An important goal is to bring calm to the borderline's chaotic relationships. According to Benjamin (1996), the borderline is in a Catch-22 that sabotages therapy, whether there is progress or no progress. Although therapy usually has a good beginning, eventually the subject realizes that the therapist is not an infinite fountain of nurturance and begins to enact extreme behaviors, such as overdoses, self-mutilation, and suicidal gestures. As Benjamin explains, this causes the therapist to begin a subtle withdrawal, perhaps just a reluctance to schedule extra appointments or receive phone calls.
Sensing the increased distance, Benjamin (1996) states, the borderline becomes critical and accuses the therapist of not caring enough and quits therapy in some dramatic fashion. Later, the borderline phones wanting to continue, and the therapist agrees, fearing legal consequences or the borderline's self-destructive actions. Obviously, this vicious circle does not require that the borderline quit therapy, but only that the therapist surrender the desired emotional supplies as a consequence of the subject's manipulations. As long as the therapist seems to hold out, the borderline continues to exacerbate and regress. Alternatively, the subject may genuinely improve but then suddenly regress as termination approaches. To arrive at a healthy state implies the need to end the client-therapist relationship, which then leaves the subject feeling abandoned and fearful. Again, pathology is the solution, at least from the subject's perspective.
The best way to stop these cycles is to prevent them from starting. Whereas the borderline believes the problem is not enough love and attention, the therapist should offer an agreement in "strength-building" (Benjamin, 1996, p. 134). Limits should be set and maintained. Refusals to meet classic borderline manipulations can be excluded in advance by putting them into the overall mission of therapy, the road to health, as a larger context. For example, the therapist might say, "You're right that I won't be willing to talk with you whenever you call. . . . The reason is that. . . your pattern now is to be very needy ... if I were to do what you want in the way you want, you would become weaker, not stronger" (p. 134). This approach establishes boundaries while affirming the subject, thus the borderline cannot feel ignored or abandoned.
As therapy progresses, phone calls and extra sessions must be limited. The focus must be on the subject's strengths and how these strengths can be brought to bear in the given situation. Self-consciously keeping this goal in mind helps therapist and subject remain focused on the pathology as the enemy and keeps therapy from degenerating into the chaos of the borderline's other relationships. Once maladaptive patterns are recognized, therapy can block their perpetuation. For example, Benjamin (1996, p. 136) holds that borderlines give up their self-destructive behaviors if they can "divorce" their "internalized abusive attachment figures." Fantasies can be examined to determine who is appeased by injury to the self. Next, the link between the present and past can be weakened with penetrating questions, such as, "Do you love this person enough to give him or her your self-destruction?" Alternatively, a dislike of the internalized image can be fostered or an attachment to someone else can be fostered to replace its influence.
Writing in Beck et al. (1990), Pretzer suggests that although borderlines exhibit many cognitive distortions, dichotomous thinking is especially prominent. An attachment figure may be seen as either totally accepting or completely condemning, for example. Because emotion and thought are so closely linked, such black-and-white appraisals lead to proportionately intense emotional reactions, throwing borderlines' lives into desperate panic and their interpersonal relationships into turmoil. The first time the subject feels ignored, his or her appraisal changes, and the attachment figure is saturated with absolute evil. Likewise, borderlines cannot feel somewhat guilty, only totally bad and worthless. Because no shades of gray exist, more adaptable reactions simply are not available. As such, a strong therapeutic alliance is particularly important, for the therapist is easily classified as completely malevolent or untrustworthy as well.
With this foundation, the therapist can help the subject test reality in areas where di-chotomous thinking dominates. For example, the individual can be asked to define the elements that go into being trustworthy and untrustworthy. Once an adequately complex definition is achieved, actual persons in the subject's life can be evaluated and shown to occupy a position somewhere between these polar opposites. With practice, borderlines can learn to identify automatic thoughts that caricature the interpersonal world, thus paving the way toward a new and more realistic way of experiencing others: Not everyone will criticize, hurt, or abandon you. If successful, existing relationships should settle down somewhat, and new relationships get a more realistic beginning. The same holds for the borderline's self-image. By refuting dichotomous images of themselves, borderlines learn that they are not absolutely unredeemable but instead have a variety of both good and bad qualities, and the bad can be segregated out and worked on in therapy. In turn, these changes feed into decreases in emotional intensity. Anger, for example, can be expressed to a moderate degree and in constructive ways. Where necessary, role playing and social skills training can be used to provide the borderline with experience in interpersonal interactions of moderate intensity.
Although the focus on dichotomous thinking is straightforward, several characteristics of the borderline complicate cognitive therapy (Beck et al., 1990). Many borderlines begin from a position of basic mistrust, making any therapeutic alliance tenuous at best. With the therapist explicitly acknowledging difficulties; taking special care to communicate clearly, assertively, and honestly; and especially maintaining congruence between verbal and nonverbal cues, an alliance should develop over time. In addition, a lack of basic trust feeds into a discomfort with intimacy. Many borderlines become anxious if their boundaries are overstepped. Subjects can be asked how therapy can be made more comfortable and should be allowed input into the pace of therapy and topics discussed. Finally, Pretzer notes that concrete behavioral approaches can be valuable in serving several important purposes. Without a clear identity, most borderlines find it difficult to set goals and maintain priorities from week to week. With concrete, specified goals, progress is more tangible and easier to measure. Moreover, subjects are not required to reveal deeply personal thoughts and feelings before trust is established, and the initial success can provide motivation to continue in therapy. Goals should be discussed frequently to keep subjects focused.
Psychodynamic thinkers are agreed that modifications of the classical technique are necessary to prevent the borderline from regressing in the unstructured environment of the couch. However, they are divided on whether to advocate supportive or expressive therapy. Because the borderline suffers from ego weakness and the therapist acts as an auxiliary ego for the subject, supportive therapy seems logical. However, Kernberg (1985a) argues that supportive therapy may perpetuate pathology by allowing borderlines unlimited gratification of pathological needs, specifically, a need to express anger at early caretakers, now symbolized by the therapist. The borderline personality is not a pathology of ego weakness, but a pathology of object relations. Instead, Kernberg proposes that confrontation can be therapeutic when addressed to borderlines' tendency to alternate between idealization and devaluation. Confrontation does not connote hostility, but simply an effort by the therapist to draw attention to the long list of discrepant statements made by borderlines in therapy and their lack of concern in making them.
Thus, if the subject asserts that an abusive lover is perfect, the therapist might say, "I'm confused. You just told me that your lover physically abused you. Does that sound like the perfect boyfriend?" In confrontive activities, the therapist functions as a mature, self-observing ego that strives for a consistency of impressions and behavior. Posing such questions not only lays a foundation for insight but also requires the subject to integrate split object-representations of self and others into more realistic composites, establishing more solid boundaries between borderlines and their significant others, bringing additional cohesion to the self, thereby decreasing identity diffusion. By addressing problems in the transference early, the way is set for a more realistic perception of the therapy later; thus a genuine alliance, one not based on fantasied objects, can be established.
Other thinkers argue that early confrontation and interpretation simply incite the borderline, who then quits therapy. From Adler's (1985) perspective, for example, the borderline suffers from an absence of soothing-holding introjects. Given the distortions to which they are subject, borderlines are unable to appreciate the therapist as a separate individual authentically interested in their welfare. Because, at this stage, the borderline can relate only to his or her projections, no real alliance is yet possible. By providing consistent support, the subject is able to internalize the soothing-holding qualities of the therapeutic relationship. Thereafter, the borderline is in a better position to grasp the therapist as a real person. Ironically, the available data (Wallerstein, 1986) seem to suggest that confrontation and supportive therapy represent dichotomous extremes. As such, each works for different patients, and both are likely to be required with the same patient at different times.
Many therapists have found credence in resorting to alternative forms of therapy when dealing with borderline personality disorder. For example, Bockian (2002) has used relaxation training, expressive arts therapy, and music therapy as supplemental therapeutic strategies when treating borderline personality disorder. These therapeutic alternatives are effective in assuaging the depressive and anxious symptomatology. Relaxation techniques can be used to allow the individual a sense of calm and control in managing daily life. Whether encouraging autogenic training or guided imagery, the goal is to strengthen the borderline's relaxation skills, thereby tempering anxiety states. The desired result of expressive arts therapy—dance, music, art therapy, or psychodrama—is to minimize feelings of self-consciousness, encourage self-exploration, strengthen alternative modes of self-expression, and heighten self-awareness. Music therapy, according to the American Music Therapy Association (AMTA), is suitable for the treatment of symptoms associated with sexual abuse, posttraumatic stress disorder, and substance abuse—experiences often linked with a borderline personality (Bockian, 2002).
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EFT stands for Emotional Freedom Technique. It works to free the user of both physical and emotional pain and relieve chronic conditions by healing the physical responses our bodies make after we've been hurt or experienced pain. While some people do not carry the effects of these experiences, others have bodies that hold onto these memories, which affect the way the body works. Because it is a free and fast technique, even if you are not one hundred percent committed to whether it works or not, it is still worth giving it a shot and seeing if there is any improvement.