When working with patients with borderline personality organization (BPO), including those with narcissistic personality disorder (NPD), we are aware from the outset that the therapeutic process will be complex and marked by crises.Yet the most dangerous situations often arise not from acute symptoms themselves, but from the persistent threat of treatment discontinuation. This risk is rooted in the structure of the borderline psyche, permeated by contradictory object relations that oscillate between idealization and devaluation, trust and paranoid suspicion.
The threat of treatment discontinuation most often emerges at the early phase of treatment, but threats of dropping out may also occur in the midphase. Dropout talk and behavior can create a crisis for the therapist, who may wonder if a more immediately gratifying treatment would keep the patient in therapy.
In clinical practice, several main factors can be identified that threaten the discontinuation of therapy:
1. Negative transference:
- The patient “deposits” hated internal representations into the therapist and then attempts to separate from them by leaving.
- The patient threatens to leave therapy as a protest against the therapist, who, by not providing the ideal care the patient desires, is perceived as uncaring or even persecutory.
2. Narcissistic issues:
- The patient experiences feelings of competitiveness and envy in relation to the therapist, feels humiliated in relation to someone he or she experiences as superior because of the therapist’s capacity to help the patient, and thus flees therapy both to get away from these feelings and to “defeat” the therapist.
- The patient experiences jealousy with regard to the therapist’s other patients and other interests.
3. Attachment and dependency issues:
- The patient becomes anxious because of attachment feelings that develop in the positive transference (which may be hidden from view) and leaves therapy to avoid the anxiety associated with dependency.
4. Fear of hurting the therapist/wish to protect the therapist:
- The patient feels that his or her intense (aggressive and/or affectionate) affects are too much for the therapist, or anyone, to bear and decides to leave before this becomes apparent. The patient may also experience a milder form of this guilt or shame over sadistic or libidinal feelings.
- The patient feels pressure from his or her family to quit treatment when change in the patient is perceived as threatening the equilibrium of the family system.
Thus, the threat of dropping out calls for a level of therapist activity that is surprising to many analytically trained therapists, who might, for instance, deal with a patient’s missing a session by waiting to see if the patient comes to the next session. The TFP therapist takes a more active role—in terms of both practical interventions and the timing and depth of interpretations—when the treatment is at risk.
At times the therapist must function as the observing ego because the patient may completely lose this capacity for periods of time. This situation requires the therapist to temporarily abandon the position of neutrality. When the therapist takes a more active role, his or her actions may provide a confrontation in action to a patient’s conviction, by projection, that the therapist is, at best, indifferent and callous or, at worst, exploitative or malevolent.
Yet despite their complexity, such situations provide the very conditions in which profound changes in the patient can occur.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy