 We demystify what goes on behind the therapy room door. Join us on this voyage of discovery and co-creative conversations. This is The Therapy Show, behind closed doors podcast with Bob Cook and Jackie Jones. Welcome back to this next episode of The Therapy Show with Bob Cook and Jackie Jones and we're going to go straight into part two of working with a client with borderline and the clinical implications of that and possible treatment planning. How do we work with that client? Okay, so I'm going to name two names. I'm going to name Masterson, who is the so-called expert on, you know, writing about how to work with the borderline condition. And a custodial therapist I realized called Eleanor Greenberg. They put either of those names into Google and they'll come up lots of literature how to work with the borderline condition. Let's start with what I talked about the dilemma in the last podcast is that basically somebody come from this position has problems in the separation, individuation phase. In other words, how they separate out, be individual, rather than being the prisoner of their care take or mother in this position. So Eleanor Greenberg had a monomic, which I like, for people who watch, listen to the special, the narcissistic podcast, Eleanor Greenberg had a monomic called Special God. For the borderline position, she has a very apt monomic and it's called Misery. Now I'm smiling on a podcast, you can't probably see me smile anyway, because, you know, sometimes, you know, it can feel very miserable when you're in a therapeutic battle with the borderline. Yeah. And the trick, of course, is to take supervision so you can actually stay outside the process. So it's Misery. So let's go through it. Yeah. Very good way of thinking about how to work with borderlines is to remember the monomic of Misery. So M is for mother. Okay. Now, as I say, the basic position is for borderline is mother issues that they haven't been able to separate or individuate from the mother. And they fail to do that, or perhaps it's the father, the primary caretaking. I'm glad you said that, Bob, because we always get the stick for stuff. Yeah. So, yeah. Yeah. So they fail to, if you like, separate. They fail to get the recognition, support, admiration from the caretaker figures whilst they're doing the necessary separating process. That's why I say mother issues. But of course, it could be father, if the mother's not around or if there's two fathers, for example. But it's important. Eleanor Greenberg called it mother issues. But that's the dilemma. The next one would be I, Misery. Remember, I was done for identity problems. So they have two basic identity problems. One is what I've just talked about is the part that I saw in the last podcast, where they moved to a helpless, regressed, young sense of identity, if you like. And the other one is when they switched to this other part, which is always fear of abandonment and will move to rage and will move to extreme anger and attempt to keep the caretaker connected, but it doesn't work. And also their identity is often very, very young. They don't grow up, so they haven't got a grown up identity. They have an identity which is very, very young. Yeah. Yeah. So that's one thing to, because if you think about it, if you can think of this in child developmental terms, then you are able to separate out from the character transference and be more grounded in the clinical treatment. Yeah. So now we're into S. Yes. S is for splitting. I said there's a big split between the two halves of the self sometimes. Masterson I think calls about the wheel and the full self. But anyway, two parts of the self where they, I've just talked about the split. They see things in very black and white terms, just like young children do. Yeah. There's no sense of greatness in relationships. This is how it is, or this is how it isn't. Yeah. And they will split from the side, which is very childlike and regressive and obviously it's very passive to the other side, which is very rageful, angry and fear of being abandoned. And they're locked out from both positions. Both of them though, are an attempt to keep connected to the primary caretaker. Now if it's in therapy, of course, connected to the therapist. Yeah. Therapist probably, unless they know this material, won't understand that at all. If somebody is raging you, they won't see it as an attempt to be connected to you. Yeah. Yeah. But again, that rage is covering up a real fear of abandonment. So there's fear underneath that rage that's coming at you. Yeah. Yeah. And it's not just I'm a bit scared that you're going to not see me next week. This is, like you say, this is real deep-rooted life and death survival stuff going on here. Yeah. That's fine. Another thing for a therapist to think of, what's this E stands for engulfment, stroke abandonment. So they're afraid of being engulfed so they can never grow up and never be an individual. But they are on top of that they have a fear of being abandoned as well. So a huge fear of being engulfed, just like their mother engulfed them, because it means that they can never be themselves, they never think, they have a sense of autonomy, no sense of growing up, never sense of spontaneity, all things we're talking about. So then they stay, as I said, usually what's happened is they'll either escalate one part or escalate the other part in an attempt to get connection. Yeah. Either way the therapist, if they don't know this stuff, will not find it easy to stay grounded in their adult. Yeah. Does this link into the injunction stuff about don't be you and don't grow up as well? Is that what you would work on in the therapy room? Well, I know my identity as a TA therapist for many, many years and I teach people to be TA therapists. I don't actually think transactional analysis language much when I'm thinking of this psychodynamic child process of a board line. But however, if I did think about it, because you've asked me, yes, don't be you, don't be yourself, be what I want you to be, probably the biggest, don't be yourself, be what I want you to be, don't exist, don't feel, don't think, don't grow up. Don't do anything, just don't. All the injunctions are there. Yeah. So the child will then have to adapt to survive, and usually what they move into is, as I said, this childlike, passive, over adapted position in an attempt to keep the mother or the projected person in the relationship. But then, of course, they feel engulfed or they feel the person's going to abandon them, so they move to a rageful position. Yeah. Both positions are an attempt to keep connection, but actually in real life pushes people away. Yeah. And in fact, there's many books written, and one of them I like is for the lay reader, and it's of course, it's walking around, what's it called, walking around on eggshells. And it's a bit like if you're in a relationship with somebody who comes from this unstable, contradictory position, and it is like walking around them on eggshells because they're, because the other person's afraid of anything that they do, the person will either go to extreme rage or extreme neediness. Okay. Yeah. I can see how that would work. It's kind of like you don't, you, as the other person in the relationship, you don't want to be seen to wake them up to a certain extent because whatever you do, it's going to be wrong. Yeah, that's right. Whatever you do is going to be wrong, and that's what the therapist will feel. Yeah. The therapist's counter-transitence will be, you know, definitely along those lines, whatever I do here will be wrong. Yeah. Now, if they've got a history themselves, in their childhood state, where in their own history, which is whatever they did was wrong with their own parents, then they're going to be highly stimulated. Yeah. Because as therapists, we are only human. That's right. And, you know, I think, I think I personally think that these issues will come out very quickly in the borderline process. And for the young therapists, they'll need to take it to therapists. But if they get to a place where they can't cope, they might have to refer on them. But of course they are then in a really difficult position because that is the, you know, real abandonment. Yeah. Yeah. We're just all, I know we've got the R and the Y that we need to finish off, but where does all this fitting with where we sometimes step into the client's story in order to re-parent and step out again? Is this something that you would stay well clear of with the borderline client? Yes. Okay. That's in a nutshell then. Yeah. Other stuff. The first thing you need to, and I'm going to talk about it, is provide boundaries, provide structure, continuity, provide confrontation, provide the adult reality testing, not an attempt to do re-parenting. Now, by definition, by providing all that, you are providing, as long as you don't give up on them and say, oh, well, you know, I can't cope with this, I'm going to pass you on to the therapist. And then you've got to be an actor of history. But so we are in a way providing a different experience, but it's not stepping into their early emotional life. Yeah. It's with structure, with boundaries. Yeah. We do confrontation rather than an adult reality testing, rather than re-parenting. Yeah. Yeah. And I would imagine, again, it's about that potency of being, you know, no matter what they're throwing at you, if they come out as that helpless child that is feeling abandoned and lost and they're throwing lots of emotion at you, please. So just let me, I don't know, have longer in a session or see you more regular or prioritise me about whatever it is. That's a trap for the therapist. Yeah. If you start doing that, where do you end? But that's what I mean. It's about us being potent. We keep them in that safe space as opposed to getting drawn into all of that. Yeah. Yeah. And it's very easy to get drawn into it, but you are correct. So rage on our misery, monomic, by Eleanor Greenberg, just pointing to