At what point does a therapist decide to terminate a client because their relationship has broken down? Over the past three years writing my blog I have received many emails from therapy clients telling me that their therapists terminated them, either for no reason or for a small infraction within the relationship.

Are therapists being over-sensitive or are clients diagnosed with borderline personality disorder unaware of their own personal lack of empathy towards someone who is on their side? Being terminated for relationship issues with the therapist does not make sense to me. The entire reason we are in therapy is because we have huge external relationship problems and this plays out in the therapeutic relationship and the therapist should be aware of this.

But at what point does a therapist say enough is enough? Is it because of transference; counter transference; a therapeutic error; a pissed off punitive therapist; a client with irresolvable attachment issues; a personality clash or the therapist who blames the client? Is it none of the above or all of the above?

As someone diagnosed with Borderline Personality Disorder I can hurt someone’s feelings at a very deep level and think I have only superficially wounded them. I have hurt my therapist on occasion and used her as an “emotional punching bag.”

It appears to be a common pattern, I get upset and accuse her of something and she calls me on it and I get insight and remorse and think, why do I always do these things? At the time I feel I am being reasonable with my demands but on reflection of her point of view I understand where I went wrong and why I went wrong. The “why” is very important is therapy.

I have managed to circumvent this pattern by recognizing my body’s response to what is happening in the present moment. Why do I feel hostile towards her, why do feelings of jealousy and envy surface, why do I feel she is “out to get me,” doesn’t care, thinks I’m a loser or many other hundreds of different erroneous beliefs and schemas that abruptly surface when I am too triggered, hungry, angry, lonely, stressed, frightened, upset or tired?

Because I am used to operating at a very high emotionally hostile level where things I have said are highly inflammatory, outrageously insensitive, stingingly and penetratingly abusive, I assume everyone else can operate at this level as well and get over it the same way I do. After a row I can “forget” hurtful statements I made and others cannot. I have lost friends and family members due to my behaviour.

So I have to be aware that my choice of words, tone, volume and body language dictates my future relationships. I have been told by my therapist, in the past, that I can take her for granted and it is not a nice feeling to receive that sort of assessment of our relationship, true as it might be. I attempt to stay in the present moment so I do not take her for granted.

Therapists are not emotional punching bags. They are professional people who deserve respect for their difficult work. I try hard to say to my therapist that I am feeling out of sorts today and not in a good frame of mind and for some reason it feels like it’s about our relationship. That’s called transference and this tricky, sticky, icky little concept is what gets us Borderliners into enormous strife in session.

A good therapist will know this, and take it into account, but sometimes therapists have feelings as well, hidden unresolved parental issues, or are even undiagnosed Borderliners themselves. And we can press their buttons quite easily. Not all therapists are self-aware, self-insightful or take self-responsibility. It is always a good thing to have had therapy yourself before therapising others, to sort out issues and problems, but not all therapists think they need this.

When I hurt, when I am triggered, I just want to lash out. But I let my body inform my brain of this these days. I work hard at not reacting emotionally, at distress tolerance, at maintaining and enhancing relationships and most of all I try to be mindful and stay in the present moment. Most of the time I do get it right.

Most of the time.

Pictures: http://calmingyourinnerstorm.blogspot.com.au/2011/07/stop-pushing-my-buttons.html, http://www.adfs.alabama.gov/FATM.aspx and http://blog.lib.umn.edu/meyer769/myblog/2011/12/

I thought it was safe to let you know how I was doing. I thought it was safe to email you about what my thoughts were regarding brief psychosis –v- depression (which is something I have finally made sense of and wanted your opinion on because I trusted you). I told you what my current working life was like and I felt as though I got a rubber stamp response because nothing in your email referred specifically to what I had actually said or achieved.

In therapy once, you asked me to always let you know how I was doing because you didn’t want me to move on and disappear out of your therapy life. You also once told me you loved me and trusted me deeply and that you would never abandon me.

With those bold statements comes a considerable amount of post-therapy responsibility to clients, even to the most adjusted but vulnerable client who has left your therapy and your rooms. With that comes a duty of care to accept that sometimes the client who wants to move on feels much dissonance, ambivalence and an overwhelmingly disproportionate sense of obligation and responsibility to her former therapist to keep her informed lest she feels abandoned by her.

This is my fault for thinking you miss me as much as I miss you. This is my lack of “theory of mind” and mentalization that I take full responsibility for. You do not feel what I do, I am rarely in your thoughts (if ever) and you can easily disregard and delete my emails and remain in an internally emotionally appropriate and functional manner because I am no longer on your radar.

Last November when I let you know what I was doing you sent me an email telling me I was sending you too many emails, but your previous wishes about keeping in touch is concretely ingrained and reverberates too deeply and this time, in February, when I caved into that irresistible urge to contact you (against my better judgement) you are now ceasing to even acknowledge my emails.

This makes me feel very sad, somewhat confused, upset, retraumatised and abandoned again and again. It hurts way low down in my stomach. I feel regressed and child-like. Because of what you said last year about loving me, never abandoning me and always keeping in touch I feel as though I can’t move on properly. This is my responsibility, something I have to control and something I need to radically accept and place tight boundaries around.

However, you too need to remember my history and my situation, one of the longest therapies ever and my incredibly intense feelings, both negative and positive, surrounding how I feel about you and how we interacted in therapy. Only you can decide what your contribution to my current situation is. You sent me an email re Better Access without comment and when I commented back you are most conspicuous by your lack of response. Ditto email re psychosis –v- depression. It would appear ignoring me and hoping I will go away is the easiest most desired outcome and the path of least resistance for you.

I hope you are comfortable, safe, well, prosperous and happy with your life. I wish you all the best. I am very sad to say but you are not safe for me and I doubt you ever will be. I do not intend to repeat this mistake a third time. But this email releases me from any further interaction, tractor beam urges, gravitational pulls and dumb, dumb decisions to ever email you again.

If you wish to find out how I am you know where my blog is, you know where my website is and, if the desire is truly overwhelming (which I doubt), there is always Google.

Sonia

Computer photo available from Shutterstock.

Sometimes, the smallest things in life can cause the greatest pain and physical reaction.  A bee’s sting is almost invisible to the naked eye and yet can easily kill someone when they have an allergic reaction.  A mere critical stinging comment can just as easily send a person suffering Borderline Personality Disorder into “emotional anaphylactic shock.”

When a person has a life-threatening reaction to the poison from a bee sting, an ambulance is called and the person is taken to hospital where they receive treatment for their illness as well as respect and dignity but when someone suffering an emotional reaction to life circumstances presents at emergency, they are sometimes treated with rejection, intolerance and disdain.  People can die from a bee sting and Borderlines can “die” from their own personal rage and self-hatred.  If you present at emergency with a swollen face and throat unable to breathe with all your body organs shutting down, is some doctor or nurse going to say, “OMG, it’s a tiny bee sting, how bad can that be, look at you, get over yourself,” like they sometimes do when Borderlines present at hospital with similar symptoms.

Yet both types of people are in much pain and danger.  One is considered entirely physical and the other is considered entirely emotional.  Or is it entirely emotional?  When a sensitive person with a history of trauma has an emotional “bee-sting” reaction to someone’s criticism there is a definite physical reaction.

Borderlines tend to be hypervigilant, which means they live with permanent muscle tension and a certain excess of adrenaline pumping round their system at any given time.  So when criticism hits, the body goes into an emotional anaphylactic state where cortisol floods the brain and body system and a type of blackout occurs where nothing anyone says or does registers.  Your body has gone into “shock.”  When I used to get into such a state someone could have cut my arm off and I would not have noticed.

Things are said during this time that are simply appalling.  I have used language I would not use in normal everyday life.  I have said things that are deeply hurtful and as my husband has said, “you can mend a vase but the cracks are always there for those to see.” My therapist says it is best to repair those cracks with gold. Her favourite quote, by Barbara Bloom is “When the Japanese mend broken objects they aggrandize the damage by filling the cracks with gold, because they believe that when something’s suffered damage and has a history it becomes more beautiful.”  I prefer her take on this matter.

