Threats by the patient to prematurely end the treatment, whether overt or implicit, take priority over all other issues except threats to the patient’s life and safety or to the lives and safety of others.
The possible motives that may prompt a borderline patient to consider dropping out of treatment include is:
- the emergence of dependency needs that create anxiety in the patient,
- the development of a negative transference (which could be defending against an underlying positive transference that makes the patient anxious)
- narcissistic issues of envy of the therapist
- hypomanic states
- flight into health
- the wish to either protect the therapist from aggressive affects
- to humiliate him or her by defeating his or her efforts, and so on.
The essential attitude of the therapist in these situations is to be active—for instance, to call a patient who has missed a session without having notified the therapist and to express concern and curiosity about what this represents.
Rarely does therapy end abruptly. Typically, it is preceded by a period during which the therapist may begin to sense, in the countertransference, a growing sense of unspoken resentment or devaluation directed toward the therapist and the treatment. This may be expressed entirely nonverbally, but can also manifest indirectly through actions — for example, when the patient begins to discuss a desire to reduce the frequency of sessions.
The next most serious threat to the treatment is any pattern of overt or covert lack of participation in the treatment process.
This lack of participation, which can take the form of dishonesty, withholding, or acting out, must be explored.
The process of therapy is particularly vulnerable to dishonesty because the problem may persist for a long time before the therapist is aware of it.
Obtaining a careful initial history, including prior treatment experiences, as well as information from third-party sources, can help the therapist recognise this pattern early on. Should the therapist learn, in the course of the treatment, that the patient is being dishonest, he or she must:
1) explain to the patient that a pattern of dishonest communication would effectively render the treatment ineffective and, if unresolved, bring it to an end and 2) explore with the patient the motives underlying the dishonest communication.
Lying is an expression of how the patient experiences self, others, and the therapy.
Patients may lie for any of the following reasons:
1) to avoid confrontations that will result in their having to assume responsibility for their actions,
2) to avoid the therapist’s disapproval or imagined retaliation,
3) to exert control over the therapist,
4) to express superiority over the therapist by duping him or her,
5) to prevent an authentic relationship from developing,
6) to exploit the therapist and the therapeutic situation..
In a deeper sense, consistent lying expresses the belief that all human relationships are exploitative or persecutory and represents a chronic transference position.
Because the success or failure of the therapeutic task depends on honest communication, lying must be treated as seriously as any self-destructive action.
The therapist must try to interpret fully and consistently the misrepresentation or suppression of information, while acknowledging that he or she is powerless to keep the patient from communicating dishonestly if the patient chooses to do so.
Interpretive efforts focused on lying or withholding of information may take weeks or months, particularly in cases with antisocial features. However long it may take, full resolution of the implications of the patient’s lying takes precedence over all other material except life-threatening acting out and danger of immediate dropout. If the patient who habitually lies also shows evidence of life-threatening or treatment-threatening acting out, the treatment should start in the hospital so as to provide the protection and accurate reporting (by hospital staff) that the patient is unable to provide.
Full exploration of the transference meanings of lying, like all interpretive work, proceeds from surface to depth. Transference interpretations will often focus first on lying as an expression of the patient’s hostility toward self as well as toward the therapist.
Deeper interpretations about the patient’s despair can be made only after the aggressive and paranoid components are interpreted.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy