Family issues as a source of resistance
Another important source of resistance in treating patients with BPD is their notion that change may entail betraying their family in particular ways as well as giving up habits they may feel work well for them in avoiding feelings.
Melody is the oldest child in a close-knit family. She has always been athletic, but she also has a long history of recurrent sports-related injuries. Melody is preoccupied with performance and sensitive to criticism. At home, negative feelings were not talked about: her parents thought they were shameful. Recurrent injuries were the only manner in which she could elicit sympathetic reactions from her parents.
When Melody went to college and encountered academic difficulties, she started to fall down stairs and trip over things repeatedly. After each accident, her family came rushing to take care of her. When it was found out that Melody’s accidents were deliberate, she began psychotherapy.
At first, Melody was highly anxious and sat in silence, unable to verbalize her feelings. Over time, however, she began to talk about her accidents as ways to not think about missing home and to explain her failure to excel at school. Whenever she spoke about her fears of parental disapproval, she would have the impulse to hurt herself. Her parents became fearful and encouraged psychiatric hospitalizations every time she spoke about her difficulties. Melody became more anxious and angry as a result. She noted that her old way of hurting herself (accidents) was more effective in diverting her attention away from unwanted feelings and gaining her parents support than talking about feelings.
When her family was asked to be involved in her treatment, both Melody and her parents decided that therapy was not helpful and terminated the treatment.
This vignette illustrates a common situation in which self-harm functions to divert attention away from emotional difficulties and to enlist noncritical caregiving support. The behavioral “acting out” is itself a common form of resistance. Both Melody and her parents resisted the process of replacing self-harm with self-reflection and verbalization of feelings in therapy. When patients like Melody start the difficult tasks of change and confronting negative affects, they will feel worse before they feel better. It is helpful to teach borderline patients and their families that this is expected and is how therapy can work.
The vignettes presented here illustrate several forms of resistance that clinicians can expect to encounter in working with patients with BPD. We have not attempted to be comprehensive about all the forms of resistance encountered. A few of the other common resistances include deceit, projection, and “splitting.” Clinicians should appreciate that what may seem like willful deceit can often better be understood as the patient’s defensive ability to dissociate or deny, or to lose his mentalizing abilities, when stressed.
Projection can also become a formidable means of resistance. The clinician needs to seek out that sometimes-modest fraction of the patient’s complaints and attributions that are true and begin to validate them.
This principle is also central in responding to splitting. Clinicians who are idealized by their patients should accept the partial truth of this, while clinicians who are vilified should acknowledge that they did or said something that makes the patient’s angry or avoidant reaction understandable.
Our review is intended to illustrate that the patient’s resistance to treatment can be aggravated by a therapist’s misunderstandings of BPD. It is easy to blame the patient for responding poorly to treatments (being “resistant”) without recognizing that when treatments don’t reflect an understanding of BPD, the treatments can aggravate these resistances.
These comments are not meant to minimize the diverse array of resistances that patients with BPD present. These patients will never be easy to treat, but when their particular forms of resistance to treatment are understood as learned behaviors that have served adaptive function, we can move toward a more empathic and sympathetic therapeutic posture. Resistance can then be replaced by more truly adaptive responses.