Google, loads of stuff on it, or Masterson, you know, and tons of stuff on that, is for rage. R is for rage. Which is a big part of this. Yeah. Yeah. The fear of being golfed, the fear of being abandonment. And of course, they are hyper-vigilant for anything that may indicate that. And they will move to rage and defaluing and annihilating as quick as a flash. Yeah. Because they want to keep the therapist, not the opposite, but because they push the therapist or the whoever away. And they feel their rage and their anger is so deep, it goes on forever. There's no boundaries. It's boundless. It's an abyss. Yeah. It's an abyss because they are rageful and not being able to be themselves. Yeah. They're also terrified that the other person will abandon them, and that can bring rage as well. And the range is, they feel it's like, will go on forever. It's a core, core issue. Yeah. Because in their mind, they've tried everything to make it work, and it's not working. Yeah. And so the therapist really needs to understand this dilemma, I hope, and stay grounded in the process. Not so easy, but at least take it to supervision if you have a problem with it. Yeah. If you have a problem yourself with conflict, or setting boundaries, or confronting people, this is the wrong client for you to work with. Which again puts you in a really big dilemma. If this doesn't manifest itself until a few sessions in, if you are quite a young, newly qualified person and you're six, eight, 10 sessions in before you realise there's something amiss here, then what do you do if you are referring gone? Because you haven't got the skillset, that will be seen as abandonment by them. Yeah. You are in a knowing situation. Yeah, you're in a very new, it's almost impossible. Yeah. But you need to leave as quick as possible. Don't allow it to go on. If after three or four sessions and you experience this, stop. But make sure you pass one, because the longer you go into this, the more entrenched this will be, and the more they will re-enact this out. Yeah. So why? Yearning. Yearning. So, yearning. Yearning, they yearn the child in them yearns for perfect love. They yearn for the other person who will give them what they call perfect love and almost like 24-hour non-conditional devotion. And they will never leave them for one minute. So it's like a symbiotic, in my frame of reference, hell. In their frame of reference, Nevada. Yeah. Because that person will give them the perfect love they've never had without any conditions at all. Because in their history, they only got love, of course, if they adapted in a certain way. So it's very conditional. Yeah. But now yearning is that someone will come along, give them perfect love, never leave them, never be away from them so far. You know, it's a bit like a slavish love, but in their head it's perfect love. Yeah. Which, again, you know, if you look at the early days of therapy or the early days of a relationship or the early days of a new job and all that sort of stuff, we're replaying the cycles of development. So we go through that honeymoon period where we want to be together all the time and everything. But then comes the individuation and separation phase of a relationship that is just going to trigger all this stuff off. So you might be six months into a relationship before you start to see any of this behavior being displayed. I think the borderline, yeah, I know what you're saying. And that's true with a borderline is so quick. So if you know this literature, if you've been trained in this, you'll know this literature. And you will spot it. The biggest trap, though, especially for the beginning therapist, is that they believe they can cure the borderline. And they usually believe they can cure the borderline person by helping them and helping them and helping them. And of course, it's the complete opposite. So in terms of treatment planning, then the first step will be to really boundaries, boundaries, boundaries, boundaries and structure. Yeah. So boundaries mean things like this. If you have 50 minute sessions with someone, you don't go one second over the 50 minutes. Yeah. That you expect them to survive in maybe their adaptive way from session to session. You know, I would even suggest you had telephone calls. You know, if somebody is going to have a telephone call with a borderline client to accept that telephone call contract or text contract or whatever you like, then that must be really kept and specified to say two minutes or three minutes or five minutes or it's an email, you know, 15 sentences and needs to be really, really spelled out. I would suggest that you don't have telephone contacts even if it's for business, even if it is only for business. Yeah. Because once you open up a passage outside the therapeutic room, then you could be opening yourself up to problems. Yeah. I understand that if that person has missed the bus or if they can't make it, or then I think he may set up a contract around logistics for text, emergency text