Monthly Archives: January 2019

Borderline personality disorder

Hi! We are two Norwegian students writing our thesis on ISTDP and therapy with patients suffering from Borderline personality organization. How do you work with these patients? And where do these patients belong, on the spectrum of psychoneurotic disorders or the spectrum of fragile character structure? Are they highly resistant or fragile?
We want to emphasize the defenses of splitting, projection and projective identification with this patient group. We want to understand the therapy methods of ISTDP with these patients compared to the therapy methods of Transference focused therapy. How does ISTDP understand the personality structure and defense pattern of patients with Borderline personality organization? We appreciate it a lot if you take your time! Emilie & Katrina
First of all, as you know, patients who have the diagnosis of borderline personality disorder share only a set of symptoms, not a common character structure. That is why Kernberg has proposed that we differentiate the DSM-V diagnosis of borderline personality structure (a set of symptoms which can be found in people with psychotic, borderline, or neurotic levels of character structure) from borderline level of character structure itself.
Patients with a borderline level of character structure use projection, projective identification, and splitting as their primary defenses. Thus, they have what we call in ISTDP a fragile character structure. Their anxiety is discharged into cognitive/perceptual disruption and they can tolerate only a low level of mixed feelings before they use primitive defenses based on projection and splitting (e.g. acting out, discharge, dissociation, projective identification).
Patients with a fragile character structure require the graded format. A gradual exposure to mixed feelings to build the capacity to bear feelings without anxiety moving into cognitive/perceptual disruption and without using the defenses of splitting and projection. This graded format requires the therapist to use only very low levels of feeling in the session tailored to the patient’s very low level of affect tolerance.
When fragile patients split, we use pressure to consciousness of splitting to build the patient’s capacity to bear mixed thoughts, urges, and feelings internally without splitting them apart.
When fragile patients project, we restructure the projection to re-establish reality testing with the therapist, then we invite the patient to experience the feeling internally that he previously projected externally. After all, if he cannot build the capacity to bear the feeling inside, he will project it outside next time.
Thus, we cognitively restructure the projection first. Then we use pressure to help the patient experience internally what he projected externally. As he bears the feeling internally, as soon as he starts to get dizzy or disrupt we do bracing. That is, we remind him of the internal feeling while cognizing. This builds his capacity to bear that level of feeling while cognizing and without projecting. As we do the bracing, we watch the patient. We continue bracing until he sighs or intellectualizes. That shows us he can now tolerate that level of feeling without projecting. Thus, we have built a new level of unconscious affect tolerance.
In contrast to transference focused therapy, we rely less on interpretation. We rely more on building the capacity to bear feelings internally without projecting or splitting. We have two primary tasks we focus on: 1) restructuring the unconscious pathway of anxiety discharge so the patient can tolerate 100% of his feelings while anxiety remains in the striated muscles; and 2) restructuring the system of resistance so the patient can tolerate 100% of his feelings without the use of splitting and projection.
Another distinction from transference focused therapy is that ISTDP has a theory of anxiety based upon the somatic and autonomic nervous systems that allows us to determine what is the optimal level of anxiety for learning in therapy. Patients with a borderline level of character structure have a very low capacity for affect tolerance or anxiety tolerance. As a result, many of these patients suffer because therapists are working at levels of feeling and anxiety are far too high for the patient, leading to the regressive phenomena for which these patients are famous. Thus, if the therapist can recognize the physical signs of anxiety and the resistance systems with which they are correlated, it is much more possible to work with these patients in an effective manner that does not lead to regression.

Splitting and Triangulation in couples

“It has been very well researched that many gay male couples have open relationships. Discussing openly the guidelines and experiences adds to the trust they have in one another. However, open relationships sometimes lead one member to fall in love and think that he has found a better partner. Comparing a new and exciting partner to the old, reliable and established mate seems to be a form of splitting and triangulation. This often leaves one member devastated and the other guilty but moving on anyhow. How could ISTPD be used for both the couple and the individuals involved?” Good question!
The idealization in love is well known. We see what we love in our partner and have not yet met what we don’t like in our partner. And for a few days or weeks or months our partner “appears” to be the same as our fantasy. No wonder he or she is SO exciting. But then reality shows up eventually, and that ideal partner turns out to be real. Then we have the chance to divorce our fantasy and love our real partner, or divorce reality and keep looking for our fantasy. In this sense, the repeat “lover” is in love with a fantasy, unable to bear the mixed feelings that arise with a real partner and the inevitable disappointments that arise when we love the real and let go of the unreal.
When a couple is having conflict about this kind of arrangement, clearly we must examine what feelings are coming up that led them to split sex off from the relationship. What conflicts are they avoiding? Is the partner who is going out of the relationship feeling angry with his partner for withholding sex? Is the search for more “exciting” sex a sign of decreasing emotional closeness, an avoidance of conflict in the relationship? Is the search for sex outside the relationship a way to act out anger? Is the search for sex outside the relationship a desire for an ideal relationship? Is it a way to split apart love and sex? For the supposedly sexless partner, is agreeing to this arrangement a way to avoid the greater emotional intimacy that comes with sex? Is this detaching a way to avoid complex mixed feelings toward the partner? Is withholding sex a way he is expressing anger toward his partner? There are many possibilities here.
To find out where the conflicts are, the ISTDP therapist would look at areas of conflict for the patient or for the couple and then explore the feelings which they avoid. As the therapist explores those feelings, he will note what defenses the patient or the couple use to avoid feelings, bring those defenses to their attention, point out the cost to the relationship, and encourage them to face the avoided feelings as deeply as possible.
When the partner who leaves says he feels guilty, does he just have guilty thoughts, or does he really feel guilty and try to repair the damage he has done to the relationship. The idea of “moving on” can cover a multitude of reactions, most often denial, dismissal, and detachment. When the other person feels “devastated”, could that also be a way to avoid feeling rage toward the partner who left him? We can certainly understand “devastation” as one of his reactions. Don’t get me wrong. But if it’s not accompanied by anger at the lost partner, we would want to examine that absence. When the partner is merely “sexless”, is he also “emotionless”? Are there other ways he distances from his partner and from his own feelings? As we watch the responses to intervention, we will get a clearer idea of the conflicts in the patient and in the couple.
Rather than rely on our ideas about how relationships ought to be, we rely on the patients’ unconscious responses to our interventions. After all, every time we intervene, we invite an emotionally close relationship. The couple’s responses of feelings, anxiety, and defenses will let us know where their conflicts are, what their unconscious longings are, and who they really are underneath their professed theories.