This article was downloaded by: [Ambedkar University] On: 11 November 2013, At: 20:56 Publisher: Routledge Informa

Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

International Forum of Psychoanalysis

Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/spsy20

Relational treatment of a borderline analysand

Carolynn Hillman Published online: 19 Feb 2007.

To cite this article: Carolynn Hillman (2006) Relational treatment of a borderline analysand, International Forum of Psychoanalysis, 15:3, 178-182, DOI: 10.1080/08037060600627461 To link to this article: http://dx.doi.org/10.1080/08037060600627461

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

International Forum of Psychoanalysis. 2006; 15: 178 182

ORIGINAL ARTICLE

Relational treatment of a borderline analysand

CAROLYNN HILLMAN

Downloaded by [Ambedkar University] at 20:56 11 November 2013

Abstract This paper, in case material, examines the role of the analyst is co-creating the sado-masochistic enactments so common in the transference/countertransference with borderline analysands. Emphasis is placed on how to resolve the enactments so that a new paradigm is created based on trust and cooperation.

Key words: relational, enactment, transference, countertransference, treatment, sadomasochism, borderline

Relational psychoanalysis considers relationships with others, not drives, as the basic stuff of mental life (Mitchell, 1988) and posits that whatever happens between analyst and analysand is uniquely co-created by both of them, by this particular analyst and this particular analysand. If the same analysand were to see a different analyst, something else would happen because it would be co-created by a different mix of personalities and personal histories (Wolstein, 1994). While the goal of the analysis is, of course, to promote the health and development of the analysand, and while the analyst brings significant knowledge and experience to this endeavor, it is a basic tenet of relational psychoanalysis that it is impossible for the analyst to stand outside the analysis and simply observe and help the analysand (Ogden, 1994). The analyst is part of what is happening and is actively contributing to what is developing. If things bog down, it is not only the analysand who is creating the problem. The analyst needs to examine her own feelings, thoughts, and experience to see what she is contributing to the blocks. This theory is easy enough to understand but not always so easy to apply, especially when dealing with aggressively demeaning borderline analysands. If a new analysand starts angrily belittling the analyst within 15 minutes of the first session when the analyst has done little more than ask a few basic questions, has the analyst really co-

created this? When, as the treatment progresses, the analysand continues to be frequently attacking and belittling and has a history of acting this way with other people and previous analysts, is it really partly something that the analyst is setting up or participating in? I would like to think not, but I am forced to say yes. Let me give you a case example. Delores is middle-aged woman whom I have been seeing in twice a week treatment for 4 years. Delores had previously been in treatment three times a week for over 20 years with another female therapist, Dr X. Delores had only stopped seeing Dr X when Dr Xs sister told Delores that Dr X had Alzheimers disease and could no longer practice. In retrospect, Delores is aware that her therapist must have been suffering from this disease for some time because Dr X had been acting irrationally (answering the door in her nightgown, insisting that Delores did not have an appointment when she did, yelling at her), but Delores had been so anxious to hold on to this relationship that she had ignored the signs or blamed herself, for instance telling herself must have been wrong about the time of the appointment, even though she knew she was not wrong. Following the traumatic loss of Dr X, Delores saw for about a year and a half a male therapist, Michael, to whom she had been referred by Dr Xs sister. Delores liked Michael and thought he was perceptive and insightful but found herself increasingly and uncontrollably

Correspondence: Carolynn Hillman, Postgraduate Center for Mental Health, 359 Maitland Ave, Teaneck, NJ 07666. Tel./Fax: 201 837-5061. E-mail: hillman7@optonline.net

(Received 18 July 2005; accepted 20 December 2005)

ISSN 0803-706X print/ISSN 1651-2324 online # 2006 Taylor & Francis DOI: 10.1080/08037060600627461

Relational treatment of a borderline analysand rageful towards him and finally left treatment because she could no longer tolerate the amount of rage she felt. She reported having romantic and sexual feelings towards Michael, but when she alluded to them with him he shied away from them and would not discuss them. Deloress presenting problems when she consulted me, besides issues around the loss of her long-time analyst and the death of her mother shortly before that, included unhappiness with her detailed and demanding office job and her noisy but affordable apartment far from where she worked, great difficulty getting along with people, feelings of loneliness, isolation, and emptiness, chronic anxiety and depression, frequent uncontrollable bouts of anger fed by feelings of envy and resentment, and a general feeling that she was and had been wasting her life. She complained that while she had some female acquaintances, no one ever called her or invited her to go out with them. Her relationships with men in her younger years had been sparse and marked by great ambivalence. For the past 15 years, she had been involved with a married man whom she saw once a week. She reported feeling highly ambivalent about this relationship. By the middle of our first session, when I had done little more than ask her a few mild questions, she started screaming at me (so loudly that I became concerned for those in the waiting room) and sarcastically belittling me, telling me how wonderful her previous analyst had been and how inferior I was. She described Dr X as a tough and critical but wonderful woman who had brought her up and taught her how to deal with the world. Delores had run all decisions, large or small, by Dr X and felt incapable of deciding things on her own. Delores reported that, each Monday session, she would be upset and agitated and that it took till the third session of each week for Dr X to get Delores grounded. However, Delores calm state did not last, and they would have to start the process all over again the following week. Delores said that Dr X had taught her how to navigate life, how to talk, act, and think, and that she felt at a loss without her. Delores angry outburst in our first session proved to be the first of many, as is common in work with borderlines (Epstein, 1979; Sherby, 1989). If my empathic attunement was even slightly off, she felt greatly wounded and enraged and screamed at me. If I hit the mark with an interpretation, she became even more enraged at me for penetrating her defenses, saying, now I really want to hurt you. As Mitchell (1988), pp. 160 161) points out:
For analysands whose past efforts at relatedness have been severely dashed, warmth, nurturance, and connection can be a frightening, highly conflictual prospect. . .. It is often not the

179

experience of empathic failure but the experience of empathic success that precipitates withdrawal, devaluation, and fragmentation. For someone who has experienced repeated failure of meaningful connection. . .hope is a very dangerous feelings.

Dolores did not like when I asked her questions, and she did not like when I didnt ask her questions. When she wasnt angry and demeaning, belittling whatever I said (So thats all you have to say?! After listening all this time thats the great thing youve come up with?!), she talked in a scattered, rambling manner, describing events in such a disorganized and disjointed way that it was difficult to follow her account and know exactly what had happened and what she was concerned about. If I asked for clarification, she would demean me (Details, details, details, you just want to know the details rather than seeing the big picture) and would continue in her rambling way. Over many months, I slowly put together the following family history. Delores was an only child until age 6 when a sister was born. Her mother was a homemaker and highly narcissistic, alternating between an undifferentiated overinvolvement, stinging criticism, and abandonment, ignoring Delores for many hours, even when Delores was very young, while her mother pursued her own interests. Mother clearly used splitting as a defense, often going from adoring someone one day to hating that person and cutting off all contact the next. Father was an attorney in a low-level law job, unable to be successful because of his difficulty dealing with people. He was largely uninvolved with Delores, and her mother discouraged any attempts on Delores part to build a relationship with him. Both parents were alcoholic. When her father drank, which was daily, he would be sarcastic and disparaging towards her mother. As Delores moved into adolescence, her parents divorced following her mothers discovery that her father was having an affair. After this, mothers alcoholism increased and she spent time hanging out at bars, flirting with men, and bringing some home. When the parents relationship dissolved, Delores sister Kay was able to forge a relationship with her father by pursuing him and entering into the vacuum left by their mothers exit. Delores, however, felt compelled to side with her mother and remained distant from both her father and her sister, whose presence she had always resented. This competition was fostered by the mother, who played the sisters against each other. Delores parents, as well as Dr X were all deceased, her father having died when she was in her twenties, her mother shortly before she stopped treatment with Dr X, and Dr X within a year of Delores having stopped treatment with her. Delores had almost no relation-

Downloaded by [Ambedkar University] at 20:56 11 November 2013

180

C. Hillman accurate, and I believe it was, my point is that because I was feeling so overwhelmed and helpless, I was unconsciously using the interpretation to assert my power by showing her how much I understood and thus demonstrating that I was in control. I was also unconsciously blaming her (for distancing), thus insinuating that she was being bad while I was the good one. As I remained caught up in this sadomasochistic enactment, I struggled to understand my own contribution to it and to find a way out. How, I asked myself, could I use what I was feeling to open up the analytic space rather than continuing to subtly close it off? Winicott (1949, p. 72) said, If the analysand seeks objective or justified hate [i.e. hate engendered by the analysands treatment of the analyst] he must be able to reach it, else he cannot feel he can reach objective love. Sherby (1989) echoes this:
If a analysand is behaving consistently and constantly in an attacking or provocative manner and the analyst is continually responding with unconditional positive regard, the analysand must come to question the analysts authenticity. And if the analysand cannot be assured of the therapists genuineness how can that same analysand trust that the analysts concern and caring is any more genuine (p. 582).

ship with her sister, who seemed to want to have nothing to do with her, a source of great regret and angst for Delores who felt very alone in the world. Neither Delores nor her sister had ever married or had children. In the face of Delores frequent attacks, I often felt hurt, angry, and unappreciated. Other times, trying to follow her disjointed recitals, I felt lost and inadequate. I tried to make myself feel better by telling myself that her first therapist could not really have been as helpful as Delores claimed given the shape Delores was in after over 20 years of treatment. I unconsciously acted out my competitive feelings towards the great Dr X by subtly, or not so subtly, attacking her. For instance, I pointed out to Delores that Dr X had given her a mixed message * be independent, feel good about yourself but youre doing everything wrong and you need to listen to me * and that this had served to increase Delores dependence on Dr X. While I believe this observation was correct and even helpful to Delores, my point is that it came from more than friendly analytic interest. As the treatment went on, despite my desire to be of help, more and more I found myself having fantasies of vindication and revenge. This was not a good sign. Despite my anger at Delores for demeaning me and treating me what I felt to be so unjustly, as a relational psychoanalyst I knew I could not just blame everything on her, despite the fact that she was very easy to blame given her blatant attacks. I struggled to find a way out of my hurt and anger. I recognized that much of what I was feeling at being at the receiving end of Delores envy and wrath mirrored what Delores herself felt (inadequate, hurt, angry, afraid, unappreciated) and that these feelings in Delores stemmed from the way her alcoholic and narcissistic parents had treated her. But this realization was not enough. We were stuck in a sadomasochistic enactment in which I either enacted the role of her passive and helpless victim or retaliated by taking on the power role, using interpretations to make myself sound smart (at least to myself) while subtly blaming Dolores. Epstein (1979, p. 261) points out that analysts working with borderline analysands often feel vitiated, inadequate, controlled, powerless and threatened The act of interpreting at such moments, then, may be an unwitting acting-out of our need to both rid ourselves of unwanted projections and to attack the analysand for what he is doing to us. An example of this is my saying to Delores, Though youre complaining about how I havent helped you, I think youre really fearful because we had a good sessions last time and now you need to create distance. While this interpretation may have been

Downloaded by [Ambedkar University] at 20:56 11 November 2013

It slowly dawned on me that by trying to act the opposite of what I was feeling, that is friendly and open instead of hurt and wary, I was subtly encouraging Delores to do the same: i.e. hide her real feelings while showing only those feelings that felt safe, which in her case were anger, resentment, and self-pity. I decided that if I wanted her to be more authentic, then I had to be more authentic myself and had to selectively share some of my experience of her without blaming her; I had to let go of the pretense of feeling only compassion and speak up for myself. Here are a few examples of how, in the weeks and months to follow, I tried to speak more authentically with her. These examples are from different sessions, and some of them I said many times. I started by talking with Delores about how, in the face of her rage and belittlement, I felt pushed away and wondered aloud if she felt like pushing me away. For quite a while, she denied any such motivation and would sarcastically tell me that I was too sensitive and was taking things too personally. She insisted she had a right to express her feelings in therapy and that screaming at me, as she had at her previous therapist, provided a much needed outlet, that Dr X had understood this, and I just needed to be able to handle it. Instead of analysing this, I replied, with a bit of an edge to my voice: You have a right to get angry, but I have a right to ask why you need to get angry right now. Other times, when she said I was not helping her (this was a recurrent

Relational treatment of a borderline analysand complaint), instead of analysing this or inquiring into how this made her feel, I said that I was helping her and pointed out ways things had improved for her. I announced a three-week vacation, which left Delores feeling deserted. I empathized with her feelings and encouraged her to express them, while at the same time saying that vacations were important to me. I believe she was as comforted by her inability to manipulate me by guilt and by my (unstated) belief that she could manage without me as much as she was by my reassurance that I would look forward to seeing her on my return. Repeatedly in sessions, she expressed frustration that I would not spar with her as Dr X had done. I said I was not going to pretend that we were enemies to hide the fact that we cared about each other. As I became more authentic, so did Delores. Slowly, with each new rage attack, she began to identify the terror of rejection, humiliation, abandonment, loss of control, and emotional annihilation that drove her to push away. She became increasingly aware of how much she feared and believed that the price that had to be paid for caring and connection was emotional subjugation and loss of autonomy and self. At the same time, her complaints about me became more accurate. For instance, she complained that I liked to sound smart by telling her what I thought (giving interpretations) rather than trying to pull the insights from her. While this was not entirely accurate as I certainly did try to pull insights from her, nonetheless she had caught me in my defenses: trying to show off how perceptive I was, or at least how perceptive I thought I was, to cover feelings of inadequacy. I responded, You know, youre right, I was sounding full of myself just now, and we laughed together in a moment of alive connection, what the Boston Change Process Study Group (Stern, Sander, Nahum et al. 1998) call a moment of meeting, and the working alliance was re-established. In short, my moving away from feeling helpless and sorry for myself and subtly attacking Delores through the use of interpretations to speaking up in a genuine way proved crucial in moving the treatment forward. As I modeled being caring and connected but also self-assertive, she came to experience that she too could allow closeness without losing her autonomy or sense of self. As I openly showed flaws and reactivity without berating myself, she became more accepting of herself warts and all. As she became increasingly able to trust that I would not destroy her, abandon her, or be destroyed by her, she slowly opened herself up and allowed her vulnerability and caring to show without immediately

181

retreating to the offensive. Instead she began to increasingly recognize and explore her fear of relatedness and to look at what underlay her rage and bitter envy. As she developed a sense of safety and trust with me, for the first time in her life Delores developed women friends, and now has moved from being socially isolated to having a busy social life. At work, whereas before despite the high quality of her work she was at risk of being fired, and indeed had been fired from previous jobs because of her explosive temper and resentful attitude, as we worked through underlying issues both in her family of origin and in our relationship she became considerably less resentful and much more cooperative and was recently rewarded with a good evaluation and a raise. Nowadays, Delores hardly yells at me and is often not belittling, though she still is so at times, but when she does is it is with less venom. Most importantly, she is able to stop and be open to looking at what she is feeling and why she is feeling it. In looking back at our first session, I can now recognize how I contributed, from the very beginning, to the enactment. Yes, true, I had only asked a few standard questions when she blew up. But when she had said she did not want to answer something (I cannot remember what, something minor), I had said, Thats okay, perhaps one day you will feel comfortable enough here to tell me. (This is a response I had been taught in analytic training and had used only rarely over the ensuing twenty-five years.). Delores responded by blowing up, reacting no doubt not only to my implying that we would create intimacy (something she longed for but greatly feared), but also to my setting the expectation that she would become an open book to me, which I now realize for her was synonymous with submitting to me and giving up all sense of autonomy. Why had I said this? Ostensibly, I was trying to set her at ease. In reality, my unconscious, responding to what it had sensed as her controlling and withholding, was saying to her: Dont think you can get away with withholding from me and controlling me. Sooner or later, youll have to give me what I want. And thus the enactment had begun. I believe that enactments like this one are inevitable with challenging analysands. We all have vulnerabilities and are capable of feeling threatened in one way or another. The challenge is not to avoid the enactment but to find a way out of it by realizing not only what underlies the analysands behavior, but also what underlies our own, and finding some authentic, non-blaming, way to speak up for ourselves in a way that furthers genuine engagement. Recently, when I was once again getting ready to go on vacation and as Delores and I were talking about

Downloaded by [Ambedkar University] at 20:56 11 November 2013

182

C. Hillman
Ogden, T. (1994). Subjects of Analysis. New Jersey, Northvale, NJ: Jason Aronson. Sherby, L.B. (1989). Love and hate in the treatment of borderline analysands. Contemporary Psychoanalysis, 25, 574 591. Stern, D.N., Sander, L., Nahum, J., et al. (1998). Non-interpretive mechanisms in psychoanalytictherapy: the something more than interpretation. International Journal of Psycho-Analysis, 79, 903 921. Winnicott, D. W. (1949) Hale in the Countertransference. Int J. Psychoanalysis 30, 69 75. Wolstein, B. (1994). The evolving newness of interpersonal psychoanalysis from the vantage point of immediate experience. Contemporary Psychoanalysis, 30, 473 498.

this upcoming separation, she began spontaneously and surprisingly speaking of ways she felt better, for instance that she has stopped standing outside herself constantly watching and harshly criticizing herself and instead is able to be present in the moment. And then she said quite simply and sincerely: For a long time I tried to deny that you matter to me. I was too afraid, and then smiled at me with warmth and connection. I was very moved. I believe that good classical analysis alone, without the relational component, could not have brought us to this moment, that it is only through authentic engagement that an analysand can experience the healing power of a relationship.

Author Hillman, Carolynn. LCSW, is a psychoanalyst in private practice in New York. She is a training analyst, senior supervisor, and faculty member at the Postgraduate Center for Mental Health and at the Contemporary Center for Advance Psychoanalytic Studies (CCAPS). In addition she is a sex therapist and the author of Recovery of Your SelfEsteem and Love Your Looks.

Downloaded by [Ambedkar University] at 20:56 11 November 2013

References
Epstein, L. (1979). The therapeutic use of countertransference data with borderline analysands. Contemporary Psychoanalysis, 15, 248 274. Mitchell, S. (1988). Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard University Press.