When you are comfortable with the reality that you cannot (even if you wanted to) be an idealized parent, it is possible to work toward achieving a therapeutic alliance, seeking alternatives, substitutes and eventually more mature means to deal with the internal affects, conflicts and anxiety.

Once this juncture in the therapeutic relationship has been reached, one may successfully introduce such comments as: "When I hear the fear in your voice, I wish I could wave a wand and make it all disappear. You must feel that way, too. But I don't have that power. Let's look to see what alternatives we can find."

The statements are all very real and candid. Don't we all wish we could find just the right word, phrase or insight to provide instant relief! That's one reason many of us decided to become physicians. As psychiatrists we have much to offer, but without an acceptance of our limitations we are exceedingly vulnerable to attack.

In Conclusion

Working with patients suffering from borderline personality disorders begins with an acceptance that they live in an immature psychological world, fueled by certain constitutional vulnerabilities, where they attempt to shield themselves from conflict and anxiety by splitting the world into all good and all bad. Although this produces an illusory sense of psychological safety, in fact, it renders relationships fragile and chaotic and drives away the very people who are so badly needed to stabilize the patient.

The challenge to therapists is not to be driven away physically or emotionally, but rather to engage with the patient in a consistent and constructive exploration of their affects and behavior, no matter how intense the explosion of feeling or how lacerating their attack on our self-esteem and professionalism. Only when patients are able to recognize what they are feeling, and how this relates to what they are doing, will they begin to develop more mature psychological structures. Exploration and insight into the developmental and genetic roots can often facilitate this process, leading to a world less split in dichotomous good and bad.
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