"Borderline" patients
Adam Blatner
adam at blatner.com
Fri Sep 8 20:01:27 CDT 2006
Kate's point is well taken, and I find it difficult to imagine why this term needs to be used, as it doesn't really help most people think about their own condition in a useful way. Other phrases and explanations can be given, usually tied more to the person's own "self system," Carl Rogers' way of describing how the patient tries to make meaning out of his or her own experience.
Patti has a point in the word's being sometimes useful as a code word for difficult client, when talking with other therapists in, say, a professional support or peer consulting group, but even then it can be a bit misleading.
Kate's point about group work doesn't really address what Bud was alluding to--which is the problem of fairly emotionally brittle, often easy to offend, often skilfully manipulative people who can be most disruptive in (note) community building groups, which have a different task than therapy groups, are often larger, and assume a degree of personal resilience and a capacity to tolerate a bit more frustration than is available to folks with this "diagnosis."
Certain groups can handle certain levels of encounter. Little children cannot, middle school kids can hardly, and only with a great deal of adult mediation, and similarly, we should note that not all seeming adults can either play tennis or golf or bridge at the same level, nor can they work in task-groups that involve a higher measure of interpersonal flexibility and give-and-take. This isn't a matter of legal non-egalitarianism, but rather just a recognition that there are some tasks that require greater skill, whether in medicine or mathematics or most sports. that's why little league isn't big league.
At a certain size group, the leader may not be a trained therapist. And even if relatively skilled in ordinary group work for that task, may not be skilled to deal with more fragile and disruptive group members. I think it is fair and realistic for groups to recognize they can't handle some people's problems--especially if that's not what they're there for.
What do you think, Kate, or others? Warmly, Adam
----- Original Message -----
From: Dr Kate Hudgins
To: Grouptalk ; tsiyahoo ; dramatherapylst at listserv.ksu.edu
Sent: Friday, September 08, 2006 5:29 PM
Subject: Re: "Borderline" patients
I too find it offensive when someone calls someone borderline like it is a diagnosis that noone can change. In fact, the original definition of it comes from the psychoanalytic stance that the person is walking a line, a borderline between neurotic and psychotic processes. Now that we know about the brain in relation to trauma, it is clear to me they are unconsciously accesing unprocessed trauma material from the right brain in primary process form--sensory and emotional information without words while also having acess to left brain processes trying to understand what is going on.
Also, the literature shows that the main acting out of the "borderline rage" happens do to an abandonment stressor. That is what the therapist needs to see when a patient is acting out. How to work with the abandonment stressor in the therapeutic relationship that is being projected or is happening in the real world and destablizing the person.
I strongly disagree with not having people struggling with borderline issues in group. They, above all else, need the connection of community support. Yes, they can be difficult for the group but ONLY IF the therapist is having countertransference issues that is preventing him or her from effective intervention and limit setting with love and compassion.
Most of our TSM client groups have more than noe or two people who carry that diagnosis and/or that of DID. TSM has found the way to work with people that are struggling this much with unprocessed trauma material being triggered off in their right brain by containment, strength building and working with transference, and even more importantly countertransferece through team meetings througout the weekend.
Kate
On Sep 6, 2006, at 11:34 AM, PATRICIA DESERT wrote:
Dear Bud--I appreciate your sensitivity to the connotations of "borderline"
and I agree that it inaccurately describes what is going on. I hold the
view that "borderline" symptomology has all to do with attachment disorder
and that "borderline" is an unfortunate choice of words for this painful
disorder. And so in this way I reframe the name of the diagnosis for my
clients while educating them to the reality that in medical circles
"borderline" is still the recognizable word of choice to describe the
symptoms. Even among us professionals though "borderline" is the
recognizable word to use when we want to succinctly communicate with each
other. Perhaps one day the DSM will remove "borderline" and replace it with
a more accurate description. Certainly attachment disorder is not a new
concept, particularly in relation to the borderline diagnosis, and certainly
it describes the primary wound. Patti
From: BARNETT WEISS <budweiss at verizon.net>
Reply-To: list at grouptalkweb.org
To: list at grouptalkweb.org
Subject: "Borderline" patients
Date: Tue, 5 Sep 2006 05:33:18 -0700 (PDT)
I think this is a very important string and hope that we can follow it up
further as persons in this "Category" are some of the most difficult to
work with especially in a group setting as they tend to split the group.
