Damned If You Do And Damned If You Don't

I had long discussion this week with a fellow therapist on whether I’d consider writing anything for professionals working with individuals on the borderline personality continuum. How did the topic emerge? She had recently been “fired” by one such client and felt very upset about it. I imagined that it had happened in a very angry way, the client speaking to this therapist in abusive language and then storming out. What is it really about when we can’t do right for doing wrong?

I have been “fired” in this way by a number of deeply troubled clients over the years. Broadly speaking, they would be considered “borderline,” I hesitate to use that term because it has such pejorative connotations, even for mental health professionals. These clients often begin treatment with heightened expectations; they express commitment to the work and idealise their new therapist. This transference is expected and needed. At this point, the therapist can do no wrong and is the good object. Something will then happen in the course of the treatment (I’ll have more to say about what that “something” is) and the client will abruptly turn on the therapist. Good object turns bad. Often this means the end of treatment.

I’ve been screamed and sworn at. I’ve been called names; told I had no idea what the f**k I was doing and treated with utter scorn; I’ve had clients slam the door on their way out and never come back, or subsequently leave hate-filled messages on my voice mail. Each time, it’s a deeply painful and toxic experience for me. It takes me hours to recover, sometimes even days. During this time, I review my work in an attempt to regain the feeling that it has value.

This need for the therapist to recover a sense of personal value holds the key to the borderline client’s experience and what led him or her to explode. I think I can best illustrate this with a recent example from my practice. After our first few sessions, Heather told me that she’d never met a therapist who so intuitively grasped her pain and understood exactly what she was going through. She said she felt deeply grateful to have found me. I’ve had enough experience with idealisation to know that, if I’m on the pedestal now, I’ll eventually end up on the trash heap.

Heather had potential to really become something. Unfortunately, she has spent decades drifting from one career idea to another and hasn’t been able to self actualise. This has left her living behind a rather grandiose image and moving from one unstable interpersonal relationship to the next. She’s also spent too many years on an ever-changing cocktail of psychiatric medications. Often better informed about available meds than her medicating psychiatrist, Heather would go to her appointments armed with articles she’d read and persuade her doctor to prescribe what Heather thought she needed. She once told me I was the only therapist she hadn’t been able to run circles around. We’re exactly the same age.

I often felt Heather attempting to communicate with me as if we were colleagues, rather than turning to me in a vulnerable, needy way as my client. In one session, she spoke about how much she liked to be the one dispensing wisdom: what she really wanted to do, she said, was write a philosophical-type book and get paid for speaking engagements. It felt as if she were making some comparison between us. In a later session, she made similar remarks; I addressed the ongoing comparisons and asked her if it might be deeply painful for her to compare herself to me, a woman the same age, and to feel what she might have done with her life. The loss of potential, the waste of the years, the shame about her damage felt excruciating and unbearable.

Within seconds, her face was twisted with scorn. “You think I envy you?” she sneered. Within minutes, she’d cut the session short with a few contemptuous parting shots about my incompetence and terminated treatment. Other clients have become much more abusive. Some have screamed at me; others, as I said, have slammed the door on their way out of my office. All of them have left me feeling “shitty,” for lack of a better word.

Burdened with unbearable shame, these clients evacuated all their pain, the feelings of unworthiness into me, as if I were a toilet, and fled therapy in order to escape their pain. Borderline clients in flight want to make their therapists (or any abandoning Other) feel shitty, though not consciously. The rage they express as they lash out is meant to fill the other person with all of the unbearable shame that they carry, the sense of inner defect, to evacuate it all and then to run. I believe the evacuation of shame is a regular feature in borderline rage, which makes it very difficult to bear for anyone on the receiving end. It’s hard enough to be the object of someone’s rage, even harder when the massive projection of shame and unworthiness goes along with it.

I’m sure other therapists have had the same experience but possibly not quite understood why they found the experience so toxic. Our worth and value as professionals have been assaulted, for reasons that are emotionally understandable but hard to bear. It may take days for us to recover our equanimity. I think this is the reason why borderlines are so vilified, even by mental health professionals. The largely negative attitudes are defensive in nature: we want to protect our own sense of worth from being savaged.

Heather periodically resurfaces. First she asked if she might resume treatment but felt she needed a more “collaborative” approach; could we operate more as co-therapists? She is not qualified as a therapist (though she might fantasise that she is) so I needed to decline this offer. When I told her I’d be happy to work together but I needed to practice as I saw fit, she again dropped out of sight. A few months later, she wrote to me in desperation, but an attempt to get started again was quickly aborted. How can she resume treatment when it means reclaiming her shame and all the pain that goes with it?

She may never be able to do so. The tragedy of those men and women who suffer from the symptoms of borderline personality disorder is that, even if they find someone capable of understanding them, the experience of shame in relation to that person becomes unbearable and they often end up savaging the relationship as a defense against that shame it inspires. To escape the horrible feeling of being a “loser,” they attempt to “win” by destroying. This includes trying to destroy their therapists and the creative work they do. Usually, the compounded feelings of shame about the damage done stop them from going back, so they end up beginning and ending therapeutic relationships in serial fashion. Some of my borderline clients have managed to hang on, learning to bear their rage and shame over time, but more of them have not.

Go Well.