Psychotherapy Of The Borderline Adult

A Developmental Approach

James F. Masterson, M.D.

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134841615
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychothérapie

First published in 1988. This volume brings diagnostic order, a comprehensible theory, and a clinical approach out of the confusion surrounding the "borderline" concept.

II. CLINICAL

A. Supportive Psychotherapy

Introduction

The art of supportive psychotherapy of the borderline adult consists of keeping up the therapeutic pressure by raising the patient’s anxiety through confrontations of the destructiveness of the defenses of the pathologic ego—splitting, avoidance, denial, projection, and acting out—while at the same time remaining alert to and empathetic with the enormous fear of engulfment or abandonment which these confrontations stimulate. The therapist must walk a tightrope adjusting the therapeutic pressure to that which the patient is able to tolerate within the limits of the transference relationship.

Should he relax his confrontations too much, therapeutic progress will stop; should he increase them too much the patient’s fear of engulfment or abandonment will become too great and more than likely the patient will stop therapy. This art uniquely depends upon the capacity to judge from moment to moment throughout the course of therapy how much confrontation the patient can tolerate in order to progress without feeling so much anxiety that he has to disrupt treatment, to titrate the separation anxiety against the strength of the transference relationship.

The next three chapters present the “supportive” psychotherapy of three patients. Chapters 7 and 8 describe the first two and a half years of supportive psychotherapy of a young woman whose fears of engulfment and abandonment produce great resistance to entering psychotherapy. Chapter 7 illustrates the long struggle with the defense mechanisms of the pathologic ego. Chapter 8 illustrates that as these defenses are reached the patient enters a true therapeutic alliance. Her self begins to emerge as she at the same time begins to face the underlying conflict with the parents. The 124 consecutive interviews over this period are included in order to demonstrate in great detail the extraordinary intrincacy and tenacity of her resistance, as well as the therapeutic intensity and activity necessary to confront the resistance and allow the patient to enter psychotherapy. I think this patient clearly demonstrates that a very frightened and defensive borderline patient will enter psychotherapy if given the proper therapeutic support.

Chapter 9, presenting the supportive psychotherapy of two older women, has a different focus. The patients began therapy with vague and superficial complaints about “life not being satisfying.” The initial therapeutic task consisted of making the patients aware of their emotional problems through confrontation of the defenses of the pathologic ego. All three women’s difficulties with intimacy prevented them from having satisfactory relationships with men. However, the latter two, in their 40’s, had reached an age where men were less available even if they did get over their problems. The former patient, at age 25, had much more to look forward to in her relationship with men if she could learn to master her emotional problems. This is a persuasive argument for doing as much psychotherapy as is possible with young adults, both men and women, before age has limited their heterosexual horizons.

7

The Perpetual Student:

“Frightened, Unloved, Without a Self”

CASE REPORT OF CATHERINE

Catherine, a 22-year-old, short, slender, blue-eyed attractive blonde, was casually dressed in a miniskirt. She was referred to me by a colleague after an evaluation which was unduly prolonged by her fearfulness about treatment as expressed verbally and by being late or missing appointments. She complained that since receiving her college degree a year ago she had been “running around,” unable to make a decision about herself or her life. She suspected that she was running around because on the one hand she could not deal with living at home, but on the other hand, she was not able to be completely away from home—a clear articulation of the borderline dilemma!

She had spent the year in travel and temporary jobs while awaiting admission to a graduate program at a local college. When the college accepted her she suddenly realized she didn’t want to attend and, disturbed by this dilemma, she sought psychiatric consultation.

She added that her return to the United States, which had required her to settle down in one place, had led her to feel “more lonely and nervous.” She felt she “needed people,” was afraid of being alone, never felt independent. She had had only one good relationship with a man in the last four years; however, she felt she had probably suffocated him and destroyed the relationship with her need for security. She tended to date men who were both egotistic and sadistic and for whom she felt sexual attraction but no affection.

Family History

Father was a successful broker who had a self-centered, domineering personality around which the family revolved. He was moody and hot-tempered, would frequently blow up, and on occasion would explode into physical attacks, mostly at the brothers, but occasionally at the patient. The mother and brothers placated the father completely, and Catherine was the only family member who on rare occasions fought with him. He perceived Catherine as still a child, expected her to comply with his wishes and was annoyed and sulked if she did not. If she did not visit on weekends he was annoyed, but when she did visit he paid no attention to her. He was particularly annoyed at her plan to live and work in the city. Although her childhood memories of him were vague she recalled him as being very interested in her as an infant and young child, this interest decreasing as she got older. She said, “I think the trouble began with him when I started to walk and talk.” She recalled him as being oversolicitous about her physical and material welfare while being completely oblivious to her real interests and feelings. He would indulge her with various gifts more appropriate to his interests than hers and if she pointed this out he sulked. He expected her to conform to the role of perpetual child and to cater to him like the mother and brothers did. She felt she was not able to talk to him about her own thoughts and feelings.