for that. But he must have no costs moving to a therapy process. They're going to be throwing everything at you. You know, even when you're saying then the sessions, if it's 50 minute session, you can't go one second over. I know that I've had situations where suddenly they strike up a conversation about the next session or I might have to go somewhere, but I might not. So I'll let you know whether I can and they just come out with all this stuff just to make it stretch that little bit further or that doorknob comment as they're going out or something. Yeah, that's right. But you know, if you know this material, then you'll be on guard against all this. Yeah. Which across the board with all clients, it's good to have boundaries and structure. Would these clients to the nth degree? Yeah. Yeah. Yeah. But if it's across the board, then it's not something that you're having to think about putting in place. You know, would you see this client more than once a week if they wanted more contact with you? Is that how you would bypass that by seeing them extra in a session? No. Not in my opinion. I think you need to start, actually start off. So look, Everfab is listening on may disagree with me here. So it's a matter of professional thinking. I think if you start off once a week, you stay at once a week. Yeah. You don't reward them for their escalation. Yeah. Because it could be seen as a reward for their escalation. They can't think, they can't feel their emotional work. They want to commit suicide. And if you don't commit suicide, they'll need another session. If they don't give you another session, that's a fundament. And then reenacting the history just like my mother did. You have bloody awful therapist. They've taken ethical complaint at you. I'll get hold of your most, your regulated body and you'll make sure you never work again. So I want to next wherever your time. Okay. Yeah. No, I can see, but this is what I was saying earlier on about them laying traps and manipulating the situation. You have to have very firm boundaries. Yeah. They will tempt all the things I've just said very fast. Yeah. Yeah. And that's one of the things is that they go from 0 to 60. What you were saying earlier on about it, it's a very quick switch. Very, very quick switch. And I've supervised many, many, many therapists have had tremendous problems, personal, professional crises and haven't known what to do. This is very, very common what we're talking about. Yeah. Yeah. And I couldn't understand it because you kind of painted yourself into a corner. You're stuck. What do you do? Either way, you're not going to win. No, no, you cannot. You cannot repeat. You cannot win. Yeah. The only way you can treat these people effectively is to start off with strong boundaries, strong structure. Yeah. Understand that they will idolize you and they'll need to realize and then what they'll do is they will move to being helpless or report being helpless. They'll move to escalating, not thinking. They'll move to many manipulative techniques so that you will move into helping them in some way. So how do you connect on a therapeutic level with these people? Well, number one, you have to stay in adult. And what I mean by that is you have to stay the age that you are. Yeah. And you need to stay grounded to be able to be able to think clinically. You need to know this material that I'm talking about. You need to understand the separation, individuation, drama that they're attempting to resolve or play out. So that will give you some compassion. And I think it's through your compassion and understanding the child's confusion and their need to... Well, they need to get out of this drama they're in and see that if they keep enacting these destructive behaviors, they will always stay in a drama-filled place. Yeah. So the second thing you need to do, I think, once you've provided boundaries and all the stuff that I'm talking about, this isn't necessarily linear. You may spend a long time talking and learning about their trauma history. So don't take it particularly linearly. But anyway, I've called it number two. And you might want to call this even educative therapy, but you need to teach them or let them know of the consequences of their destructive behavioral patterns. Even if it is straightforward as when you are like this with me, I am ex. Yeah. When you're like this with me, even though you might think that I may change these boundaries here, that is not going to happen. And if we look at what normally happens to you in relationships when you attempt to do these things, and they then explain what happens, you start sort of showing them that they're acting out and their destructive acting out doesn't resolve things today, but actually makes things worse. Yeah. So you're appealing to them to start thinking to stay an adult and to understand connections between their acting out and their destructive behaviors. Now, you might want to call that educative therapy we want to. I'm quite happy with the word educative therapy actually, but you're helping them make connections between their acting out of destructive behaviors and whether it works or not. And obviously it doesn't work. So then they start making connections and hopefully thinking about things. Yeah. So if we look at the thought feeling behavior, they would generally be doing the behavior stuff. Yeah. Yeah, that's right. And yeah, absolutely. So you are encouraging them, if you like, to think and to work things through. Now, what will usually happen then, of course, is that as they start to take some responsibility about thinking and ownership of those connections, they will then probably start acting out in some ways because they're going to have a fear of being engulfed like they were by their original mother or the therapist abandoning them. So it's very important then number three, which I'm going to talk about here, is that you do not reward them for their crazy, I'm saying crazy loose terms, passive helplessness, thinking distortions. But you don't reward them in some way. Yeah. For being young, for not thinking, for acting out as a helpless three-year-old, when in fact they're a 35, 40-year-old adult in front of themselves who can think, otherwise they'll be brain dead. Yeah. Yeah. So the snippets and the moments where they are thinking and the adult has in the age that they are and having a conversation, that would be knotted in the session. Yeah. Yeah. If you reward them, you're going to fall into a trap. You have to challenge that helpless, aggressive, crazy or compliant behaviour directly. Yeah. If you don't, you will net history with them. Yeah. I get that. I've seen that. I've done that. Yeah. Okay. So another point in this list is you also need to encourage them to express their internal feelings and their internal world instead of repressing them or adapting to what they think you might want them to do. Yes. Yeah. So the major goal, one of the people coming from this type of profile, they usually come in because they have problems in relationships, maintaining personal relationships or friendships. They usually, the contract or the major goal on what they want. This is why this links into the yearning position I'm talking about is they want to be in a stable, loving, neutral relationship. So if you've gone, you know, like I said in therapy, you've started to teach them that their behaviours and their enacting acts is pushing people away. And they may be able to start integrating some of these things. But I think that should be the major goal. Right. The major trap is that when they start to, I can explain to you, when they see this as the major outcome, the major goal, and they pick somebody who they see as nurturing and all the things we're talking about, as soon as they start to what I call masses and call self-activate and grow up and start thinking and functioning for themselves outside the relationship. Yep. Then they will usually start doing all this stuff we're talking about and, you know, be afraid of abandonment and manipulate more and push people away and move from idolising to devaluing very quickly as soon as that stimulus of them attempting to grow up. Yeah. Yeah. So they will say engage their thinking and start to be more adult than the abandonment comes because in their mind they're fixed so you're going to leave me. Yeah. Because in very simple terms, if I self-activate, my mother will die or go crazy. Very bottom line. Yeah. Yeah. Which in that young place is a lot. Yeah. And hear of that very famous song by Patsy Klein called I fall to pieces. That's what they feel. That's what they feel. One of the things, just to finish off on with this, that, you know, I can kind of connect with or see as one of the big things around this is the word confusion. Oh, they're very confused. Yeah. I've seen that on the face of clients. Literally, you know, you think we're just getting somewhere and then there is literally a look of utter confusion that goes on. Well, they're very confused emotionally. And they're terrified of their mother dying, going crazy or abandoning them. So they have to go to all the extreme measures they can to keep their mother alive so they might get some love. And that's what they do with the therapist. Yeah. Now, yeah, I've given you what I think is the sort of way of working with them, what to look out for. Can they actually get there and maintain stable emotional relationship? Yes, I think they can to an extent. But it'll take a lot of practice. Yeah, yeah. And I would also teach the partner about how to do educative therapy with the partner and what to look out for as well. Yeah. So I'd probably, as we work through the whole of therapy issues with the client who's come in, if they've got themselves into a relationship in the way we're talking about, I'd probably ask the, I'll probably do some couples therapy actually, so in order to help the partner have some sort of education around this. Yeah. Which again, you know, would make sense, particularly