All posts for the month February, 2014

Nancy McWillilams, a prominent teaching psychoanalyst, in her book, “Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2011)”, makes the following observations:

Take the case of a person


     “with borderline personality organization contacting an emergency service with a threat of suicide. Emergency mental health workers are ordinarily trained in a generic crisis-intervention model (ask about the plan, the means, and their lethality), and that model usually serves them well. Yet people with borderline psychologies tend to talk suicide not when they want to die but when they are feeling what Masterson (1976) aptly called ‘abandonment depression.’ They need to counteract their panic and despair with a sense that someone cares about how bad they feel. Often, they learned growing up that no one pays attention to your feelings unless you are threatening mayhem. Assessment of suicidal intent only exasperates them, since the interviewer is, in terms of the patient’s not-very-conscious subjective experience, distracted by the content of their threat when they feel desperate to talk about its context.”

       “A clinician’s effort to follow standard crisis-intervention procedures without a diagnostic sensibility can be counter-therapeutic, even dangerous, because it can frustrate borderline patients to the point of feeling that to be heard, they must demonstrate rather than discuss suicidal feelings. It also leaves the therapist hating the client, since the person seems to be asking for help and then rejecting the helper’s earnest efforts to give it (Frank et al, 1952). Emergency workers trained in identifying borderline patients become adept at responding to the painful affects behind the suicidal threat rather than doing an immediate suicidal inventory; paradoxically, they probably prevent more self-destructive acts than colleagues who automatically evaluate suicidality. They may also have fewer demoralizing experiences of hating clients for ‘not cooperating’ or ‘not being helpful.’”

McWilliams’s observations and understanding of borderlines seems to match my own. After years of working with borderlines, it gives me a framework for understanding what I often get to intuitively.

A client of mine has been suicidal. She is in her mid-50s, with major depression, serious anxiety, and borderline characteristics, with some minor medical disabilities. The combination has made her unemployable, failing vocational rehabilitation, and petitioning for Social Security Disability. She has been rejected once, and while she “is running out of money to pay rent and live, she knows she may well be rejected again.” She will “not live in a shelter, debase herself to live at that street level, and might as well kill herself and get it over with…”

After being rejected by SSA the first time, she threatened suicide with a plan, means and high intent, I got County agents to take her from our rural area to a metropolitan emergency center. There it was determined that, as a Veteran, she could be triaged to a Veteran’s Administration hospital. In both places she was subjected to the crisis assessment and intervention model described above, with constant camera surveillance to counter any suicidal lethality. That was followed by a course of “evidence based cognitive-behavioral therapy, individual and group at the VA.”

The VA would never consider a psychodynamic approach, such as a psychoanalytic approach where the emphasis is on the relationship, transference/countertransference, and invocation of the abandonment depression between the therapist and client. They would not consider it because psychodynamic/psychoanalytic approaches are not ‘evidence based (the complexity of the psychoanalytic approach and its effects cannot be adequately tested in the scientific lab).

My client called me during her VA hospital stay, explaining that “no one really listens to me and connects to me like you do….they are trying this cognitive reality testing and training stuff on me, telling me I’m going to be fine, that I might have to go to a shelter, but that will be alright…my stubbornness is nonsensical and self-defeating and so on…” Classic cognitive-behavioral stuff. The truth is: all psychotherapists, myself included, utilize cognitive-behavioral (and to some extent its latest variant, Dialectical Behavioral) therapy).

Paradoxically I have tried the same techniques with her in the past and failed, only succeeding when I agree with her about the brutal truth that she has no way out of her dilemma that seems to satisfy her desire to live. She “knows I get her…even when I throw up my hands, and say I have nothing for her (except compassion).”

I believe that the cognitive-behavioral and dialectical-behavioral techniques are effective for many mental health treatment plans, but can be useless when used dispassionately, without attention to how the interaction with therapist and client is invoking the primordial relationship (from earliest childhood), with its attendant issues of trust or distrust, senses of nurturing or abandonment, and the clients experience of constant distrust and disappointment; an experience not necessarily matched by reality, but constantly present in the borderline. This causes people, therapists included, to intensively dislike borderlines to the point of hating them, but if you understand what is going on, you can get past that. It is at that point, that you reach a higher level in your abilities as a psychotherapist, and I believe the psychoanalysts have much to offer on this level!