Mother presented a much more subtle but equally conflictual problem. The patient described her as rather dependent, helpless and fearful, placating and catering to the father’s outbursts. She clearly favored the older brother whom she flagrantly overindulged. While on the surface she acted as a go-between with Catherine and her father—ostensibly to show her interest in Catherine by protecting her—actually it was to act as a reinforcing agent for the father’s demand that Catherine placate him like the mother and brothers. Whenever the mother’s relationship with Catherine conflicted with the relationship with her husband or older son it was Catherine’s interest that was sacrificed. For example, Catherine’s assertions upset the father which upset the mother. When Catherine expressed her own interests and feelings the mother accused her of being self-centered. This attitude was subtly concealed beneath more overt attitudes of overindulging Catherine and treating her as if she were a helpless, fearful child—probably a projection of the mother’s image of herself.

The older brother, age 26, was a dependent, self-centered, stingy man who was flagrantly overprotected and indulged by the mother. He continued to live at home despite a good job. He was the frequent butt of the father’s hostility and related to the father with the same pacifying compliant manner as the mother. He had yet to date and seemed afraid of girls. He was patronizing and hostile to Catherine who felt, nevertheless, superior to him.

The younger brother, age 18, was a shy, withdrawn, young man who was a senior in high school and who sided with his brother against Catherine.

Past History

Catherine was the second of three children in a middle-class home. She recalls very little of her earliest years except that in the first five years she had frequent upper respiratory infections, a mild case of asthma, and received a great deal of attention from both parents. She recalls that even then the home was dominated by the father, and that as long as his mood was good there was little difficulty. In fact, one would have to suspect that even during these times the mother’s and father’s infantilizing attitudes were having their effect. There was a lot of rivalry and battles between her and her brother. She started the local school without difficulty and did well. When she was eight, in the third grade, she fell ill with vague gastrointestinal complaints which lasted for one year—a time which she again recalls as one in which she received a lot of attention. However, during this period, in the third grade, the family moved to another city. She had great difficulty adjusting to the change and making new friends and consequently was depressed and lonely for a year. She recalls the years between ages seven and 12 as being particularly bad because of the father’s temper outbursts; she would run away from the house when he came home. At the same time he spent most of his time away traveling and was only home on weekends. When she was 13 and in the eighth grade the family moved again, and again she had trouble adjusting and was depressed and lonely for a year. She reports no difficulty in high school where she was a good student, nor in going away to college where she finished her studies and graduated without trouble. She chose to travel to avoid a final decision about a career since she didn’t know what she wanted to do.

From her high school years on she had always had an active interest in boys and had dated a lot. However, she described a pattern, which evolved over several years, of always having relationships with two or more men—one of whom she fantasied as the “caretaker” whom she loved but did not have sexual relations with, and another whom she was attracted to but had no affectionate feelings for and with whom she did have sexual relations. If she did have sex with the former it never led to orgasm, while sex with the latter usually ended in orgasm. For the last three years she had had an intermittent relationship with Charles (the “caretaker”), whom she felt she loved and might eventually marry, and with Fred (the sexual outlet).

Comment

Catherine defended herself against her anxiety about being on her own—against separation-individuation and autonomy—by avoidance of committing herself either to a career or to a relationship with a man. The career avoidance had been concealed beneath the smokescreen of being a perpetual student. She could go away to college and travel as long as home was her base. This smokescreen, however, dissolved when she had to commit herself to a life as an independent, responsible adult by entering a graduate program. She was also vaguely aware of the splitting in her relationship with men; she tended to cling to one man while she acted out her hostility with another—having a realistic relationship with neither.

I suggested to Catherine that she had concealed her emotional problems about leaving her parents and becoming independent through the device of being a perpetual student and through various dependent relationships and that she should get a job and settle down in one place while she worked this problem out. I suggested interviews once a week since I felt that Catherine’s fear of psychotherapy—i.e., fear of engulfment—was so intense that she could not tolerate greater involvement at this time. In the interviews that follow it is important to note Catherine’s preoccupation first with men and then with her father. The focus on these two areas is initiated and continued by her as a reflection of her problem. I am principally responding to what she considers important.

THE THERAPY

Interview #3

Catherine immediately demonstrated the extraordinary transference fluctuations that occur in borderline patients by reporting that my writing as she spoke in the previous interview made me seem mechanical and nonpersonal and made her feel like crying.

My writing, which took my exclusive attention away from her and exposed her to separation anxiety—anxiety about loss of the object—interrupted the projection of the wish for reunion fantasy—RORU—on me and triggered the WORU. To set reality limits to this projection I stated I was just doing my job and when I queried as to where she had felt this way before she recalled that when her father shouted at her she would cry instead of standing up to him because if she stood up to him “we’ll kill each other.” She then reported hating his attacks, wishing him dead but nevertheless loving him. She also reported memories of his attacking her, pulling her hair and throwing shoes at her. Catherine had thus defined the arena of the initial therapeutic encounter.

Interview #4

She reported provoking the sexual interest of two men without intending to follow through. I did not mention the transference implication but instead emphasized the reality that if she provoked sexual interest without intending to follow through she was liable to get into trouble.

Interview #5

There was a long silence after which Catherine described that she felt “faint,” “like shaking” and that she was very depressed after the last interview.

Interview #6

She reported that one night when she was alone for the first time in a girlfriend’s apartment, she had panicked and felt there was someone in the house coming to get her. She recalled that she often had felt that way. She had also been upset by hearing that a friend of the family was placed in a psychiatric hospital.

She described her relationship with men as being either physical or protective. Charles was protective; she held on to him. “This image of him is very important to me.”

Interviews #7, #8, #9

During the next three weeks interviews #7, #8, and #9 dealt with the patient’s procrastination and avoidance about finding an apartment of her own; she had been living like a nomad or gypsy moving from one friend’s apartment to another. I confronted her by saying that this behavior was symptomatic of her whoie problem—i.e., avoidance of dealing with anxiety about committing herself. She accepted the confrontation without comment.

I repeated the statement. She responded, “It must come from overprotective parents but there’s nothing wrong with that!” I challenged this statement! The patient remained silent and cried. I then pointed out her resistance to facing the conflict with her mother and father as evidenced by this response to my challenging her stereotyped view. Suddenly she replied, “Today you said something that’s both familiar and unpleasant and you are getting closer to home.”

At this point it may be helpful to digress a moment from the psychotherapy to summarize Catherine’s borderline problem.

ANALYSIS OF CATHERINE’S BORDERLINE PROBLEM

This patient was precipitated into treatment by the fact that her defenses of avoidance of commitment to a career or to a relationship and her acting out of the wish for reunion were challenged by her chronologic age of 22. Heretofore she had been able to conceal her conflict over being independent beneath the façade created by living the life of a perpetual student. This life permitted the acting out of dependency needs, and physical distance from her parents allowed her to avoid confronting the conflicts with them. Her anxiety mounted when she could no longer be a student and had to make a choice of a career.

The defenses of the patient’s pathologic ego were avoidance of independent action or assertiveness in work or in interpersonal relationships combined with denial of the destructiveness of this behavior. Emotional involvement in relationships was handled by distancing mechanisms (both physical and emotional) and isolation.

She played the role of the good child with her parents in order to receive their supplies.

She maintained a similar distance from real involvement with a man and instead used her present relationships with men to deal with the residue of anger and depression left over from her past conflict with her parents—i.e., she projected the wish for reunion on the man and then acted out her need to be taken care of with him. Transient relationshi...

Table of contents

• Cover Page
• Frontmatter Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• Introduction
• Theoretical
• Need for Treatment
• Review of the Literature
• A Separation-Individuation Failure: Interpersonal
• A Separation-Individuation Failure: Intrapsychic
• The Clinical Picture: A Developmental Perspective
• The Psychotherapy
• Clinical
• A. Supportive Psychotherapy
• Introduction
• The Perpetual Student “Frightened, Unloved, Without a Self”
• The Perpetual Student “I'm Beginning to Find a Self”
• Life Begins to End at 40 “My Life Is Going Nowhere”
• B. Reconstructive Psychotherapy
• Case 1: A Second Chance—Peter
• Acting Out the Wish for Reunion “It Feels Good”
• A Therapeutic Impasse “Which Way to Go?”
• Abandonment Depression “If She Dies, I Will Die”
• Homicidal Rage “I Want to Kill Her”
• On the Way to Autonomy “I No Longer Feel Responsible to Her”
• Case 2: A Daughter's Legacy
• The Tie that Binds
• Tragedy
• Mourning
• Triumph
• Summary and Discussion
• Appendix Opening Remarks of Paper Presented at Margaret Mahler Symposium
• Bibliography
• Index