space for voice in borderline.pdf

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Relational treatment of a borderline analysandCarolynn 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

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ORIGINAL ARTICLE

Relational treatment of a borderline analysand

CAROLYNN HILLMAN

AbstractThis paper, in case material, examines the role of the analyst is co-creating the sado-masochistic enactments so common inthe transference/countertransference with borderline analysands. Emphasis is placed on how to resolve the enactments sothat 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 theblocks.

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. Deloreshad 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 blamedherself, 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 insight-

ful 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:

[email protected]

International Forum of Psychoanalysis. 2006; 15: 178182

(Received 18 July 2005; accepted 20 December 2005)

ISSN 0803-706X print/ISSN 1651-2324 online # 2006 Taylor & Francis

DOI: 10.1080/08037060600627461


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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 consultedme, 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 diffi-

culty getting along with people, feelings of lone-

liness, 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 inher 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 butwonderful 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. 160161) points out:

For analysands whose past efforts at relatedness have beenseverely dashed, warmth, nurturance, and connection can be afrightening, highly conflictual prospect. . .. It is often not the

experience of empathic failure but the experience of empathicsuccess that precipitates withdrawal, devaluation, and fragmen-tation. For someone who has experienced repeated failure ofmeaningful 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, belittlingwhatever 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 thefollowing 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, sting-

ing 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 relationshipwith 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-

Relational treatment of a borderline analysand 179


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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, tryingto 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 treat-

ment. 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. Irecognized 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 realiza-

tion was not enough. We were stuck in a sado-

masochistic 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 vi-

tiated, inadequate, controlled, powerless and threa-

tened 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

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 thegood one. As I remained caught up in this sado-

masochistic 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 anattacking or provocative manner and the analyst is continuallyresponding with unconditional positive regard, the analysandmust come to question the analysts authenticity. And if theanalysand cannot be assured of the therapists genuineness howcan that same analysand trust that the analysts concern andcaring is any more genuine (p. 582).

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 bemore 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

180 C. Hillman


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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, whileat the same time saying that vacations were impor-

tant 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, aban-donment, loss of control, and emotional annihilation

that drove her to push away. She became increas-

ingly 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 com-

plained 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 pullinsights 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 vulner-

ability and caring to show without immediately

retreating to the offensive. Instead she began to

increasingly recognize and explore her fear of relat-

edness 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 beingsocially 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 resent-

ful and much more cooperative and was recently

rewarded with a good evaluation and a raise. Nowa-

days, 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 sheis feeling and why she is feeling it.

In looking back at our first session, I can now

recognize how I contributed, from the very begin-

ning, 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, reactingno 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 inevi-

table 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 our-

selves 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

Relational treatment of a borderline analysand 181


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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 youmatter 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.

References

Epstein, L. (1979). The therapeutic use of countertransference

data with borderline analysands. Contemporary Psychoanaly-

sis, 15, 248

274.Mitchell, S. (1988). Relational Concepts in Psychoanalysis. Cam-

bridge, MA: Harvard University Press.

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, 574591.

Stern, D.N., Sander, L., Nahum, J., et al. (1998). Non-inter-

pretive mechanisms in psychoanalytictherapy: the some-

thing more than interpretation. International Journal of

Psycho-Analysis, 79, 903921.

Winnicott, D. W. (1949) Hale in the Countertransference. Int J.

Psychoanalysis 30, 6975.

Wolstein, B. (1994). The evolving newness of interpersonal

psychoanalysis from the vantage point of immediate

experience.Contemporary Psychoanalysis, 30, 473498.

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 Psychoana-

lytic Studies (CCAPS). In addition she is a sextherapist and the author of Recovery of Your Self-

Esteem and Love Your Looks.

182 C. Hillman

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