In our clinical practice, we often encounter manifestations of aggression and destructive tendencies in patients with borderline personality organization (BPO) — including borderline, paranoid, narcissistic, histrionic, and other personality disorders.

It is important to understand that BPO patients direct overt aggression more often toward themselves than toward others, therapists may be the target either of more or less veiled threats of aggression from midrange borderline patients or of direct threats of aggression from patients in the malignant narcissistic to antisocial range. 

In the model of Transference-Focused Psychotherapy (TFP),  when beginning to treat a patient with a history of serious self-destructive behavior, the therapist should directly address the fact that the patient might harm or kill himself or herself in a way that would also attack the therapist. 

The therapist must make it clear that he or she takes this potential very seriously and is proposing a treatment to help the patient move beyond this position in life but also that although the therapist would regret it if the patient did harm or kill

herself, the therapist’s life would go on as it had before. 

Such a clear position aligns with the fundamental principles of the TFP model, where the boundaries of the therapeutic relationship must be clearly defined and maintained to provide a holding space for the affective intensity that the patient brings into the session.

If a therapist feels that he or she could not cope with the eventuality of a patient’s death, it is essential to work through that either in supervision or in the therapist’s own therapy or analysis.If the therapist continues to feel that he or she could not accept the possibility of the patient’s death, he or she should not treat severely ill borderline patients. 

If a therapist who could not accept this possibility begins to treat such a patient, the patient may sense the therapist’s fear and is in a position to control the treatment (in ways that defend against integration of the split-off aggressive part) and also to act out or indulge his or her aggression by torturing the therapist with concerns about suicide.

It is important to emphasize that accepting the possibility that the patient could commit suicide allows the therapist to work more effectively and therefore makes this possibility less likely.

One way a therapist might decrease his or her anxiety about the possible death of the patient in cases of life-threatening pathology is to arrange a meeting with the patient and his or her family as part of the contracting phase. The family meeting is an extension of the contract setting process and addresses the family’s understanding of and expectations from the therapy and the therapist. The meeting would include the patient’s parents if he or she is young or continues to be dependent on them (e.g., financially or as a major emotional connection) or a spouse or partner if indicated. 

Family members sometimes assume that the patient’s being in therapy guarantees that he or she will be automatically “cured,” or at least will be out of risk. This idealization of treatment can represent a denial of the seriousness of the patient’s pathology and can quickly change to an angry attack on the therapist if the magical expectations are not met.

It is important that the therapist explain to the family that the pathology is very serious and that although therapy offers the possibility of real change, there is no guarantee of a good outcome or of completely eliminating the possibility of suicide. 

If family members can accept this reality, the therapist will be less at risk of attack through the patient’s self-destructiveness, and the patient will be safer because a possible motivation for suicide will have been defused. 

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy