Many therapists are hesitant to name and discuss this diagnosis. However, the therapist’s explanation to a patient who believes that he or she is suffering from anxiety and depression and who has no understanding of the deeper psychological issues involved that the diagnosis appears be a personality disorder, and then an explanation of that concept in layman’s terms, can be reassuring to a patient who does not understand the source of the chaos in his or her life. It is helpful to explain that BPD involves:

1) intense and quickly changing emotions (“life as an emotional roller coaster”)

2) unstable and stormy interpersonal relations

3) impulsive actions that can be of a destructive nature

4) an underlying lack of clarity about the patient’s sense of who he or she is and difficulties assessing others realistically that generally is the root of the other problems.

It is important to emphasize that although acting-out behaviors may be the most dramatic manifestation of the illness, they do not constitute the illness. Rather, it is the fragmented and confusing sense of self that is at the core.

The more severe the patient's disorder and the more distorted their interpersonal interactions in the therapeutic relationship, the more powerful the primitive object relations in the transference. These evoke an intense countertransference. The therapeutic position is vulnerable to the threat of potential acting out of transference feelings by the patient and, at times, to the therapist's temptation to act out their own countertransference. Without a well-thought-out and mutually discussed therapeutic frame and contract, the mutual enactment of transference and countertransference obscures the therapist's clear understanding of the psychodynamics of what is taking place.

With higher-functioning patients, different challenges emerge. The dynamics of higher-functioning patients are more difficult to track because their reactions in therapy appear almost normal. It is not easy to notice subtle deviations, and this is where the therapeutic frame and contract also helps - minor deviations from the agreed frame open the way to exploring deeper dynamics.

When guiding the patient toward discussing the therapeutic contract, the therapist must address:

1) universal and essential parameters of treatment that apply to all cases in psychodynamic therapy

2) resistances that can appear in the form of specific behaviors that could threaten the treatment.

These behavioral resistances stem from the fact that exploratory therapy threatens the patient’s fragile homeostasis. Even though splitting-based defense mechanisms do not provide for good adaptation to the complexities of life, they do provide some relief from anxiety insofar as they order the patient’s world around externalization via projection. Any questioning of this system—any change in a person’s defensive structure— causes anxiety until the new structure is in place. Behavioral resistances require the establishment of specific parameters that go beyond the universal parameters of psychodynamic treatment and that vary according to the individual patient.

Although the patient must make a commitment to try from the start to work within the parameters of treatment, the therapist should understand that difficulty following the contract may constitute a primary topic in therapy before full adherence is achieved.

Even though the contract is set up before the therapy begins, the work of therapy often involves referring back to the contract and sometimes involves revising it or adding to it during the course of treatment.

The therapist should not feel an obligation to work with a particular patient if that patient does not accept fundamental aspects of the treatment.

It is the therapist’s job to make sure that he or she is providing proper treatment. This is analogous to the situation of a surgeon who will not proceed with an operation unless essential conditions, such as a sterile operating field, are in place. If the patient does not accept the essential conditions of exploratory therapy, the therapist should either offer or refer the patient to a less structured, more supportive treatment. If a patient is not ready or able to commit to or is not interested in committing to the conditions of treatment, a less intense and less ambitious treatment is indicated, at least for the moment.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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