Therapy has taught me that my perception of events and criticism is usually erroneous.  Even if people are critical and disrespectful, it is about them and not me.  If my ideas get criticized it is not because I am a loser and I deserve to die, it is because we both have a different belief system and ways of handling situations.  There is no right or wrong, just opinions.

I have criticized my therapist on many occasions including recently when she raised her colleagues’ fees in the light of almost certain public benefit cuts.  Her reply was that her practice survived before the benefits were given and hopefully will survive after the benefits are cut.  She raised her fees because she valued herself and her colleagues.  She did not feel the need to get upset or question herself or her actions because she believed that what she was doing was the right thing to do.

It is this sort of self-valuing that is empowering to people like myself who always feel others are more valuable and powerful than I will ever be.  When we assert ourselves and say, “No, I don’t like that because….” we can start to realize that it is ok not to people-please all the time.  I said no to unpaid overtime because I value myself as a worker otherwise I will feel undervalued and get resentful.  Like my therapist I am worth it.

Mindfulness and radical acceptance of people and situations as in Dialectical Behaviour Therapy is the key to, well, if not happiness, then a more content and peaceful self.  It is the road to what Abraham Maslow calls self-actualisation – autonomy, independence, few but deep friendships, a philosophical sense of humour, resistance to outside pressures and transcendence of the environment.  These are the things I strive for and have spent much time in therapy trying to get a good grasp of.

A great book, which promotes self-actualization that I am reading at the moment, is “The Art of Happiness” by the Dalai Lama.  While I may not quite reach the emotional plateaus that His Holiness is capable of, I can certainly learn how best to inoculate myself when swarms of emotionally stinging bees are trying to infiltrate my brain and body system.

Picture from:  http://discountcleaningproducts.blogspot.com/2010/06/how-to-treat-bee-wasp-stings-what-you.html

At last, someone who is giving Borderline Personality Disorder a new image, a new spin, a positive focus and dispelling all of the myths surrounding this socially constructed disorder.  Thank you, Marsha Linehan, for coming out of the closet.  What a breath of fresh air you are!

I have read Marsha’s book on Dialectical Behavioural Therapy and since then I have been recommending this type of one on one therapy, based on Cognitive Behavioural Therapy, radical acceptance, Buddhist meditative practice and mindfulness with the adjunct of group therapy and inter-session therapist phone-calls, to many people.  It proves beyond a shadow of a doubt that there is life beyond this subjective, patronizing, ineffective, degrading and destructive diagnosis, generally given out by the psychiatric industry. 

So it takes someone very brave (or naïve) to come out of the Borderline closet.  There must have been something in the atmosphere that week because I also outed myself as a diagnosed Borderline.  Perhaps Marsha and I are channeling each other through the Universal Unconscious Carl Yung talked about where some people are so in tune with the current global zeitgeist of evolutionary mental thoughts and images that they unblock some old ideas and lock some new ones into the merging and emerging brains of like-minded people in a telepathic manner.

In Freud’s day BPD’s were called “hysterics” and their trauma was dismissed as unconscious fantasy.  Imagine being told your childhood rape, incest, or sexual assault was the product of your over-active and reactive imagination?  Would that not do your head in?  While Freud has a lot to answer for with the abandonment of his “seduction theory,” he did do his best to convince the medical/psychiatric/neurological population at the time that this was the cause for hysteria.  Seeing as no-one publicly believed him he felt he had no choice but to abandon it and find a more acceptable reason for women’s distressful circumstances and situations.  Since then evidence based research has led to a rather large correlation between sexual abuse, whether repressed or not, and BPD signs and symptoms.

Latest research into Borderline Personality Disorder (BPD) is also starting to show this diagnosis to be part of the Post Traumatic Stress Disorder spectrum.  Currently, in order to receive a diagnosis of BPD you have to fulfill five of the following nine symptoms which include efforts to avoid real or imagined abandonment, unstable, intense interpersonal relationships, identity disturbance, impulsivity, recurrent suicidal behavior, emotional instability, chronic feelings of emptiness, inappropriate, intense anger and transient, stress-related paranoid thoughts or severe dissociative symptoms.

Many of these symptoms are experienced by most of the population to a lesser degree.  For Borderline Personality Disorder to be diagnosed these symptoms have to be rigid and inflexible, interfere with your every day living and impair your life and relationships to a greater degree.  This diagnosis can be very subjective and sometimes based upon the psychiatrist’s own personal preferences, biases and prejudices.  Sometimes difficult patients who ask lots of unwanted questions in psychiatric units can be labelled with Borderline Personality Disorder, when all they are trying to do is find out more about what works for them, how it works for them, why what is happening is simply not working and that the treatment being foisted upon them is ineffective and disrespectful.

People with Borderline Personality Disorder need to have their stories acknowledged with understanding, compassion, empathy and validation.  Their behaviour was adaptive and geared up towards survival.  Those survival skills honed as a child are no longer needed in the adult world but when stress and distress becomes overwhelming, old coping mechanisms come to the fore.  If Vietnam Vets have flackbacks due to Post Traumatic Stress Disorder then BPD sufferers are still fighting a personal war that ended many years ago.

Borderline Personality Disorder sufferers are over-represented at hospital emergency departments and psychiatric units.  Staff, both doctors and nurses can be critical, judgemental and scathing towards these people presenting with self-harm and suicide ideation.  Individuals with BPD frequently possess good interpersonal skills, empathy and compassion in abundance but the problems arise when emotional triggers are pulled and the person starts to decompensate and regress.

Rather than castigating and abandoning a person when this happens the mental health professional needs to realise that the person with BPD is doing the very best they can with their limited abilities focussed purely on surviving the hostile and overwhelming experience.  Their adult coping skills have been overwhelmed by a biological response that starts in the amygdala (the emotional centre of the brain) and that results in the person simply unable to hear and respond to what the other person is saying because the anger, pain and darkness have taken their brain and world view hostage.

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes.  They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

There are many famous internet-diagnosed BPD sufferers in the world who have managed to live meaningful and fulfilling lives.  People with BPD are not all like Glenn Close’s character in Fatal Attraction.  Princess Diana was posthumously diagnosed with BPD as was Marilyn Monroe.  According to some websites Britney Spears, Lindsay Lohan and Amy Whitehouse also appear to fulfill some of the criteria.

Suffering is not a foregone conclusion.  The best antidote to the pain and suffering of BPD is to find a good Dialectical Behavioural Therapist and live in the solution, not the problem.  Yoga, meditation, self-reflection, healthy eating choices, learning to let go and move on and put history behind is what DBT is all about.  Medication in the form of mood stabilisers can be an advantage, but mindfulness therapy can change the brain for the better.

DBT is like non-invasive brain surgery and within twelve months it is possible that some people can be living a fuller, happier, more mindful and meaningful life.

Pictures:  http://lisboncpc.blogspot.com/2010/05/relationship-with-borderline.html and http://thinkingmansyoga.blogspot.com/2010/12/why-do-you-call-it-yoga-and-meditation.html

We all know good therapy when we experience it, that warm fuzzy feeling where we are heard, understood, validated and start healing from the inside.  But what about bad therapy, what does that feel like?  And what if bad therapy turns ugly and ends in termination?  Here are five reasons why good therapy turns bad and ends in termination.

1.  Countertransference – when a client triggers the therapist’s issues.

It has been a long established rule of good therapists never to take on a client who will trigger personal issues.  The therapist who has been raped may not be able to cope with the raped client.  The therapist with children who finds out her client is a paedophile or the client who triggers off mother-issues with the therapist who has not resolved her own childhood.  These well-meaning people can sometimes unwittingly do more damage than good if they have not received their own therapy or supervision.

2.  Without warning, without explanation and without any further contact.

This is cruel and unusual punishment for the client.  I don’t get this.  I have had many an email from former clients of terminating therapists, readers of my blogs, who are desperate for answers many years down the track.  Surely they deserve closure.  Usually a therapist is the last port of call for people who have exhausted their family and friends but still need satisfactory conclusions to their problems.  So they pay a therapist to bounce off ideas and issues, end up overwhelming their therapist for whatever reason, who then terminates them immediately.  So where do they go from there?

3.  Abandoning the client with abandonment issues.

Most long-term, emotionally volatile clients have rejection, abandonment and anger issues.  Myself included.  Sometimes therapy can become a self-fulfilling prophesy. In the Freudian theory of repetition-compulsion we are compelled to repeat the past with significant others.  We create in the therapy room the same conditions in our outside life.  The good therapist should know this, be on the look-out for it and have an action plan to deal with it.  The good therapist should not take transference personally.  Clients do get angry in therapy and it is up to the therapist to work out who the client is actually angry at.  One cannot abandon a client the same way one cannot abandon a newborn baby.  Marsha Linehan with her Dialectical Behavioural Therapy has the right approach when she says that the only reason a client gets terminated is if they miss four sessions in a row, other than that the client is always right.

4.  The Doppelganger effect.

I am a client, a mother and a daughter and I have a daughter, a mother and a therapist.  I am familiar with the dynamics of power in these relationships.  Sometimes when client and therapist are evenly matched a power struggle can ensue.  This is not unlike those mother/daughter power struggles of which I am intimately familiar.  Only the therapist, like the mother, holds the balance of power.  A good therapist like a good mother however will mostly concede and let the client/daughter think she has won.  Power might corrupt some, but absolute power wielded correctly, efficiently and with loving/kindness has the power to regulate, facilitate and heal.

5.  The Suicidal client.

This is the most difficult client of all.  The one all therapists dread.  The good therapist will make a contract with his/her client along the lines of please ring/fax/mobile/text/email me before you kill yourself.  Simple isn’t it?  But it does work.  I have the greatest admiration for therapists who can hold their suicidal clients till those feelings pass.  But unfortunately some therapists refer their clients on or section them off to a psychiatric hospital, which is of course a necessary step.  A good therapist cannot help a client if he/she is suicidally successful.  But a great therapist is there afterwards when the client gets out of hospital and resumes therapy without therapeutic judgment.  The not-so-good therapist leaves the client, heaves a sigh of relief and moves on.

Nancy McWilliams admits in her book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process that she can sometimes be a masochist with a depressive personality, which can gear itself up towards rescuing her clients from themselves.

In her section “Therapeutic Implications of the Diagnosis of Obsessive or Compulsive Personality,” she says “… by accepting compulsively self-harming people into analytic treatment unconditionally, the therapist may unwittingly contribute to their fantasies that therapy will operate magically, without their having at some point to exert self-control …”

This is known universally in Therapy World as “rescue fantasies.” Sometimes there is a repeat pattern of trauma in therapy where the obsessive, compulsive self-harming client with abandonment issues regresses and imploringly begs the therapist for extracurricular activities, and the therapist panics and enables the client to regress further by trying to pull them out of their regression with a magical cure, trying to rescue the client by crawling into their fantasies and merging with them. This can cause the client to withdraw and disintegrate or verbally attack the therapist in a sadistic manner due to feelings of overwhelming engulfment. This is where the cure can be worse than the disease. 

Therapists who encourage merging fantasies, like parents who indulge their spoiled children are not doing their clients any favours. These well-meaning, highly sensitive and intelligent healers were sometimes the Atlas child in their family of origin. In a lot of cases, they were the oldest, who was expected to help bring up younger siblings and whom the family relied and sometimes depended upon.

But the more the therapist, and parent, gives the more the client wants and expects and throws a tantrum when the therapist does finally set some well-needed boundaries. Enabling bad behaviour is not therapeutic.

For clients, it’s the mastery-control, repetition-compulsion drive that Freud espouses, but what is it for therapists who cannot set good boundaries when the client is clearly regressed and out of control?

Are they caught between a rock and a hard place?