When borderline patients who often exhibit parasuicidal behavior come to us, the therapist frequently faces difficulties in determining how exactly to conceptualize such manifestations and how to integrate them into the treatment framework. This raises the following questions:
From a dynamic point of view, are they the same as suicidal behaviors?
From a practical point of view, should the same conditions of therapy hold for these behaviors as for behaviors with a clear lethal potential?
The following is a typical reaction from a therapist struggling with appropriate limit setting:
“I can understand the need for the patient to go to an ER if she is at risk of killing herself, but is that necessary if she is dealing with an urge to inflict a superficial cut?”
It is helpful to remember that a principal rationale of limit setting is to keep the patient’s affects within the treatment setting rather than permitting them to be discharged through acting out. Therefore, the main question is:
“What will the impact of the nonlethal self-destructive behaviors be on the work of the therapy?”
Exploratory therapy is based on the principle of allowing the patient to communicate, to discover, and to examine his or her own story, with the help of
the therapist, to move beyond defensive obstacles to understanding. The therapy
leads to new understanding and a more coherent narrative of the self. Yet this
process can threaten a patient’s current psychological equilibrium, as
maladaptive as that equilibrium may be. Consequently, patients may act in ways
that take attention away from the mutual effort to understand—acting out as a
form of resistance to exploration.
It is unreasonable to expect that a therapist will discern in advance all the possible resistances that a particular patient may bring into the treatment. It is also possible that a patient may develop new behaviors as resistances to exploration in the course of therapy. Therefore, the therapist should continue to watch for such developments and be prepared to introduce new parameters as needed at any point in the treatment.
With regard to self-harm, it may take time for the therapist to know whether the patient cuts because it is a learned behavior for coping with anger, an enactment of an internalized object relationship involving trauma and including an identification with both perpetrator and victim, an attempt to influence the therapist or make him squirm, or some combination of all of these.
In Transference-Focused Psychotherapy (TFP), some forms of minor self-harming behavior may be controlled by setting a parameter in the contract specifying that each time the patient cuts or hurts himself or herself, he or she needs to be examined by an internist or general practitioner to check for the need for wound care before returning to outpatient therapy. The objectives are to make it clear that self-injurious behavior is outside the realm of therapy, to ensure the patient’s safety, and to provide the time and space to interpret the meaning of the behavior as well as the meaning in the transference of having to establish a parameter.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy