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Depathologizing The Borderline Client - Page 3

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An Early Wake-Up Call

Early in my career, before developing IFS, I began seeing Pamela, an obese, 35-year-old office manager who came to the mental health center where I worked complaining of depression and compulsive eating. In our first session, she said she thought her dark moods might be related to having been sexually abused by a babysitter when she was 10 years old, but that she also felt alone in life and stuck in a job she hated. She liked that I was young and seemed kind, and wondered if she could come in twice a week. I, in turn, looked forward to working with her, appreciating how eager and articulate she was compared with the sullen adolescents who made up much of my caseload. For a number of sessions, I coached her as she debated leaving her job and developed an eating plan. I felt confident that her trust in me was growing, and I was enjoying the work, which seemed to be progressing nicely.

Then came the session when she began talking about the abuse. She became frightened and weepy and didn’t want to leave my office at the end of the hour. I extended the session until she seemed to recover and could leave. I was bewildered by this shift, but understood that we’d hit on an emotional subject.

In her next session, Pamela was apologetic and worried that I wouldn’t work with her anymore. I reassured her that I thought the last session had been the beginning of something important and that I was committed to helping her. She asked if she could come in three times a week, in part because she was having some suicidal thoughts. I agreed.

This pattern repeated in the following session: she began talking about the abuse, then became mute, started to cry, and seemed increasingly desperate. I tried to be empathically present, trusting my Rogerian instincts. The subsequent session began in the same way, and then someone knocked on my door. Although I ignored the knock and encouraged Pamela to continue, she erupted furiously, “How could you let that happen? What’s wrong with you?!”

I apologized for forgetting to put the in-session sign up, but she’d have none of it and bolted from the office. I tried futilely to reach her several times that week, grew increasingly panicked as she missed all her appointments, and was about to call the police when she showed up unannounced at my office, repentantly pleading for me to continue seeing her.

I did continue, but no longer with an open heart. Parts of me had felt powerless and frightened during the week she was missing, and other parts resented the way she’d treated me. I should have had the sign up, but her reaction was way over the top, I thought. I began resenting all her requests for more of my time.

I’m now certain that the work with Pamela didn’t go well in large part because she sensed this shift in me and my feelings about her. There were further suicidal episodes and escalating demands for reassurance and more time. She even began running into me on the street. I suspected she was stalking me—which made my skin crawl. Try as I might to hide it, I’m sure my exasperation and antipathy leaked out at times, making her recruiters more desperate to get me to care and her distrusters more invested in driving me away.

After about two years of working with her in this way, she died suddenly of a heart attack related to her obesity. I’m ashamed to admit that I mostly felt relief. I’d never developed any real awareness of my role in her downward spiral and had been feeling increasingly burdened by this “hopeless borderline.”

Advancing Self-Leadership

After many years of learning from clients like Pamela about their inner systems, my style of therapy has changed radically. From that experience with her, I understand why so many therapists retreat to their own inner fortresses, hiding their panic and anger behind a façade of professional detachment. If you don’t have a systemic perspective on what’s going on, you’re faced with what seems like the wildly oscillating expressions of different, often contradictory, personalities.

From the IFS perspective, however, the shifts in demeanor that signal the appearance of different subpersonalities aren’t bad news. Far from necessarily being evidence of extreme pathology on the client’s part or incompetence on the therapist’s part, the emergence of these subpersonalities signals that the client feels safe enough to let them out. In IFS land, things like flashbacks, dissociation, panic attacks, resistance, and transference are the tools used by the different parts and, as such, are useful signposts indicating what needs to happen in therapy.

If therapists understand borderline personality disorder in this way, they’re more comfortable with jarring shifts, personal attacks, desperate dependence, and apparent regression, as well as controlling and coercive behaviors. Because these behaviors aren’t signs of deep pathology, they shouldn’t be taken personally. They’re part of the territory. The attacks are coming from protective parts whose job it is to make you feel bad and force you to retreat. The regression isn’t a crossing of the border into psychosis: it’s a sign of progress because the system feels safe enough to release a hurting exile. The manipulation and coercion aren’t signs of resistance or character disorder: they’re just indications of fear. The self-harm and suicidal symptoms aren’t signals of scary pathology: they’re attempts to self-soothe.

This perspective can help you remain the “I” in the storm—grounded and compassionate in the face of your clients’ extremes. It’s like having X-ray vision. You can see the pain that drives the protectors—which helps you avoid overreacting to them. The more accepting and understanding you are of your clients’ parts when they emerge, the less your clients will judge or attack themselves or panic when they feel out of control. The better you get at passing the protectors’ tests, the more they can relax, allowing your clients’ calm, confident, mindful self to separate from the protectors and emerge.

A hallmark of IFS is the belief that beneath the surface of their parts, all clients have an undamaged, healing self. At the beginning of therapy, most borderline clients have no awareness of this inner self, so they feel completely unmoored. In the absence of self-leadership, parts become scared, rigid, and polarized, like the older kids in the parentless house. As the therapist perseveres with his or her calm, steady, compassionate self, clients’ parts will relax, and their self will begin to emerge spontaneously. At that point, clients will start to feel different, as if the stormy waves of life are more navigable.

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  • Comment Link Monday, 04 November 2013 19:48 posted by Jeff Kayes, LPCC

    I don't think I will apply for sainthood anytime soon! Your article was humbling for sure. I found that I had to remind myself (quickly!) that I do succeed with some of my clients. Thank you for your brutal honesty with your internal reactions in working with these two women.

  • Comment Link Friday, 27 September 2013 18:02 posted by Sherry J. Zitter LICSW

    This is a moving, skillful and superbly helpful article to me. It ha shifted my relationship to 2 of my clients who have a huge amount of self-hate and a tough time holding onto the work we do in between sessions.
    The most useful part for me, of course, is the focus on noticing my own parts and how they can take over my natural compassion and wisdom. When I unblock my own heart, and open it toward any client is any situation with deep curiosity, miracles can happen -- as Dick shows us time and again.

  • Comment Link Tuesday, 06 August 2013 15:03 posted by Terri

    I am a Borderline. I have been having a terrible time adjusting to a new therapist, after the retirement of a much loved and cared for counselor. The feelings of abandonment and loss have been horrible. Thanks for a great article that has helped me understand more about myself than years of therapy ever have.

  • Comment Link Sunday, 30 June 2013 13:03 posted by Stana Paulauskas PhD

    Excellent article and highly attuned compassion for self and client!!

  • Comment Link Wednesday, 19 June 2013 23:49 posted by Cecille del Gallego, LCSW, CEAP

    So spot on and very well articulated....I think the article captures the complexity of working with those who have had enormous pain and who have been violated on so many levels. It gives voice to the deepest yearning that is essentially in all of us - to be seen, heard, accepted and believed in. Great job humanizing this "population"...

  • Comment Link Sunday, 16 June 2013 20:57 posted by Jake Eagle

    Dick, I really appreciate your article this month, Depathologizing the Borderline Client. The specific details you shared about using IFS—both in dealing with parts of your client as well as dealing with parts of yourself—were illuminating.

    This may not surprise you, but I recently experienced remarkable success using IFS with a client struggling with multiple parts—I don't label my clients—but she most certainly would be labeled with multiple personalty disorder by most in our profession.

    I think what may have be unique in my approach is that I had her read the first 60 pages of Internal Family Systems after our first session. I asked her not to read any more of the book because I didn't want her to get caught up in the details, but the first 60 pages provided a context for our work. She immediately recognized herself reading your book and felt hopeful for the first time in her life. No one had previously been able to explain her confusion and internal conflict, but after reading your book she felt seen.

    During the six months of working with my client she has identified all of her parts, engaged in conversation with all of them, and now talks openly about her family and how they are learning to live together and love each other. It's been a remarkable and relatively quick transformation. I don't think it would have been possible without your IFS model.

    Hope you're well and maybe I'll see you again in Tulum.


  • Comment Link Monday, 10 June 2013 16:23 posted by Kimberly April (not my real name)

    Thank you for humanizing the reality of the results of adult survivors of childhood abuse, and for specific ways to help therapists effectively relate to, treat, and heal those affected by this senseless horror. I am a survivor, and yes, I saw parts of myself in your dialogue. I am almost finished with my therapeutic journey of 4 long and sometimes painful years, yet also colored by unequivocal joy encontered through the ability to finally feel and deeply connect to another human being, my therapist. I appreciate all of your research and practical steps with parts work designed to help heal a shattered self. Doing parts work was one of the most painful yet healing parts of therapy after the much feared phase of establishing safety and trust, which took a very long time, and was filled with a lot of acting out in many forms.
    Thanks again for this article and your work which has given those of us who have survived destructive secrets of the past much hope for unibiased treatment and point us to a live worth living, full of connecting with others. I am not out of the woods yet as the termination part of therapy seems to be a difficult one full of loss and pain, because although I intellectually realize that my therapist is not my father, all my little girl wants to do is take her blankie and climb up on the couch and sit next to him, because he helped me feel safe and finally alive. (This definitely is embarrassing for me because I am older than he is, and part of the baby boomer generation.)I am sure I will get through this because my therapist has given me coping skills, and I know he will walk with me to show me the way. Although he will not walk for me, he will walk with me, and that for me makes all the difference!

  • Comment Link Monday, 20 May 2013 18:22 posted by toni aguilar

    this article has excellent advice for the therapist whose "parts" get too reactive and take things personally. (one of my clients taught me the term "QTIP"--quit taking it personally.) the rage (coming at us or simply to us)that some of these clients can exhibit is very difficult for some of us to handle w/o getting weary, no matter how compassionate or skilled we are. i DO believe in and use the idea of internal family systems, and i teach all my clients that all human behavior is purposive, geared toward whatever the subconscious THINKS it needs for survival. so i try to hang onto curiosity and that compassion at my core....but whew! i find it to be very hard work sometimes, choosing just the right words, the right tone, the right demeanor to help those protectors accept all of us who are in the room! thanks for running the article.

  • Comment Link Saturday, 18 May 2013 22:02 posted by Gary Brown

    though I am not a therapist, nor a phsychologist or anything like that, I have been reading and enjoying this magazine for five or six years. I found this article to be very interesting and if I might dare to say, insightful. I talk with a lot of people and many of them ask me questions similar to those a therapist might receive.
    I like to relate back to different articles I have read in this magazine to suggest things to those people. Many times I find that those to whom I speak find the way we interact to be thoughtful and insightful, I suspect this article will lead to further insights I might be able to share with those who ask for my input.
    Thank you for the article, I feel it was a very worthwhile read.

  • Comment Link Wednesday, 15 May 2013 16:14 posted by Suzanne Watts

    As a therapist treating survivors of sexual abuse, this article was very informative for me. Therapists can be very nervous about treating clients who have been diagnosed with Borderline Personality Disorder, especially if they are described and identified with that label. Viewing these clients as trauma survivors enables therapists to reframe their own countertransference reactions and possibly see the clients in a different light, as you so elequently pointed out.

    However, as the article concluded it appeared as though you might have been referencing a client with Dissociative Identity Disorder (Colette in your article). It is difficult to tell given the brief summary of your interactions. I found that internal family systems therapy is very effective in treating DID and am interested in learning more about it.

    In any event, all trauma therapists can benefit from helping clients speak to their inner "parts" which may have opposing messages at first glance.

    Thank you for the informative article!

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