999; Kernberg, Seizer, Koenigsberg, Carr,& Appelbaum, 1989) advocate establishing a "contract" in the pretherapy phase of consultations. Within this framework therapists should clarify with the patient that their role is not to get involved in the actions of the patient's life outside of psychotherapy sessions. They would make clear to the patient that their availability is limited and that they would not expect to receive phone calls between sessions. Therapists have different tolerance levels for phone calls between sessions. My own preference is to have a suicidal borderline patient call me if the patient feels that suicidal impulses are out of control and hospitalization is required. Moreover, borderline patients with poorly developed object constancy or evocative memory (Adler, 1985) may feel that their therapist has disappeared over the weekend or over a vacation period when they cannot summon an internal image of the therapist to sustain them through a stressful time. A brief phone call may reestablish the connection with the therapist and head off a good deal of self-destructive behavior or even suicide.
Allow transformation into the bad object: Containment and management of hatred, sadism, aggression, and anger are fundamental to the psychotherapy of patients with BPD. These affects are central to the psychopathology of the patient and are activated in the therapist's countertransference. Therapists commonly feel that they are being falsely accused (Gabbard, 1991), and they are frequently tempted to retaliate against the patient as a way of defending themselves against what they perceive as attacks on their character. Borderline patients frequently have internalized a hating self and a hated internal object, either of which they may frantically try to externalize using the defense of projective identification. In this regard, Rosen (1993) has pointed out that such patients are searching for a "bad enough object." Recreating a sadomasochistic object relationship with the therapist is often experienced by borderline patients as familiar, predictable, and even soothing because this relationship paradigm is what they have known since childhood. Therapists who resist this transformation into the bad object by acting increasingly saintly and empathic may force patients to escalate their provocativeness and try even more desperately to transform the therapist (Fonagy, 1998).
Promote reflective function: Many patients with borderline personality disorder lack the capacity to reflect on their own internal states and those of others (Fonagy, 1998). Because of early attachment problems, they have a great deal of difficulty recognizing that their actions and interactions are motivated by internal states and that others operate out of separate and different internal states. This capacity to mentalize or conceive of internal states in self and others must be promoted as an integral part of the psychotherapy process. Interpreting meanings of enactments may be premature in such patients. A beginning step is to assist the patient in elaborating on the emotional state that may have led to the enactment.
Reflective function or mentalization can also be encouraged by helping the patient observe moment-to-moment changes in feelings that occur in the here-and-now interactions between therapist and patient. The eventual goal is for the patient to internalize the therapist's observations of his or her internal states. Encouraging the expression of fantasies about the therapist's internal state may also promote mentalization. Hence Gunderson (1996) suggests that when a therapist is called in the middle of the night, a useful question at the next psychotherapy session might be "How did you think I would feel about your call?" In this manner the therapist helps the patient recognize that the therapist has a separate center of autonomy and subjectivity. Asking the patient to think through consequences of self-destructive behavior also promotes reflectiveness and may assist in heading off the patient's damaging enactments.
Part of borderline patients' psychopathology is an absorption in their own suffering to the point where the subjectivity of others is completely disregarded. When a borderline patient lacks reflective function, the therapist must provide this reflective aspect rather than simply empathizing with the patient's point of view. Fonagy and Target (1996) stress that "in order to move the child from the mode of psychic equivalence to the mentalizing mode, analytic reflection, of whatever orientation, cannot just 'copy' the child's internal state, but has to move beyond it and go a step further, offering a different, yet experientially appropriate representation" (p. 231). In so doing, the therapist gradually helps the patient learn that mental experience involves representations that can be played with and ultimately altered. This perspective implies a theory of therapeutic action that emphasizes the therapist as a new, real object as the patient gradually appreciates the therapist's separate subjectivity.
Set limits when necessary: Boundaries are typically tested by patients with BPD. They often experience the usual professional boundaries as sadistic and cruel deprivations by the therapist. Some patients demand and beg for more overt demonstrations of caring, such as extension of the session beyond the time boundary, decreases in the fee, hugs during the therapy, and 24-hour availability (Gabbard & Wilkinson, 1994). Therapists who fall into the trap of trying to gratify these demands soon come face to face with a profound insatiability in the patient. The demands become endless and tormenting.
Help the patient re-own aspects of the self that are disavowed and/or projected elsewhere: The experience of being incomplete or fragmented is at the core of borderline psychopathology. Through the defense mechanisms of splitting and projective identification, BPD patients may disown aspects of themselves. The disowned aspects are then projected into others in their environment. They may feel they need others to make them whole, and they may have a profound lack of self-continuity from week to week when the therapist sees them for a psychotherapy session. Therapists must attempt to help patients with borderline personality disorder understand that they are unconsciously and automatically projecting aspects of themselves into others as a way of trying to control those disturbing parts of themselves. Interpretation of a patient's fear that integrating the bad and the good aspects will lead to a destruction of all loving aspects by the intense hatred may be an effective way to help the patient in the task of integration. Psychotherapists must point out that hate and anger will always be present but can be tempered and integrated with love to create a constructive balance within.
Reflection Exercise #5