When the patient with a borderline personality disorder emits a plaintive cry of despair or strikes out at us with a verbal slap in the face, we constrain the impulse to be overly protective or to recoil. Then we begin the search for understanding. Why did it happen? What in the patient's developmental history predicted the eruption? What internal conflicts, affects and anxieties engendered the patient's attack? Consciously focusing on the clinical reality of the moment increases our ability to be understanding, empathic and accepting. Although an interpretation of our discovery only occasionally helps the patient, puzzling it out in our own mind focuses our response in the right direction.
Beginning the Work
Usually during the beginning phase of treatment we are involved in keeping patients alive, helping to identify the painful and intolerable affects that lead to destructive behaviors while simultaneously providing a "holding environment," as described by Winnicott (1965). This is neither an easy nor a quickly completed task.
This beginning phase of identifying and containing affects is one that can seem endless but is a core factor in successful treatment. Typically, the patients' explosions do not occur at a gentle pace after you have comfortably established a good working relationship. Characteristically, they erupt in the middle of the night when you have barely had a chance to say "hello." There is a frantic telephone call and the intensity of despair elicits the psychiatrist's reflex reaction to soothe and reassure. The next day, relieved that the patient is still alive, the psychiatrist may be reluctant to rock the boat with probing questions about what precipitated the call, much less what transpired to enable them to feel better.
It is not uncommon for less experienced psychiatrists to hope that the fires of separation anxiety will be extinguished by constant availability and soothing empathic responses, as found in Kohut (1971). Besides the fact that these fires rarely burn out before the therapist begins to be depleted, there are at least two other reasons that this approach does not work.
One is described well by Gunderson: "Such contacts can increase the detached borderline patient's awareness of repressed neediness, which is then accompanied by intense shame and the emergence of suicidality [1996]." It is analogous to the hunger that is triggered when we pass a bakery, and the smell of baking bread stimulates the flow of gastric juices and fires a craving we didn't even know was there.
Secondly, with disorders that are as developmentally deep and wounding as those present in borderline patients, our availability for a 15-minute telephone call cannot begin to plumb the depths of their anxiety and neediness. Brief contact may provide temporary relief, but we need to provide much more if the patient is to alter the underlying problems.
Of course, the patient will be angry if the therapist, in addressing the previous night's telephone call, gives nothing more than an interpretation such as: "I guess you were feeling frightened about being alone and wanted me to wave a magic wand to drive away the nighttime fears." While probably accurate, hearing the behavior described in the light of day can make the patient feel isolated and ashamed unless the underlying affects and needs are addressed.
Instead, the therapist must demonstrate interest in listening to and understanding the intensity of the fears that precipitated the telephone call, and then, without implying criticism, explore what it was about the telephone call that seemed to make things better. Engaging the patient in this manner puts you both on the road to a working relationship that can slowly tease out those primitive fears that generate such anxiety.