My mentor in doing community building will take them aside privately and
basically advise them not to participate in the community building sessions
as it would not be a good process for them due to their "extraordinary
sensitivity." He will instead direct them toward a therapist he knows who
has been very successful with moving these persons along.
While the approach mentioned by Ann, written up in the journal, makes a
lot of sense to me and I will see about looking it up for all the details,
there is still something that bothers me about the label "borderline." On
the border of what comes the logical question and knowing someone who is
showing many of the intense symptoms, it is easy to say on the borderline
of insanity altogether or about to be a victim of another abandonment or
worse. I think the primary issue is the abandonment issue and that
resonates far more with the persons who are called "borderline" in my
experience. Moreover, persons of this nature would probably enter into
therapy more easily if in fact the calling to the group was more along this
lines.
Another person who is highly successful with persons in this category is
Jeffrey Young with his Schema Therapy http://www.schematherapy.com/ which
he created after many years of being one of the primary trainers in
Cognitive Therapy. In Young's work, he actually does some psychodrama as
well as using EMDR and even moves into some spiritual work which many
"borderline" persons tend to be drawn to. This latter I think is a coping
strategy for them in dealing with the abandonment issues.
Other's thoughts?
Blessings, Bud
Ann Hale <annehale at swva.net> wrote:
Patti, Stephen Sidorsky presented on, and wrote for the Journal
an excellent article on the Psychodramatic Treatment of Borderline
Personality, vol 37, no 3 (Fall, 1984) pp. 117-125. There has also been
some succcess in treating a group of about six-8 who are entirely
borderline. They spend time in group getting to know their diagnosis
backwards and forwards, and prt of the sessions is identifying aspects of
it when it is occuring. The therapists (four) work in tandam of twos, and
the facilitators trade off, in sequence. And, each person sees their own
therapist. It is an interesting approach. The purpose of the group is to
dilute dependency on the primary therapist.
----- Original Message -----
From: PATRICIA DESERT
To: list at grouptalkweb.org
Sent: Monday, September 04, 2006 2:24 PM
Subject: Re: client or trainee
Hello Everyone--Adam hit on an area that deeply resonates for me at
this time--that is, characterological disorders. I am in the midst of
working with two clients exhibiting classical symptoms of Borderline
Personality Disorder. It continually manifests in rage at me for not
fixing them, for caring more for my other clients, for holding to time
boundaries of sessions when they are late, for not giving them 2 hr
sessions whenever they want them, for long phone message between sessions
criticizing all that I haven't done, for not remembering exactly what was
said last summer, last month, last week, etc., etc. These criticisms are
relentless.
I have had 18 years of enormously rewarding work with clients, mostly
Axis I disorders and some with mild to moderate Axis II. Until this year,
after working with these two for over a year, I have never felt this sense
of frustration, anger, or at times inadequacy. And for the first time in
my 18 years as a therapist I acted out my anger at one client and told her
with no compassion or empathy that her behavior was both rude and
disrespectful to me and to the other client whose session she attempted to
interrupt.
