Where does the boundary between external reality and the patient’s inner world lie? Why is the ability to recognize this boundary so crucial for therapy?
The need to distinguish between the patient’s internal world and the external reality is an ongoing challenge. For example,
A patient stormed out of a session saying, “You’re cruel. You should have told me there was going to be construction work outside your office today—you know how sensitive I am to noise.”
The therapist was left feeling he was indeed cruel until he reminded himself that he had had no advance notice that the work would be taking place.
Difficulty in distinguishing between internal and external reality, and some patients’ ability to convince others that their internal reality is the objective reality, can lead to severe practical problems in the treatment of borderline patients, including charges of mistreatment or inappropriate behavior on the part of the therapist.
The tactic of exploring incompatible views requires a sense of balance on the part of the therapist.
On the one hand, the therapy advances by observing the patient’s distortions.
On the other hand, there can be no interpretation of unconscious material unless the patient agrees with the therapist on what, ultimately, the “reality” of the situation is. The only distortions of reality that can be interpreted are those that become recognized as such and become egodystonic.
Therefore, the goal is to elaborate the patient’s subjective experience or belief and then to establish whether the patient is—or can be made to be—aware of the degree to which his or her belief deviates from a commonly shared reality.
How is the capacity for reality testing identified in interpersonal relationships within the model of Transference-Focused Psychotherapy (TFP)?:
The general approach in TFP is to have the patient elaborate his or her view of the world and, in particular, of the therapist and the patient-therapist interaction. One reason for the focus on the interaction is that it is the only setting in which the therapist can accurately assess discrepancies between the patient’s description of his or her experience and the experience itself.
For example, if a patient repeatedly describes his wife’s callous mistreatment of him, the therapist does not usually have enough data to know if the description is accurate or includes some distortion. However, if the patient harshly criticizes the therapist for callous treatment when the latter has merely been adhering to her role, the therapist has a clearer view of the patient’s tendency to perceive external real objects through the distorting lens of an internal object representation.
Therefore, TFP therapists must be careful to resist the very human temptation to immediately correct a distorted image of themselves because it is precisely the exploration of this distorted image that brings essential data to the therapy.
Reality Testing and the Working Through of Distortions in the TFP Model
Clarification, confrontation, and interpretation are the investigative tools by which the therapist assesses the patient’s capacity to test reality. The process may go in several steps, as the following example illustrates.
In the early stages of therapy the therapist should examine the patient’s image of the therapist without rejecting it and without accepting it.
The internal object representation being projected onto the therapist is at first explored without any attempt to link it back to the patient’s mind.
The therapeutic expectation is that the patient’s gradual exposure to and tolerance of that projected representation as it is experienced “in the room” will eventually facilitate the patient’s acknowledgment of the role of that representation in his or her internal world.
The therapist’s consistent stance of commitment to the treatment and interest in the patient are part of what leads to the patient’s questioning the image that he or she projects on the therapist.
However, when the patient’s distorted views threaten the advancement or the continuation of the therapy, the therapist may have to take a more active role in challenging the distortion and trying to establish common elements of shared reality.
Exploring the incompatible realities generally leads to uncovering a part of the patient’s internal world being projected onto the therapist.
In extreme cases, a patient may firmly hold on to a view that represents a temporary loss of reality testing. In such a case the therapist must make the diagnostic distinction between an acute episode of psychosis, which can sometimes occur in the course of treatment with a borderline patient, and a transference psychosis in which the loss of reality testing occurs only in relation to the therapist and does not affect the patient’s life outside the therapy.
How is the capacity for reality testing assessed in borderline patients within the TFP model?
In most cases the perceptions of borderline patients are based on an element of external reality—a trigger event. This makes it especially important for the therapist to maintain a sense of proportion and to periodically ask himself or herself a very important question:
“How does the patient’s reaction compare to what an expectable reaction within the normal range of thinking and behavior would be?”
This question is based on a practical, operational definition of transference—that transference is any reaction of the patient to the therapist that is beyond what a normal expectable reaction might be.
For example,
in the case of the therapist starting the session 5 minutes late, it is true that the therapist kept the patient waiting, but it is also true that a normal expectable response would be for a person to understand that such things happen occasionally without seeing it as proof of the therapist’s rejection.
However, a therapist might think, “Keeping the patient waiting was very insensitive, perhaps even cruel. I should have thought about her fragility.”
This line of thinking confuses the patient’s internal reality with external reality, suggesting a countertransference reaction that the therapist needs to reflect on.
The therapist’s shift to seeing himself or herself as cruel suggests that he or she has accepted the projection of an internal object: it is an example of projective identification.
Therapists’ concern about patients’seeming fragility reflects concern about challenging a patient’s defense system. Patients find a certain internal stability in projecting the cruel object onto others, albeit at the expense of peaceful interpersonal relations.
The therapist may be concerned about the distress the patient might experience if the therapist questions the patient’s projection.
Therapists must remember that they need to choose either to proceed in this way, with the hope of deep change, or to offer a more “supportive” therapy that respects the patient’s defensive system, leading to less distress in the moment but also less chance of deep change.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy