 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. We said at the end of the last one that we were going to do history on it, but because it's I was sure and we can do what we want. We've decided to do part one and part two of working with the borderline client. I'm Jackie and I'm one of the co-hosts of this podcast. The therapy show behind closed doors and this is the wonderful Bob Cook. So, Bob, we're doing part one and two. I wanted to say another hefty one then, but maybe that's me filtering things. We did two weeks on working with a narcissistic client and we're going to do two weeks working on the borderline client because they are quite complex. They're complex and often I was thinking about how I felt at the moment. It's very hot at the moment. I'm sitting in this office and it's hot and often I think therapists when they get embroiled in a process with a so-called inadvertent comments borderline client. They often feel very hot under the colour and this is what we can talk about. So, yeah, classically these types of clients that we're going to talk about here is called the borderline client because best way to look at this is in terms of the continuum for health where I said you put neurosis on one side, the left side of the quadrant and psychosis on the other end and in terms of adult functioning, the neurosis is they've got quite good adult functioning though they may have traits and then we go right to the other side where you've got psychosis where people are out of touch with reality and don't have much adult functioning. Now, the middle ground is where the borderline sits which we rise for borderline. In other words, they can operate fairly well sometimes in terms of reality testing and at other times they fall into maybe even fluid psychosis whether out of touch with reality which is why it's called or this condition is called the borderline process. I see this client more in connection with early emotional confusion where they've had a lot of trauma in their history rather than see it in terms of a borderline condition but they do fluctuate between neurosis and psychosis quite quickly. Yeah, so this is all linked into early early childhood stuff. Well, as is most of confusion. Yeah, as of as in a way is most of these disorders we're talking about and they all have traits and more disordered people are the more trauma they will have had but I think the so-called borderline client is highly traumatized suffering from real emotional confusion from a child which then gets enacted out as they attempt to grow up. Yeah, yeah and I wanted to say function normally in adult life but I'm not sure what functioning normally actually means in adult life because we all have certain traits that show up at certain times. Yeah, but I think there was a way of looking into and you know therapists all say well what is normal but if we use perhaps TA language to look at this a bit the PAC model then we could say another way of looking at this would be how much access a person has to their adult ego state and when I say adult ego state, I mean reality basically, you know, reality functioning and staying in the here and now. Now the more disturbed a person is or the more problems they have they're more likely to dip into the side of unreality which we might call psychosis. So when I think you say normal life I think a bit more in terms of a person's ability to access their here and here and now functioning which in TA we call adult ego state. Yeah, which again going back to the really really early podcast that we did that was one of the main criteria of you know taking on a client is that they have enough adult capacity to be in therapy. That's right and difficult to judge so if somebody rings you up or you might do an assessment even over the phone or even face to face, this disturbance might not show up so easily in the first assessment that you might do and may be triggered more by the therapeutic content that you work with. So even though you would do an assessment and if you're pretty experienced you can have a good hunch about how disturbed a person is and you still might get it wrong. Yeah, yeah, yeah. When you say a hunch do you look for a feeling when you're with a client when you're doing the first assessment? Oh we did that podcast on assessments and I think you know I've been working for quite a long time now and you do get feelings with clients but I think the feeling is really backed up by what I would call a professional hunch which is probably backed up by facts. Yeah, yeah. So if somebody came in to see you would you have an inkling quite early on that you know this person had borderline characteristics? Yeah, yes I definitely would and I think that's partly because of my level of experience. Yeah. I think mostly by my level of experience and also perhaps by the training and the literature that I will have read. So what would you be seeing with somebody that walked in the therapy room? With a borderline process? Yeah. It's an interesting one because if you look at their literature would say bipolar. Now one of the characteristics of a bipolar traits or disorder is that they shift very quickly or can shift very quickly and even in a session between two distinct parts of the self. Now usually somebody who's got bipolar traits will what is often called time travel but traveling between two parts of the ego will take perhaps a day or even a morning but a more disturbed person is they might even do that in the session. So if that's happening that might be mistaken for what is often called the borderline switch from different parts of themselves. So it's not that straightforward but what I would look for somebody who's borderline is somebody that may move very quickly between devaluing a person and admiring a person. Okay. In other words somebody might idealise people but also attack them. And would that be relevant to the therapist as well that they would switch with the therapist in a session? Oh inevitably. Yeah. I mean that's just taken as red. It's what the therapist does about that. Now in the assessment they struggle they're struggling of course not to move to a devaluing place but it'll often come out that switch they move from anger to passivity in the assessment situation. So I'd look for that. Secondly people who have that type of emotional process will have great difficulties in holding interpersonal relationships and stroke intimacy. So they will report having difficulties maintaining long-time relationships and having challenges around intimacy. Okay. That's another thing I would look for. On all levels so to within the family, within relationships, within a working environment. Someone who's got a even if a high functional borderline the answer is yes to your question. They're better off actually in the work because they can have some element of control therefore they're more able to stay in their adult eager state but in personal relationships and life they struggle. Okay. So those are some of them. If you were to look at the DSM or diagnostic category for the features of a borderline personality disorder and again remember I'm going to talk about it disorder but also at a trait level. Yeah. I've got here one of them. The first one is a fear of morbid abandonment. In other words they have a great fear of being left. So in the assessment, if you took an assessment of their history and their profile and you talk to them about relationships what would probably come out is their neediness and their fear of abandonment. In other words a fear of being left. So what they do of course is move to a place of overneediness in terms of compensation. Yeah. But they will have a great fear of abandonment which will of course go back to the early childhood but is a very familiar trait in the therapy. It will come up about time and time again that they fear people will leave them and therefore they move usually to a place of learned helplessness so the person doesn't leave them. Yes. Yeah. Which I think can show up in a therapy room regardless of a diagnosis or whether somebody's you know borderline. Sometimes the client can appear to be helpless in the therapy room looking for or the therapist to fix them or to make it better or to do something. Yeah. Yeah. Now when people come to therapy they usually come with what I call a Father Christmas experience. Yeah. So looking for the therapist. It doesn't have to have a beard but a therapist who will actually be there, that they're sort of Father Christmas and take care of them and do it all for them and etc etc. Yeah. And certainly when you're talking about passive-aggressive in another podcast of course that's often where passive-aggressive profile will come from that they have learned helplessness and you know they go from a passive position in hope that the Prince Charming will come along and work it out with them. Yeah. So the borderline does that but they don't do that wholly. In other words they will move very very quickly from this passive idealizing helpless place to a devaluing attacking part of themselves which has a fury at being childlike. At themselves or project that out. Well at themselves but they of course will project that under the therapist but it's primarily at themselves. Yeah. Yeah. The biggest trap. We'll talk about this so probably the next podcast. I know they'll cross over this slightly but the biggest biggest trap for somebody for a therapist or people in relationships basically with people who've got these early confusion issues is by attempting to help or support the helplessness position of the the kind. Yeah. That is the thing that we buy into that helplessness. Yeah that we are somehow attempt to cure what wasn't curable all those years ago. Yeah. And if we buy into that we are trapped and we enacting that early drama of childhood that they are playing out or enacting with the therapist. What the therapist needs to do and we'll talk about again in this next podcast is confront the helplessness position the borderline moves into. Which then I would imagine touches on the rage part if you're not playing the game. Yeah. So one of the in the diagnostic features that we just talked about the DSM five I think is the second or third feature they talk about the feature of the borderline client or the unstable client who will move very quickly from admiration idealization of the therapist and they'll do this in personal relationships to devaluing and attacking the therapist. Now that's very quick. See with the bipolar that won't happen quickly. That's going to much, much longer and they don't attack so much actually they go into a mania position the the past you know the bipolar position and the depressive position whereas with the borderline position it's much more around a helpless idealization admiration move into attacking and devaluing and and and what is called the borderline rage. I'm very I'm very intimidating intimidating and could be very frightening for the therapist. Not experienced that yet so far Bob. Oh right well if you do. I've had him being a bit miffed with me but I wouldn't say I've had the full on rage. Well depends how disordered or lack of functioning are but if you if you do have an experience of full blown up psychotic rage it's very can be very frightening and intimidating for the therapist and especially the younger therapists. Yeah how can you imagine? You don't know what to do. Yeah so that also gets played out in life so they will report when they come from therapy often difficulties lack of stability continuity and maintenance of personal relationships they are unable to do it in other words. What they will talk about is how they move backwards and forwards from a rage to helplessness or they are wanting to attack the the the the other person. Yeah which you get you know as a parent I would imagine we can relate that to how it is with a young child that is very black and white again it's kind of opposite sides to the same coin that admiration devaluing it's you know my dad used to say things like there's a very fine line between love and hate and it's kind of like the same thing to flick from one to the other. Well yes but however a borderline will do this very intensely yeah it'll be life and death for them yeah so the you know the temperature in the therapy room will be very high. The colour as you said. It will be a Leonard Cohen type process and what I mean by that it'll be very intense and it'll be about life and death yeah and it will feel that way there won't be any lightness so therapy sessions of people who present this way are not a therapy session that will be light in any way. Yeah which you know is the reason why a lot of us have supervision because if you're having this kind of I'm not sure whether I'm right or wrong now there's an 80-20 rule with the clients that you take on is that still a thing you know that if you were to take on a borderline or narcissistic client that you need to limit the amount in a week. Well I certainly think that you're going to take on highly disturbed clients who can at the drop of a hat and move to a psychotic position or the ways that we're just talking about you wouldn't have many of them no because they'll be very draining yeah and you know they're going to move very quickly from idolising you to attacking you yeah and when they moved to wanting to analyze you and devaluate you and it's like how do you keep professional persona on and it's not that straightforward. No no and I suppose you know going off the path a little bit in in the day and age we are in now with social media and online things you know if they're trying to take us out that potentially is is quite detrimental to us in our business. So if we talk I think she's will just talk about the borderline dilemma here I know I'll repeat it in the next podcast but I think I need to because if we're talking about features of a borderline without talking about the borderline dilemma we have a bit more problems so even though I repeated again another podcast I'm going to say it here yeah you're completely correct you need to think in terms of early developmental milestones and early development developmental trauma that gets enacted out in the therapy room and in life yeah when you're looking with this type of person so the dilemma early early dilemma for the person that we're talking about here happens very early in life between one and a half and three and one and a half and three in child developmental terms is often called the separation identification time or approximate period when obviously inevitably the child has to grow up and the toddler strikes out if you like in terms of freedom and individual being an individual they have to be an individual and grow up and they strike out no a normal healthy process the parent understands that isn't so mortally wounded and allows them to test their own autonomy in a safe way of course in terms of boundaries bring point yeah everything that goes with that and they allow them so allow the child to you know in inverted commas grow up in a safe way which is very very important psychologically of course for the toddler to grow up but you imagine a situation where the child growing up you know in that helpless place where all their needs are being met and as they start to grow and we'll get into one one year and they start to walk and etc etc and they start testing their own power and they make that leap for freedom if you want to put it that way in a safe boundary situation and then the mother feels so hurt and what they perceive as abandonment of the toddler growing up that they withdraw all love and punish the child for individuating and attempting to grow up yeah so so the child then feels abandoned worthless devalued hopeless and the only way they can get any affection and strokes is to start being helpless and being very young again and infantilized and then the mother feels that their needs are being met in that sort of way we're talking about and starts to give the child strokes and and recognition and that's the dilemma the dilemma is that the child isn't able to grow up psychologically without stepping backwards and being a child to comfort and need the mother now if you think about that and transport it to their attempt to stabilize relationships and have intimacy they're not able to do it because every time they they start to to take care of the other person or to maintain their own personal relationships or to grow up or to be an individual they feel that they can't do that they have to be taking care of the mother and being helpless regressed and needy so they are able to grow up yeah that's the dilemma that gets enacted out time and time and time for the people around them as they grow up one of the things that you know sometimes I get asked questions about when you're talking about an early child or trauma is that how to think isn't it where you can't grow up yeah yeah but it's kind of like through the child's eyes a trauma well if you being if you suddenly you attempt to you know take a step upstairs or you attempt to sort of really make some powerful step for autonomy or take risks but you get a mother that gets furious at that they may or may not hit them may verbally shout at them and saying your job is to take care of me not to actually um act out or be powerful or whatever language you want to know yeah yeah um you have to take care of me and then everything will be all right in life yeah that's pretty traumatic isn't it yeah yeah but I'm just you know people people that are listening to this they're understanding of what that trauma might be you know that that feeling of abandonment and things it's not necessarily that a parent has passed away or been in a major accident or trauma it's the emotional psychological trauma yeah so my daughter's 22 she got married last week I did the father by speech and I was talking about when I met my daughter when she first came into the world at 22 and she captured my heart and here we are 22 years later but you imagine if I never allowed her to be an individual yeah she would never have been able to function in the world in a healthy way because she'd always be taking care of me being dependent on me being regressed being she's just be always be a child wouldn't she yeah yeah yeah but I think it's important to point that out because sometimes when we talk about trauma you know people's filter or people's idea of what that trauma is you know kind of is from 0 to 10 on the sliding scale of traumatic events but from the child's point of view that is traumatic to never be able to be an individual to never be able to prioritise themselves and what they want to do without being connected to the parents in some way yeah and taking care of the yeah you know in a way that you you have when I'm saying take care of them I mean stay little stay passive not thinking for themselves yeah which is that learnt helplessness where you can't think for yourself it shuts down yeah yeah so the mother's thinking is all important yeah yeah and it's debilitating it is it's yeah they end up stuck they're completely stuck yeah they can't think for themselves because it's dangerous because they might front the parent the parent has to take the thinking the parent has to have the monopoly of truth the parent is the one that is in charge of their emotional life and the only way they can get any care or loving is to play this learned helpless child yeah which which gets the strokes and validation from the parent that's right yeah yeah because that's what it's all about a lot of the time is is the validation and the recognition and the strokes yeah yeah so that when the child attempts to think for themselves back here that we talked about in this early years attempts to have feelings the mother with doors love with doors care yeah so the child then feels abandoned and goes into terror yeah that the mother isn't around yeah and that that terror that you say it's it is terror it's a survival thing it's life and death stuff like you were saying earlier it's it's not it would be nice to have this it is it's life and death yeah so you can see with totally on toddlers that the mother walks out of the door yeah yeah a moment they get to make it terrified yeah now with a borderline that we're talking about here the mother stays outside the room until the child becomes more more more helpless and more passive and more terrified and then they come back in again and strokes them yeah so they get stroked they get recognized for being little they get recognized for not thinking they get recognized for being the slave to the mother yeah now the question is how can you have a mature relationship from that position if you're always enacting that out if you're always expecting the the other person to do the thinking for them to do the feeling for them to do to do all these things and when of course the person can't do it because they're not their mother and they wouldn't want to do it anyway then the person gets terrified of the enactment of that abandonment and goes into a rage or becomes even more helpless yeah yeah and I you know what one of the things I I would like to think that the listeners get from this you know not necessarily psychotherapists or coaches or anything but just you know the lay person is it a kind of understanding as to where this stuff all starts this is where yeah when we talk about borderline and narcissistic and all these things often we see the end result of it as as an adult and being in a relationship with somebody that's displaying these disorders or traits but when we see how and where it starts hopefully it puts a more compassionate view on things I know it's not nice if you're on the receiving end of it but again it's not that they're deliberately doing this to hurt the other person no they're continuing playing this drama out yeah other people in an attempt to one get a different outcome yeah secondly to have a sense of continuity and their own identity and how they see themselves and other people in the world yeah but of course it can never work because if they're always you know playing out this dramatic situation always projecting onto another person then they're never going to have a healthy adult functioning relationship they're going to be living in the terror of abandonment or stroke or stroke being helpless and needy as an attempt to keep the other one in the relationship yeah so the relationship is going to be very toxic it's going to be very emotive it's going to be very exhausting yeah because if you're in a relationship and someone is very uh over needy very helpless very young it doesn't um think things through but all of them as an attempt to keep you in the relationship yeah and then they then at a moment if you like or may seem like a very quick process the the person moves to being very angry and devaluing then you've got a very unstable relationship now why the person has done that by the way is that they um fear the person in the relationship going just like their mother did when they withdraw for having feelings and being individual yeah but of course if you're going to if you think about the other side of being in relationships it's like you're having a relationship with a child or a child that's very helpless one moment and then very angry the next moment yeah both are vain attempts by the client to keep the other relationship but actually does the opposite I was just going to say but ultimately it plays out the same way because to be in that relationship is going to be very difficult to stick around so the abandonment that they're doing everything to prevent is is quite possible so they will do that with the therapist yeah they will idolise a therapist they'll go to a place of being helpless they'll go to a place of not thinking it's because that's how it was and that's how they got the love of the mother but at the same time they'll be really frightened that the therapist will withdraw be taking care of the thinking and all those things and any sniff of that they will then move to attacking or they'll escalate the helplessness yeah now if you take that as a logical conclusion just take it to logical inclusion then if they're not getting what they want from the therapist which is impossible because you know the therapist is not the mother or the father and also can't repair history right so it's impossible there's nothing I could do nothing would be enough right then what will happen is that the client will either escalate even more helplessness and attempt to get what is impossible or they'll rage so what do you think the worst thing a therapist could do in that situation what when somebody is in a rage when somebody is either acting out helpless passive increased helplessness not thinking appearing like a three-year-old yeah that's one level and then they may experience more so getting very angry and waging because anything the therapist does appears like abandonment so what the worst the worst thing I was going to say to you is is when the therapist doesn't set boundaries yeah buys into that helplessness and goes to come a place what can I do to help but there's nothing they can do to help because it is of course in the first place yeah yeah and again you know the boundaries I think is is really important because once you buy into that once you're embroiled in that if you try to step out of that then that's seen as abandonment by them that's what I'm saying yeah it's always fearing abandonment yeah so the borderline is really really really stuck because when they attempt to have any individual thinking themselves any individual feeling cells having any sense of power they fear the therapist abandonment yeah so they'll do one or two things they'll increase their aggressive child life behavior or they'll move to attacking both ways they see as an attempt to keep the therapist in a relationship but of course what it does is it pushes away the therapist and the same process I'm explaining here they do in relationships which is why relationships fail yeah yeah and you know it it's very difficult or it must be very difficult to be you know in in that relationship because it's kind of like a game of chess and whatever you do they're going to perceive that as as an abandonment issue you know if somebody's coming at you you know really full of rage and everything and you respond in a neutral manner and not kind of react and respond to that is that seen as an abandonment is that seen as you not being connected with them and how they perceive that behavior yeah it's quarter to 10 a night you just watch your favorite tv program and you get your favorite tipple which would be grand bui whiskey with me sitting down and the phone goes yeah you pick up the phone and its clients from this perspective we're talking about saying can I just have a couple of minutes to talk to you but something awful has happened two minutes turns into 10 minutes 10 minutes turns into 20 minutes 20 minutes turns into half an hour how does the therapist ever go off the phone now with that type of kind almost impossible yeah because that's extreme they can say you you are just like all the others you're leaving me i might as well kill myself in fact i'll go and do it now yeah so bob would be if we're going to start talking about some situations and how we handle this and and the treatment of this we need to end this podcast and move into the next one okay a good picture of the features of how somebody with this profile would present so the next podcast yeah is more about what we do about it yeah so it's all about the idealation and the devaluing it's it's that yeah it's what we do next yeah okay okay so we'll be back soon for the next installment part two of working with the borderline client okay good see you soon 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