by Frank C. Sacco, Ph.D., CSI President, Scholar in Residence
OK, I am a bit of a psychoanalytic groupie. Dr. Gabbard is an old friend and a leader in the field of psychiatric education. He is a clinician first and a teacher drawing from a deep and rich reservoir of experience. I was struck by two points. First, he talked about creating hope and the therapy with BPD and how BPD is becoming a dirty word and an unpopular diagnosis full of prejudice. He also let me off the hook for being guilty for having counter transferences. They are a necessary part of all therapy. Once the clock starts, whether in short-term therapy, Neurofeedback and supportive therapy, or long-term treatment, counter transferences will occur almost instantly. The therapist’s job is to read him/herself when the counter transferences become recognized. It’s not whether, it is how early does the therapist recognize his/her reactions and responses to the client; countertransference is always there!
Dr. Gabbard showed us the evolution of boundary crossings when counter transferences are ignored. Being blind to countertransference creates the temptation and motivation for boundary crossing, or gradual eroding of the ethical boundaries of psychotherapy. BPD has strong dramatic pulls in all directions; therapists have to buckle their seat belts for the emotional ride. The therapist needs to empty her/his mind; allow the client to project it in; let it rip. The therapist will go from hero to goat; the projections tend to be all good or bad. Underneath is a wound in the client’s mind, a mental tenderness caused by trauma and is distracting the person’s ability to live life happily in the present. The therapist’s job is to collect, re-package, and replace old habits with new ones.
BPD use primitive defenses that are aimed to pierce the therapist’s psychological skins. Get into you. Infect your thought, judgement, and eventually your actions toward the client. Dr. Gabbard supported an approach to psychotherapy that offered BPD a psychological home, a secure mental place where the tortured mind could escape. He keeps the focus on the client and re-directs the poison vomited on him/her as a therapist into a safe container, the actual job of the mother. This becomes the foundation of how trauma begins to impact the development of the child. Infants who experiences lack of caretaking become numb to the world or become paralyzed and easily victimized.
The second big lesson involved the idea that BPD have “radar” and can read your thoughts. I have had this experience on many occasions. I would be tired and not want to be sitting in a cold city apartment on a Friday afternoon. I was sick of the tortured stories. She caught me. I denied it of course but it did scare me how she could read my mind so clearly. This is what presents the challenge in therapy. The empty mind concept is an old martial arts concept used by warriors. The point in treating BPD is that the radar can generate what the therapy is about. The empty mind allows for a discussion about the contents typically about painful affect, memories, or physical reactions. The therapist becomes the canvas and the client psychologically vomits the contents onto the therapist often piercing the canvas.