couples because then they're involved in the conversation and involved in the process and it's an open book that there's nothing covert going on that's going to catch them out or anything. So challenging clients in terms of the counter-transference particularly, in terms of how the therapist might react to the challenges and the traps and the out of awareness manipulation. Yeah. So lots of supervision will be needed and probably a lot of therapy might be needed in terms of the therapist as well. And this is long-term work, two, three, four years minimum. Yeah. And I think it is, as I said, they may get their goals met to a certain extent, but they'll need to do a lot for therapy we just talked about. And I also think include the partner in the process as well towards the end. Yeah. Yeah, because they're going to be the ones that witness the change in behaviour, they're going to see. And when we make a change, whether that's through therapy or some other way, we need to kind of keep our hands on the steering wheel for a while until that becomes we form a new habit. And if we're stressed and overwhelmed or something happens, we can kind of revert back to the scripty stuff that we've always done. So this client might go at some point, two, four, six years down the line, but they might need to come back at different times because, but if you're that constant object, if you're that secure person that they can come back to if and when, then that's going to be a benefit to them as well. Well, it's interesting if you just think about it with this particular part that you have a morbid fear, a morbid fear of abandonment. So endings and the ones that are the ends is really, really important. Yeah. Talk about well before the ending happens. Yeah. Like six months before, three months before. Yeah. All the way down line. Yeah. End in a healthy way because they've never had endings in a healthy way. Yeah. They haven't. This is all about helping the client separate, being an individual, being powerful, taking ownership of their own thoughts, feelings, destiny, and at the same time being able to maintain a relationship. Yeah. Yeah. That I can be individual and together in a relationship with you, which for me, I think that's where that confusion comes in. How does that work? I don't know how to do that. No. How to be independent and in a relationship. That's right. Yeah. They certainly weren't allowed to experiment or grow up and resolve that dilemma. Yeah. It's very interesting. Yeah. And I'll say I think the biggest tip I can give to therapists is lots of supervision and lots of therapy and say that it's his long-term work and also can be very rewarding and satisfying. Yeah. Yeah. And for me, I think one of the things that I would say as a people pleaser, that's part of my history is to maybe be on high alert that you don't get drawn into that vulnerable, helpless part of them and step into that enactment. That's right because if you start rewarding that type of behavior, yeah, actually therapy won't happen. Yeah. No. No. You'll get is what you've just said there is at its best an enactment of the historical drama. Yeah. Which is why as a therapist, it is so vitally important that we are self-aware, that we know we know who we are in that room as well and the transplants and the counter transplants and all that stuff is all running in the background. Yeah. And then usually come to therapy with relationship issues. Yeah. That's usually and of course that's a general term for a lot of people coming. Yes. Yeah. When you start assessing though, this was in the other podcast, if you see big, very quick movements in the ego states or you see a shift in one part of their person out of the other and they talk about many of the things we talked about in the last podcast. Think first about whether you can work with them and even if you do take them on and even if you do take them on, don't go too far into the therapy if you think that you aren't able to work with this type of person. Far better to refer them on right at the beginning to some place more experience of work with this type of separation, individuation issue than stay in it when it becomes more and more hard as the terror intensifies for the client of you leaving. Yeah. Because if that happens, they will escalate their destructive behaviors and usually in a usually both of you then in a very challenging position. So are we going to do histrionic next time, Bob? We keep saying this. We will get one and two. We will get the histrionic. I think what we haven't got to either is the antisocial person either. Right. So we do need to move up to the antisocial and the histrionic and also yeah, we must do that next time. Okay, I will hold you to that. So I shall see you next week. You would do. Thank you. Bye bye. Bye. You've been listening to The Therapy Show behind closed doors podcast. We hope you enjoyed the show. Don't forget to subscribe and leave us a review. We'll be back next week with another episode.