Obviously my stuff got triggered big time and I recognize that I need
supervision around this and am getting it. However, I'm curious to hear
from anyone else who has had their own similar responses to these kinds of
clients and some action methods that were helpful, besides the TSM
Containing Double and mindful breathing, both which are definitely
powerfully helpful at times. Private practice is sometimes a lonely
place, with little peer connection, and hearing from you all about your
experiences is helpful. Thanks. Patti
----- Original Message -----
From: Adam Blatner
To: list at grouptalkweb.org
Sent: Tuesday, August 29, 2006 2:11 PM
Subject: client or trainee
Hello All, Responding to an excellent professional question: Can a group
member join a training group: And responding further to Bud's response
(attached after this below):
Bud's attitude is understandable and somewhat compatible with many
directors and perhaps even Moreno's generous spirit, but it is also I think
mistaken for the following reasons. Part of this emerged with the
difficulties emerging with the encounter group fad of the 1970s:
There are many people who are clearly mentally ill and just want
to get better, have no aspirations to being a therapists.
Some people, on the other hand, are vibrantly healthy and
self-sufficient, and while they have some mild issues that need to be
worked on, they basically have the character to train and be therapeutic
for others, should they be interested in taking on that task.
A significant number fall between the two, and their problems are
associated more with their interpersonal style. In the APA's Diagnostic and
Statistical Manual, the problems they encounter are noted in the category
called personality disorders, also known as "Axis 2" disorders.
Many people who have depression, anxiety, and other Axis I
diagnoses are also co-morbid, meaning they have more than one problem--not
just their anxiety, but also character or personality tendencies that set
them up for the defeats that then eventuate in depression and/or anxiety,
or other symptoms. (Another example of co-morbidity is the way people with
mild PTSD--perhaps not fulfilling all the criteria for full diagnoses--
and/or addiction problems may also come crashing into more clearly Axis I
types of symptom clusters.)
The second and most important thing that wasn't much recognized
before the mid-1960s is the pervasiveness of varying degrees of Axis II
tendencies, which can be mild, moderate, or severe, and more, the key here
is that these folks don't have primary anxiety--i.e., feeling ego-alien or
uncomfortable with their own symptoms; rather they are ego-syntonic with
their life style, whether it be passive-aggressive, obsessive-compulsive,
hypomanic, hystrionic, borderline, narcissistic, etc. What this means is
that they become upset when people get tired of their behaviors, abandon
them, divorce them, fire them from their jobs, but they don't see what they
did that got people so riled up! Folks with character problems tend to
deny it, minimize it, and so forth. Now we're getting closer to the games
people play in wanting to become "therapists."
It doesn't matter if you buy the diagnostic categories I've
mentioned--they're just tools, and I'm not all that attached to them in
their specifics. What we're talking about is, in Eric Berne's Transactional
Analysis language, the "games people play."
I will confess that I have some mild characterological
tendencies, and I haven't met anyone yet who doesn't have a bit, so we're
talking about how much, and whether a person is really committed to
cleaning up his or her act. Lots of folks don't really get down.
Perhaps another factor here is whether much significant therapy can
happen in a group--especially a training group. The problem is that there
is a dual relationship: On one hand, there is the deal with my problems
goal; on the other hand, there's a bit of do you respect me as a therapist,
can you? I confess, there are people with patterns of behavior that are
intense enough, and lack of insight deep enough, and a kind of resistance
to really looking just thick enough, or lack of mental agility, so that
while I might find them okay to work with as clients, I would never ever
consider them capable of actually helping others. We have to really get
clear about this.
I am afraid that there is a kind of humanistic egalitarianism-- in
California it used to be called "woo woo," that is post-Hippie "whatever"
"it's all good" blind to the actual range of issues in people. It would be
nice to assume that all can be wonderful, but there is absolutely no
evidence that supports this assumption.
So back to the problem: I've been in groups, sometimes with people
who were in counseling programs, and it was clear to me that they were not
only miles from being ready to help others, or even begin to; but were
fairly blind to the deficits in their personalities that would be
problematical: Some were painfully inhibited, passive, reticent, highly
defended; others were "drama queens," seeking emotional catharses and
tending to dominate and exhaust the group. And so forth. Experienced group
leaders could make a list of their most trying group members.
We must also remember that the desire to graduate, to be seen as
being good as the group leader, to be a trainer, is a common desire of
people whether or not they have the talent, ability, experience, maturity,
or other role requirements for the job. To accede to such desires is only
one step away from letting any teenager do brain surgery without having to
go to medical school, much less residency.
So, yes, trainees who have more than the mildest of problems
should indeed have as their primary therapist someone who is out of the
stream of their own vocational guidance, someone who can confront their
manipulations, and someone to whom they don't have to hide those
manipulations. They also need someone outside the group to whom they can
complain about the group leader. (This observation is a variation on the
saying, "No man is a hero to his wife's psychotherapist.")
So it's not the "rules," that are the problem, but the actual
principles that acknowledge the reality that transferential problems will
emerge, they are common, and they are made almost impossible to address if
the group has any other agenda than the commitment to explore the
interactions themselves, with a view to clearing up blocks and blind spots.
A secondary hope to be appreciated, admired, respected, to prove
competence, to gain final approval for vocational advancement, is a
significant dual relationship. Add the financial element: What is the group
member paying for, therapy or training? This further muddies the water.
Well, sorry, but I want to indicate to the group members that the
more conservative practitioners aren't just defending their guild status,
but trying to address actual complexities in dual relationships. I'm
open to your thoughts. Warmly, Adam Blatner
----- Original Message -----
From: BARNETT WEISS
To: connie at souldrama.com ; list at grouptalkweb.org
Sent: Tuesday, August 29, 2006 11:52 AM
Subject: Re: Question
Of course, I am not a TEP so I can only answer from my perspective
having trained many persons in the past in some of the work in many venues.
I really don't see what the problem is in welcoming a person from one of
your groups into a training program. If there is to be a distinction drawn
about this, I am not at all clear as to why there should be.
Psychoanalysis to begin with and many other psychotherapeutic approaches
have implicit rules about the relationship of the therapist to the client
that exclude such conversions and even those are somewhat murky decisions.
In most of the training programs, you have to go through the therapy
yourself to be more completely aware of what your clients are going to be
experiencing when you work. So the trainee has to find someone else to do
the therapy with them.
In the training groups that I have lead, I was doing the therapy for
everyone at first and then working with the more advanced students
co-directing the psychodrama's of other members of the group as we went
along with greater and greater hands off as they built their skills and
confidence. I really don't quite see the distinction here. I also made
myself vulnerable at times and became a protagonist briefly choosing my
director and working with it.
I remember a time at Beacon when Zerka asked me to direct her in her own
psychodrama as she needed to get some clarity about some things. I was
happy to do so while others in the group were quite fearful and actually
reacted very intensely when Zerka was working as it brought up a great deal
for them. While dealing with the group became quite a challenge, I was
quite confident in working with this protagonist since I knew that I had
one of the best co-directors ever...Zerka!!
In fact, I see everyone's psychodrama as being co-directed by the so
called designated Director and the protagonist themselves. If you are not
following the direction of the protagonist, in my estimation, you are
moving in the wrong direction. Words similar to those from Zerka are
emblazoned in my memory.
So again, I don't get why a client couldn't become a trainee at any
time.
Blessings, all, Bud
Connie Miller <connie at souldrama.com> wrote:
Dear Adam:
Muddy?? This is a swamp!
Ultimately it is the decsion of the trainer. My groups are for
"Training in Aciton Methods" and they also comprise those wanting
psychodrama certification. This in fact stimulates those in training to
want to get certification later in psychodrama. Otherwise I feel like we
will never have those certified to do psychodrama increase and
psychodramatists will then become a special and exclusive group and will
die. Also this is why I agree with you about teaching different parts of
psychodrama separately to help spread psychodrama. And of course I would
never allow anyone in the group who was not using the group methods in
thier own work but only wanted to use the group for therapy.
I however am studying for the written part of the tep exam where it asks
under the ethics part,,, what do you do if someone in your therapy group
wants to join your training group? Technically I guess the right anser is
not allowing duel relationships but is this what the all the traianers are
actually doing?? Right now, I have only met one. this is why I am looking
for group feedback.
Thanks Connie
-----Original Message-----
From: Adam Blatner [mailto:adam at blatner.com]
Sent: Monday, August 28, 2006 08:39 AM
To: list at grouptalkweb.org
Subject: Re: Question
Dear Peter, Connie, and group.
Peter, your open-hearted attitude is commendable, but I wonder if
you have considered the potential for less-than-worthy motivations. There
are people who want the status of professionalism, but are yet unwilling to
take on the full responsibility for self-management that this implies. What
I'm referring to is the role of "patient" or "client," in which the
therapist has a more non-judgmental attitude of "I'll try to help you at
the level that you are functioning." Some of these levels can be quite
immature, entitled, un-self-modulated, dependent, passive-aggressive, and
so forth. Many people are not willing to live up to the simplest
requirements of being responsible enough to pay regularly and in good
faith, to show up regularly and on time, of refusing to be civil under the
excuse of victimhood or the right to emotional expressiveness, and so
forth.
To move to a training group is a kind of graduation into a
recognition by peers and group leader that one has moved into a full
process of taking charge of one's life. Not all issues are resolved--I
quite agree with Peter about this-- but there has been a graduation of
sorts that is the equivalent of finishing therapy in the sick or
dysfunctional role.
The problem is tricky, and it is a dual role-- clients wish for
unconditional regard, but this term is misleading. It confuses the
archetypal maternal unconditionality--I'll draw you forth however you may
be, age 1, age 3, age 8, age 80...
and the archetypal paternal conditionality: You are recognized
as being qualified to swim, do brain surgery, take 2nd level geometry, only
when you have clearly demonstrated your mastery of the first level or other
realistic requirements.
Alas, the actual requirements for training as a counselor have become
hopelessly muddy, and it is quite possible to be excessively immature and
still get into a training program somewhere, and even graduate. This is
because there are significant financial incentives to accept all comers, to
keep people in rather than wash them out, to blur and overlook
deficiencies. Arguments that the number of training programs and trainers
should be limited evokes counter-accusations of being elitist and
guild-like. Arguments that call on the belief in the innate goodness of
people confuse the reality of people being a nexus of hundreds of roles and
role components, some of which are more talented, and the ways strengths
often compensate for, and not infrequently disguise weaknesses. So
significant discrimination is needed.
In some universities, this graduation - acceptance into a graduate
school - problem of transference, dependence, and approval is circumvented
by a general policy that there be a period in which graduates must travel
elsewhere and perform for supervisors who have not been in the nurturing
role, the object of parental transference. Perhaps later, having
demonstrated clear competence and maturity, they may be re-considered for a
position in the upper graduate or even lower faculty level. It's an
interesting challenge--perhaps one that requires a hard look at the limits
of good feeling, tele, etc.
I hope I haven't muddied the issues too much. Warmly, Adam
----- Original Message -----
From: Peter Howie
To: connie at souldrama.com ; list at grouptalkweb.org
Sent: Sunday, August 27, 2006 10:49 PM
Subject: Re: Question
Hi Connie,
It is often a natural step. The psychodrama groups are developmental. The
training is developmental. Not all work can be done in a training groups
and hence experiential groups are required as well for trainees. Not all
development can be done in experiential groups and hence training is
available. What does the training do? It expands a persons functioning,
their capacity for warming themselves in a spontaneous fashion, their
capacity to role reverse with others and creates mental models for the
process of doing so. While I run the groups differently the larger purpose
is the same - a more spontaneous world.
Cheers
Peter Howie
Brisbane, Australia
At 12:19 PM 24/08/2006, you wrote:
I was wondering what other trainers do when a group member wants to
join the psychodrama training group. what are your feelings on them being
in both?
ConnieGrouptalk mailing list
List at grouptalkweb.org
http://grouptalkweb.org/mailman/listinfo/list_grouptalkweb.org
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Therapeutic Spiral International, LLC
ww.therapeuticspiral.org
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