Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy
By Ronald Mah
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About this ebook
"Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy" addresses how the couple with a partner with borderline personality disorder challenges the therapeutic relationship in couple therapy as borderline issues and behaviors inevitably erupt simultaneously at home and in session. The therapist often considers working with the individual with borderline personality disorder among the most difficult clinical work to manage in therapy. The book explains how the couple can be the fundamental healing dynamic for the individual with borderline personality disorder. The couple therapist is guided through examination of the borderline character how to manage borderline reactivity targeted not only at the partner but also at the therapist. The therapist is prompted to attend to his or her feelings and instincts provoked by the individual- that is, counter-transference for assessment and direction for treatment. This includes borderline, partner, and therapist vulnerability desires to be "special." For the partner and the therapist, this leads to lack of preparation when naively traipsing among borderline traps hidden in the relationship, subsequent emotional, psychological, and relational injury- "Ouch!", and the shocked question of "Where'd that come from!?"
The existential trinity of the individual with borderline personality disorder: betrayal, abandonment, and rejection (B-A-R) direct the partner and therapist response trinity: caring compliance, intimacy, and acceptance (C-I-A). Directions for combining confrontational and holding theories for therapy address borderline acting out, aggression, and abuse of the partner and the therapist. The individual's core paradigm that he or she cannot suffer emotional or attachment distress and survive is identified and subsequently, is challenged. Changing the borderline paradigm leads to clinical strategies for individual and relationship change. Practical applications including realistic quantitative change goals in five specific areas are explained for how they lead to qualitative change. Explanations and examples are presented about how incremental behavioral changes lead to greater intimacy and more fulfilling relationships.
The book explains how the partner of the individual with borderline personality disorder is often targeted by the individual and in couple therapy to the detriment of growth and change. The therapist learns how to re-direct the partner from misguided attempts to meet needs and demands that perpetuate the individual's personal borderline-based mythology and dysfunctionality. Strategies are presented to empower and direct the therapist's stance and role to resist and challenge borderline demands, remove borderline entitlement to punish the therapist and the partner, while providing the deeper psychological support the individual craves. The therapist learns how to empower and direct the partner in a critical quasi-therapeutic role that provides boundaries, nurturing, and the reparative relationship necessary to support, heal, and guide the individual with borderline personality disorder.
Ronald Mah
Therapist, educator, author and consultant combine concepts, principles, and philosophy with practical techniques and guidelines for effective and productive results. A Licensed Marriage & Family Therapist (licensed 1994), his experiences include:Psychotherapist: individual, child and teen, couples, and family therapy in private practice in San Leandro, California- specialties include challenging couples, difficult teenagers, Aspergers Syndrome, Attention Deficit Hyperactive Disorder, learning disabilities, cross and multi-cultural issues, foster children, child development, parenting, and personality disorders;Author: twenty-one project/books on couples therapy for a doctoral program, including substantial work on major complications in couples and couples therapy (including depression, anxiety, domestic violence, personality disorders, addiction, and affairs); articles for the Journal of the California Association of Marriage & Family Therapist (CAMFT) on working with teenagers, elder care issues affecting family dynamics, and assessing dangerous clients, online courses for the National Association of Social Workers- California chapter (NASW-CA) on child abuse prevention, legal and ethical vulnerabilities for professionals, and difficult children, “Difficult Behavior in Early Childhood, Positive Discipline for PreK-3 Classrooms and Beyond” (Corwin Press, 2006), “The One-Minute Temper Tantrum Solution” (Corwin Press, 2008), and “Getting Beyond Bullying and Exclusion, PreK-5, Empowering Children in Inclusive Classrooms,” (Corwin Press, 2009); Asian Pacific Islander Parent Education Support (APIPES) curriculum for the City of San Francisco Department of Human Services (1996), 4th-6th Grade Social Science Reader, Asian-American History, Berkeley Unified School District, Berkeley, CA, (1977), and trainer/speaker of 20 dvds on child development and behavior for Fixed Earth Films, and in another time and career three arts and crafts books for children: two with Symbiosis Press (1985 &1987) and one with Price, Sloan, and Stern (1986);Consultant and trainer: for social services programs working with youth and young adults, Asian-American community mental health, Severe Emotional Disturbance (SED) school programs, therapeutic, social support, and vocational programs for at risk youth, welfare to work programs, Head Start organizations, early childhood education programs and conferences, public, private, and parochial schools and organizations,Clinical supervisor: for therapists in Severe Emotional Disturbance (SED) school programs, child and family therapists in a community counseling agency, Veteran Affairs in-patient clinician working with PTSD and dual diagnoses, foster care services manager for a school district, manager/supervisor for the Trevor Project-San Francisco, and therapists in a high school mental health clinic;Educator: credentialed elementary and secondary teacher, Masters of Psychology instructor for Licensed Marriage & Family Therapy (LMFT) and Licensed Professional Clinical Counselor (LPCC) track students, 16 years in early childhood education, including owning and running a child development center for 11 years, elementary & secondary teaching credentials, community college instructor, and trainer/speaker for staff development and conferences for social services organizations including early childhood development, education, social work, and psychotherapy.Other professional roles: member Ethics Committee for six years and at-large member Board of Directors for four years for the California Association of Marriage & Family Therapist (CAMFT), and member Board of Directors of the California Kindergarten Association (CKA) for two three-year terms.Personal: married since 1981 after dating since 1972 to girlfriend/wife/life partner with two wonderful strong adult daughters, and fourth of five American-born children from immigrant parents- the older of the "second set" of children.
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Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy - Ronald Mah
Ouch! Where'd that come from!?
The Borderline in Couples and Couple Therapy
Ronald Mah, M.A., Ph.D., L.M.F.T.
Published by Ronald Mah at Smashwords
Copyright 2013 Ronald Mah
Ronald Mah's website- www.ronaldmah.com
Smashwords Edition, License Notes
This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each recipient. If you're reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author.
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Linked Table of Contents
Abstract
Chapter 1: CHALLENGE OF BORDERLINE PERSONALITY DISORDER
Chapter 2: INSIGHT-ORIENTED, HOLDING, & DIALECTICAL BEHAVOR THERAPY
Chapter 3: BORDERLINE PERSONALITY DISORDER & COUPLE THERAPY
Chapter 4: EFFECT ON COUPLES AND PARTNERS
Chapter 5: FEATURES & CRITERIA
ASSOCIATED FEATURES
Chapter 6: CULTURE, AGE, GENDER, FAMILY PATTERNS, PREVALENCE, and COURSE
DIFFERENTIAL DIAGNOSIS
Chapter 7: ABANDONMENT FEARS AND ATTACHMENT
PATTERNS OF UNSTABLE AND INTENSE RELATIONSHIPS
SENSE OF SELF
IMPULSIVITY AND SELF-DAMAGING MOOD
REACTIVITY OF MOOD
Chapter 8 EXPERIENTIAL TRINITY & RESPONSE TRINITY
B-A-R: BETRAYAL, ABANDONMENT, & REJECTION
B-A-R-T: BETRAYAL, ABANDONMENT, & REJECTION AND TERRORISM
C-I-A: CARING CONTRACT COMPLIANCE-INTIMACY-ACCEPTANCE
Chapter 9: EMOTIONAL INTELLIGENCE
PERCEIVING EMOTION
USING EMOTIONS TO FACILITATE THOUGHT AND UNDERSTANDING EMOTIONS
MANAGING EMOTIONS
Chapter 10: CHALLENGING THE PARADIGM
CANNOT SUFFER AND SURVIVE
STRESS 'EM!
FRUSTRATION AND FAILURE
SUFFER
Chapter 11: SENSITIVITY and SUPPORT
SKILLS and STRENGTH
POWER AND CONTROL
ANGER EMPOWERS
SURVIVE and FLOURISH
Chapter 12: ALONE, LONELY, DESPERATE, & CHOICE
Chapter 13: QUANTITATIVE CHANGE
REAL THERAPY
Chapter 14: EMBRACE CHALLENGE
SFFS SS SS SF
Chapter 15: DIFFERENCES IN THERAPY
RESPONDING DIFFERENTLY
Chapter 16: THERAPIST VULNERABILITIES
THERAPIST-CLIENT RAPPORT
THERAPIST AS BETRAYER
Chapter 17: INTEGRATION OF MULTIPLE FACTORS
FOCUS ON PARTNER'S BEHAVIOR
Chapter 18: PARTNER INSIGHT
PARTNERS IN BORDERLINE HEALING
CONCLUSION: CLINICAL FLEXIBILITY AND ADAPTABILITY
Bibliography
Other Books by Ronald Mah
Biographic Information
****
Abstract:
Ouch! Where'd that come from!? The Borderline in Couples and Couple Therapy
addresses how the couple with a partner with borderline personality disorder challenges the therapeutic relationship in couple therapy as borderline issues and behaviors inevitably erupt simultaneously at home and in session. The therapist often considers working with the individual with borderline personality disorder among the most difficult clinical work to manage in therapy. The book explains how the couple can be the fundamental healing dynamic for the individual with borderline personality disorder. The couple therapist is guided through examination of the borderline character how to manage borderline reactivity targeted not only at the partner but also at the therapist. The therapist is prompted to attend to his or her feelings and instincts provoked by the individual- that is, counter-transference for assessment and direction for treatment. This includes borderline, partner, and therapist vulnerability desires to be special.
For the partner and the therapist, this leads to lack of preparation when naively traipsing among borderline traps hidden in the relationship, subsequent emotional, psychological, and relational injury- Ouch!
, and the shocked question of Where'd that come from!?
The existential trinity of the individual with borderline personality disorder: betrayal, abandonment, and rejection (B-A-R) direct the partner and therapist response trinity: caring compliance, intimacy, and acceptance (C-I-A). Directions for combining confrontational and holding theories for therapy address borderline acting out, aggression, and abuse of the partner and the therapist. The individual's core paradigm that he or she cannot suffer emotional or attachment distress and survive is identified and subsequently, is challenged. Changing the borderline paradigm leads to clinical strategies for individual and relationship change. Practical applications including realistic quantitative change goals in five specific areas are explained for how they lead to qualitative change. Explanations and examples are presented about how incremental behavioral changes lead to greater intimacy and more fulfilling relationships.
The book explains how the partner of the individual with borderline personality disorder is often targeted by the individual and in couple therapy to the detriment of growth and change. The therapist learns how to re-direct the partner from misguided attempts to meet needs and demands that perpetuate the individual's personal borderline-based mythology and dysfunctionality. Strategies are presented to empower and direct the therapist's stance and role to resist and challenge borderline demands, remove borderline entitlement to punish the therapist and the partner, while providing the deeper psychological support the individual craves. The therapist learns how to empower and direct the partner in a critical quasi-therapeutic role that provides boundaries, nurturing, and the reparative relationship necessary to support, heal, and guide the individual with borderline personality disorder.
link to Table of Contents
****
**Author’s Note: Other than public figures or people identified in the media, all other persons in this book are either composites of individuals the author has worked with and/or have been given different names and had their personal identifying information altered to protect and respect their confidentiality.
Chapter 1: CHALLENGE OF BORDERLINE PERSONALITY DISORDER
I received a request for feedback from a fellow therapist who I had previously consulted for on some difficult cases. Selena was a very sharp and capable therapist who had worked well with a range of clients in her private practice. There was something about this couple however, that got on her nerves. Selena told me,
"I have been working for the last four months with a real difficult couple. Frieda, the wife is a fifty-something privileged white woman who self-described as bitter, twice divorced, entitled, angry, and menopausal. She has with three children by three different fathers. The youngest child is with her third husband, Cliff who is also white- his second marriage. She's as borderline as you can get. And very difficult as you may have guessed. Cliff is not the big challenge. He's kinda meek, especially when she gets going. He tries his best. He's very conscientious. He's getting worn down. My guess is that he's depressed. I feel more and more stuck in our sessions and feel… walking on eggshells… actually more like navigating an emotional minefield... like tiptoeing through the flowers with hidden mouse traps! It's probably what Cliff goes through all the time with Frieda. I get totally drained on every level each session with this couple. When I see them on my schedule book, my body fills with dread. I know it's not him- it's her! I am liking her less and less all the time. I have brought up this client and the couple several times with my normal consulting therapist and examined my counter-transference this way and that. I've judiciously done research reading about working with borderline personality disordered clients. I've done my homework.
I hate to admit it, but I'm wanting to terminate… I want to lose this client! I feel bad about abandoning Cliff, but she's violated so many interpersonal boundaries. I'm getting worn out. Her latest, is complaining loudly about jerks who making getting in and out of the office parking lot difficult. She does this on the way out of the office, so that the jerk
who is my next client appointment can hear her. Cliff tries to discretely mutter apologies for her. I live in a small community, so she knows people that I know including some people in official or professional roles. She brings them up in sessions, asks me about their personal life, and then gossips about them. She asks if I see this person or that person in therapy.
Frieda doesn't follow through anymore with any reading or homework I suggest in therapy. She plops down and goes on and on about how horrible everything is with Cliff- basically, the same stuff every session. She dominates the sessions whether she's talking or not. When she's talking Cliff just defers. You can see he doesn't want to challenge her. He starts to a bit, but she just brings more heat to the battle and he gives up. Shuts down and hangs his head. But then there's other times when she's so loving and positive about Cliff and the relationship… and about therapy. Life and the relationship is like a bed of roses. In these times, I find I can really like her. It's like happy time in therapy... pretty flowers and butterflies and birds singing... with Cliff following her lead about how things are going well. She used to listen carefully, consider what I said, and then try to expand upon it. She said therapy was helping her a lot. It was helping Cliff a lot. When she first brought up something Cliff did, she seemed ok with processing it carefully with me. Frieda told me I had a good style that worked for her. Their first couple therapist hadn't been very helpful she said. Cliff had said the first therapist was OK.
Then, about the fourth or fifth session while we were talking about an argument they had, I said something or the other about looking at it from Cliff's perspective. Something flashed briefly in her eyes. The session was almost over so I didn't get to find out what that was about. Snap! I stepped on some hot spot...a trap. Ouch! She canceled the next two appointments… that is, she had Cliff call to cancel them. Where'd that come from!? I didn't realize it then, but we went through another honeymoon
therapy period of several sessions before I provoked her again. I don't even remember what I said. The next session, she 'forgot' her checkbook. She forgot it for two more sessions. And then was pissy when I told her I needed payment before the next session. After a couple of more cycles, I started to recognize a pattern. There's more but basically, it's still the same while also having gotten worse! Therapy can be smooth and very cooperative- seemingly productive. Then suddenly, she'd get triggered and she would rip me. Ouch again! Whenever she does this, Cliff gives me a sympathetic look. It's what he goes through! Sometimes, she suspects anything I say has some ulterior motive… some roundabout way to put her down… especially, if I support Cliff in any manner. If I'm silent for any amount of time, she accuses me, 'So, now I'm boring you? Don't you have anything to say about my pathetic life?'
Despite all the tension and acrimony between them, I can tell they really care for each other. They love each other and want to stay together. I can't believe I'm doing any good work with her. I feel trapped. I want to refer her out, but I know I'd feel guilty for foisting her on another therapist! She's not so nice anymore. When she's likable, I don't trust it. And, I'm right because she does turn on me again. I can't stomach this woman anymore. But there are times I really like her! I can tell she has a really good heart- one that has been broken so many times. I feel so sorry for Cliff. He must feel trapped. I know that's not therapeutically healthy or appropriate, but it's what I feel! She makes me feel so bad… a failure as a therapist. I'm supposed to like my clients! Damn, writing this, I realize how much I can't stand seeing this woman anymore. What is happening? What should I do? Arrrgh!"
What do many therapists do? They terminate, avoid, and run away from the individual with borderline personality disorder. Working with individuals with borderline personality disorder is often considered among the most difficult clinical work. Roberts (1997) offer an explanation from Masterson of the intrapsychic structure of the individual with borderline personality disorder that rings true for the therapist, yet may still be difficult to translate into the therapeutic process. …the intrapsychic structure of the borderline personality disorder is characterized by a split ego and split object relations units… The particular developmental arrest of the borderline personality disorder results in an archaic ego governed by the pleasure principle and, as such, concerned principally with the maintenance of pleasure and the avoidance of pain and unaffected by any self-destructive ramifications of reality. Thus, primitive defences such as splitting, avoidance, denial, acting out, projection, and projective identification are employed, with no regard for their ultimately self-defeating consequences. And, predictably, ego defects in the areas of impulse control, frustration tolerance, reality orientation, and ego boundaries persist. At the same time, a reality ego, albeit underdeveloped, exists, but it is split off from the pleasure ego, so it has no corrective influence on the regressive and ultimately self-destructive urges of the more archaic pathological ego. Further, the individual with a borderline personality disorder operates, not with one, but with two distinct internal paradigms of relationships. These split object relations units are comprised of two emotionally polarized pairings of an internalized self representation and an internalized object representation. Forming the rewarding object relations unit (RORU) is a part object representation that is powerful and supportive of clinging, dependent, regressive behaviour, a part self representation that is good and compliant, and the pleasant effects of feeling good and taken care of linking the two. The parallel and split off withdrawing object relations unit (WORU) is comprised of a part object representation that withdraws or attacks in response to separation or individuation, a part self representation that is inadequate, bad, and unattractive, and an affective connection of anger, frustration, and worthlessness
(page 234).
When conducting individual therapy, the therapist is challenged to be the rewarding object relations unit (RORU)- the good guy,
also labeled by the client such as Frieda initially as the best therapist I have ever had.
At some point, however, the therapist becomes the withdrawing object relations unit (WORU)- the betrayer, also condemned by the client as another trusted person who has screwed me!
