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Section 25
Therapeutic Detachment and Borderline Clients

Question 25 | Test | Table of Contents

The therapeutic alliance is taught and commonly regarded as essential in engendering change. The formation and maintenance of such an alliance often involves the corrective emotional experience of the patient with the therapist and the therapist's ability to relate empathetically. We posit that some situations and specific clients are better served by therapeutic detachment. In the following case, we put forth the principles and purpose of this therapeutic option.

It is a common conclusion in the psychotherapy literature that the therapeutic alliance accounts for a significant part of the variance in client change. In a review of the impact of the therapeutic alliance, the following four elements were identified as composing the therapeutic alliance: (i) the patient's capacity to work purposefully, (ii) the patient's affective bond to the therapist, (iii) the therapist's empathic understanding and involvement, and (iv) agreement about the goals and tasks of treatment. This review of the research led to the conclusion that "... the alliance may be even more central to change than initially thought". However, establishing and maintaining a therapeutic alliance may not necessitate personal involvement on the part of the therapist.

To the contrary, there are situations where therapeutic detachment may engender a more positive therapeutic outcome. Clients with personality disorders are especially skilled in trying a therapist's patience and defenses. Such clients, especially those with borderline personality disorder, can be expert in identifying and exploiting the therapist's vulnerabilities. The borderline client may work quite hard at destabilizing the therapist. Through the promotion of the therapist's countertransference, the client effectively can maintain therapeutic resistance and avoid intrapsychic conflict. The promotion of awareness of countertransference is pervasive throughout writings on therapy with borderline clients. Kottler stated:  "The therapist cannot avoid the excessive demands made on her, the dependency, aggression, and attacks that are common. All the usual subtle interventions, such as interpretations, are ineffective. We must reach into our bag of tricks and pull out something that will help the client stay in line and protect us from abuse."

In this paper, we examine the conceptual foundations that underlie the processes of therapist attachment to and detachment from clients. A case illustration will be presented in which therapeutic progress had been hindered by a caring involvement with a volatile and difficult client, and in which a subsequent detached and more distant interpersonal style allowed the therapist to be more effective in pursuing treatment goals.

In their introduction to psychotherapy work, students typically are taught it is best to fully "be with" clients. This "being with" involves emotionally empathizing with clients and their particular perspectives and situations so that a corrective emotional experience can occur. In one psychotherapy text, Roger's view of empathy and empathetic listening is emphasized as a basic value that drives all helping behavior:

It means entering the private perceptual world of the other and becoming thoroughly at home in it. It involves being sensitive, moment by moment, to the changing felt meanings which flow in this other person, to the fear or rage or tenderness or confusion or whatever that he or she is experiencing. It means temporarily living in the other's life, moving about it delicately without making judgments.

Guy put it this way, "... the truly outstanding clinician has something in addition to skill and expertise. He or she possesses a deep sense of caring and compassion that results in a level of empathy and sensitivity that touches others in very extraordinary ways". "Being with" our clients is intended to foster an ability to be accurately and appropriately supportive. This kind of empathy is a common thread in all therapeutic approaches, and is often considered essential to progress. However, beginning psychotherapists should recognize that the mirror image of therapeutic empathy, that is, therapeutic detachment, may promote growth in clients and therapists alike in certain circumstances.

Our beginning point is to examine four of the most common assumptions about therapist involvement. The first assumption is that empathy is a sine quanon of effective psychotherapy. We are taught to place ourselves in a position to appreciate fully our clients' emotional world. This mandated need to empathize becomes foreground and problematic when we find ourselves unable to relate readily to a client and are at a loss in how to behave. Beginning therapists may erroneously view empathy as the ability to relate to a client via the therapist's own experience. As such, many beginning therapists feel at a loss when they encounter their clients in circumstances to which they cannot personally relate.

The second assumption is that clients improve in an atmosphere that promotes a corrective emotional experience. Therapists are taught that clients' dysfunctional attitudes and behaviors need to be treated in a different way from past reactions of important others. Instead of reacting judgmentally to deviant sexual behavior, for example, therapists are instructed to be accepting interpersonally and to be at once warm and corrective.

The third assumption is that clients recognize authentic caring on the part of the therapists. This assumption presupposes that therapists care authentically, even though this is not always the case. The corollary is that when therapists do care, their caring is necessarily recognized and appreciated by the clients. Indeed, beginning therapists are taught nonverbal behavior that suggests caring, namely, face the client squarely, adopt an open posture, maintain eye contact, etc. It is cautioned: "The averted face is too often a sign of the averted heart".

The fourth assumption is that supportive therapist behaviors are a foundation for clients to initiate behavior changes. In fact, one article noted that "Every form of psychotherapy incorporates interpersonal relationship factors to varying degrees, regardless of the particular theoretical underpinnings". Empathy and authentic caring provided in a corrective emotional experience are supposed to engender change. The clients, so influenced by the therapeutic experience, then should progress into healthy personhood.

Our central thesis is that with certain clients, psychotherapists are most effective when they care less. The multidimensional nature of therapeutic distancing can be best appreciated in the context of psychological progress. New therapists often enter their work with the stereotyped notion that good therapy comes about only from personal and meaningful connections with clients, which, in turn, are followed by broad and life-changing client insights. If one cannot or does not form these connections, then something is "not right." In training, therapists are taught that quality caring is essential. Terms like unconditional positive regard and accurate empathy are consistently emphasized in therapy training, so much so that manifestations, such as the Rogerian "umm," head nod, and forward-torso lean sometimes carry over into all aspects of the new therapist's life.

In turn, indications of minimal degrees of caring about clients are seen as a marked deficiency in both the therapy and the therapist. The idea of minimal caring is advocated only in selected or radical behavioral treatments, and that is only because the behavioral program is seen to require detachment. In our experience, novice therapists who do not demonstrate "proper depth of caring" are referred for individual psychotherapy themselves to remedy this deficiency or are counseled out of their graduate programs. Indeed, we hold to these same values as part of the repertoire of the complete psychotherapist, but these practices do not hold in all treatment contexts.

Some clients are emotionally distant and unable to respond to empathetic interpretations. Other clients are so disordered that they lack fundamental relationship skills. Still others have personality disorders that make it difficult for therapists to approach them in healthy and constructive ways. Difficulty in fostering and maintaining healthy relationships is the hallmark of many personality disorders.

Therapeutic detachment is helpful for therapists who have become overinvolved with their clients. Such overinvolvement can happen for a number of reasons. It may occur because the therapists personally identify with the client, and are substituting the client's issues for their own issues. When therapists are frustrated by a lack of progress in their clients, this frustration may engender excessive therapist involvement in an effort to invoke client change. Therapists who do not have clear boundaries may try to make the therapeutic relationship into a friendship or more personal relationship.

Therapists working with clients with borderline personalities can employ distancing to enhance both the therapeutic relationship and progress made in and out of therapy. Interpersonal difficulty is a hallmark of borderline personality disorder. People with this disorder are often exhausting to work with and rarely make significant strides in improvement. Therapists working with borderline clients are commonly affected by the client's successive mood swings, and may internalize therapeutic failure. Thus, distancing is a tool that the therapist working with borderline clients may find useful.
On a more global level, therapists often find themselves following a path in which the demands of the client and situation become subsumed to long-established practices and beliefs that have come out of training and academic knowledge. The issue, of course, is when does the therapist go beyond the structures from training. Three principles may be posited as to when therapeutic distancing might be useful:
Therapy is not working;
Emotional reactions on the part of the therapist are impediments to behavioral changes by the client; and/or
Therapists commit themselves to an expanded repertoire of responses and options.
- Galloway, VA; Caring less, doing more: the role of therapeutic detachment with volatile and unmotivated clients; American Journal of Psychotherapy; 2003; Vol. 57 (1).

Personal Reflection Exercise #11
The preceding section contained information about therapeutic detachment and Borderline clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
The Impact of Outcome Expectancy
on Therapy Outcome in Adolescents
with Borderline Personality Disorder

- Bäumer, A. V., Fürer, L., Birkenberger, C., Wyssen, A., Steppan, M., Zimmermann, R., Gaab, J., Kaess, M., & Schmeck, K. (2022). The impact of outcome expectancy on therapy outcome in adolescents with borderline personality disorder. Borderline personality disorder and emotion dysregulation, 9(1), 30.

Peer-Reviewed Journal Article References:
Berenson, K. R., Dochat, C., Martin, C. G., Yang, X., Rafaeli, E., & Downey, G. (2018). Identification of mental states and interpersonal functioning in borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 9(2), 172–181.

Cavicchioli, M., & Maffei, C. (2020). Rejection sensitivity in borderline personality disorder and the cognitive–affective personality system: A meta-analytic review. Personality Disorders: Theory, Research, and Treatment, 11(1), 1–12.

De Meulemeester, C., Vansteelandt, K., Luyten, P., & Lowyck, B. (2018). Mentalizing as a mechanism of change in the treatment of patients with borderline personality disorder: A parallel process growth modeling approach. Personality Disorders: Theory, Research, and Treatment, 9(1), 22–29. 

QUESTION 25
What are three situations in which therapeutic distancing may be considered? To select and enter your answer go to Test.

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