Frieda also did this as she turned on her therapist Selena. Taking heed of a classic therapeutic maxim, the therapist should know that the client has made him or her feel what the client feels. As the therapist, Selena feels ambushed, disappointed, hurt, betrayed, saddened, anxious, and afraid, any sense of specialness or immunity can be shattered. The client has an abandonment depression which is followed by defence against the experience of this dysphoric state. That is, self-activation leads to depression which leads to defence.
The therapist feels Frieda's aggressive defensive reaction. He or she can easily be drawn into the client's world to try to offer emotional sustenance. More precisely, the pathological ego of the borderline personality disorder forms an alliance with either or both the rewarding and withdrawing part object relations units (Masterson, 1981, pp. 133-135). This is manifested clinically when separation stresses, self-activation, or progress in psychotherapy disrupt the defences and stimulate the abandonment depression. To defend against the experience of these painful affects, one of these false self organizations with its corresponding constellation of defences is activated. When the alliance is with the RORU, self-activation and separation strivings are terminated, regressive and self-suppressing defences are re-employed, and the client is relieved of separation anxiety and abandonment depression.
This dynamic at less intensive levels is usually well within the therapeutic experience, expertise, and behavioral and interpersonal comfort level of the therapist. Many clients with emotional and psychological wounds find therapist care and attention validating and empowering. However, with the individual with borderline personality disorder, there comes another side to the relationship. On the other hand, an alliance may be established with the WORU, in which case the source of the abandonment depression is projected onto the environment, thereby effectively externalizing it so as not to experience it. And in some cases the same person activates these two alliances alternately. These alliances with the two object relations part units may be evident from the patient's extra-therapy relationships, as others are invariably perceived as either supportive, enabling, and caregiving or as cold, uncaring, or punitive. They will also be observed in the `transference acting out' in the psychotherapy setting, wherein these alternating perceptions are imposed on the therapist, with no or limited awareness that they are the patient's projections (Masterson, 1976, p. 102, 1981, pp. 146-164)
(Roberts, 1997). The individual with borderline personality has no secure or integrated sense of self. Kernberg (1986) described it as ego weakness,
where the ego is in perpetual risk to fail apart. The individual will cling onto another, taking on the identity he or she is assigned. However, he or she will then feel threatened and invaded by the other and have to violently withdraw. In order to preserve some sense of coherence and integrity the ego is driven to employ powerful and primitive defences, such as splitting off bad or persecutory experiences from good or idealizing ones
(Spurling, 2003, page 27). The individual with borderline personality disorder engages in projective identification, where parts of his or her ego are experienced as being inside of others. At the same time, he or she experiences parts of others being forced into him or herself. A pervasive confusion results between self and the other.
An individual such as Frieda develops borderline personality disorder often from intensely difficult childhood experiences. The childhood of the borderline patient is marked by profound disappointment in the natural hopes and expectations of phase-appropriate soothing and stimulation and appreciation from the parents, interference with phase-appropriate idealization of the parents, and lack of a generally reasonable and empathic response from the parents. This disappointment, repeated over a period of years, produces a profound rage in the patient, a deep mistrust of human relationships, as well as a literal fear of annihilation. The deep mistrust and early disappointment make it impossible to integrate primitive phase-appropriate narcissistic structures of the grandiose self and the idealized parent imago, which then persist in an unaltered form to adult life, producing the narcissistic aspect of the clinical picture. The enormous rage consequent to the disappointment and also often fired by hostile unempathetic enemalike intrusions by the parents, produces a whole new set of problems for the patient that is not faced by an individual in ordinary development. A variety of fluctuating ways are found to deal with this rage, ranging from depression to schizoid withdrawal to somatization to acting out producing the borderline clinical picture
(Chessick, 1976, page 541). While the childhood experiences may be clearly linked to current functioning, the individual often is unaware of it. The therapeutic challenge becomes how to elicit awareness and insight. An individual may have deep denial or a lack of memory about childhood experiences. It may require major transference experiences, crises, and work to bring these horrific memories into consciousness. This often takes quite a while during which the individual may be going through a series of relationship disasters with accompanying distress and despair… and acting out. For some individuals, childhood memories are available, but the intensity of pain, fear, and loss may be minimized. This may be difficult work as well.
The syndrome of borderline ego-integration has been described as early as the 1680s when Sydenham described a group of patients who 'love without measure those whom they will soon hate'
(Weddige, 1986, page 52). From being good guy to bad guy… from rescuer to assassin… the therapist finds that the interpersonal and relationship dysfunction of the individual often manifests in the client and therapist relationship. Working with a couple with a borderline