Tuesday, June 04, 2013

Richard Schwartz - Depathologizing the Borderline Client (Internal Family Systems Therapy)

Here is a new article from Richard Schwartz, founder of Internal Family Systems Therapy, published in the May/June 2013 issue of Psychotherapy Networker. In this article he addresses the issue of the "borderline" client in the psychotherapeutic relationship through the use of his Internal Family Systems model.

Specifically, he looks at we can get triggered as therapists by a client (with Borderline Personality Disorder) who often equals parts highly defended, lacking any appropriate boundaries, solicitous, and self-destructive. It's important for therapists to be self-aware with these clients, paying attention to our own parts and how they react with this kind of client.

Originally, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum of issues, describing an intermediate level of personality organization [N-2] between neurosis and psychosis.[124] The diagnosis is often identified by a need for intimacy, and a fear of rejection - "I hate you! Don't leave me!"

There is a growing demand for the elimination of the BPD diagnosis. Many people who work with trauma survivors prefer the term Complex Post-Traumatic Stress Disorder.

Image: Courtney Love is the poster-child for BPD in the media.

Depathologizing the Borderline Client

Published in 2013 May/June
By Richard Schwartz, Ph.D.

I've specialized in treating survivors of severe sexual abuse for many years, which means that many of my clients fit the diagnostic profile of borderline personality disorder. Therapists typically dread these clients since they can be among their most difficult, unpredictable, and unnerving. My clients have often been highly suicidal—some threatening suicide to manipulate me, and others making serious attempts to kill themselves. Many have been prone to self-harm, cutting their arms or torsos and showing me the raw, open wounds. I’ve known them to binge on alcohol to the point of ruining their health, to drive under the influence, and to show up drunk for sessions. Sometimes they’ve acted out by stealing and getting caught or exploding into such rage in traffic or on the street that lives were actually in danger.

At times, they’ve formed a childlike dependence on me, wanting—and sometimes demanding—not only my continual personal reassurance, but also my help in making even small decisions, like whether to get a driver’s license. Some have had tantrums when I’ve left town. Others have wanted regular contact between sessions and asked to know in detail how I felt about them and what my personal life was like. They’ve continually tried to stretch my boundaries by demanding special treatment—such as free sessions and extra time on the phone to talk about every detail of their lives—or violating my privacy by finding out where I live and dropping by unannounced. When I’ve set limits on my availability by telling them when or if they could call me at home, some have responded by implying or stating outright that they might cut or kill themselves.

Sometimes I’ve been idealized—“You’re the only person in the world who can help me!” Other times, I’ve been attacked with head-spinning unpredictability—“You’re the most insensitive person I’ve ever known!” During therapy, some clients have suddenly shifted into behaving as if scared young children had just taken over their bodies; others have erupted in almost murderous rage at seemingly small provocations. Repeatedly, progress in therapy has been followed by self-sabotage or a backlash against me that’s made treatment seem like a Sisyphean nightmare.

Early in my career, I’d react to such behaviors as I’d been taught: correct the client’s misperceptions about the world or about me, firmly enforce my boundaries by allowing little contact between our weekly sessions and refusing to disclose my own feelings, and make contracts for them to help them refrain from harming themselves or acting out. Not only did this rational, impeccably “professional” approach typically not work, it usually made things worse. My careful, neutral responses seemed to turbocharge client dramas, and I spent large chunks of my life preoccupied with clients who never seemed to get better.

In retrospect, I can see that despite my best intentions, I was subjecting too many of my clients to a form of therapeutic torture. By interpreting some behaviors that scared me as signs of severe pathology and others as forms of manipulation, I often made matters worse. I hardened my heart against these troubled clients, and they sensed it. They felt that I’d abandoned them emotionally, especially during crises, when they most needed a loving presence. My well-intentioned attempts to control their risky behaviors frequently convinced them that I didn’t get it, and even that I was dangerous, no different from their coercive perpetrator.

Of course, I’m not alone in having these experiences. Many therapists become detached, defensive, and directive when confronted with the extreme thoughts and behaviors of their borderline clients. It’s hard not to have these reactions when you’re responsible for protecting someone who seems out of control. Alternatively, some therapists react by trying to be even better caretakers, expanding their boundaries beyond their comfort level until they grow so overwhelmed and resentful that they end up unloading their clients onto someone else.

The Internal Family Systems Perspective

These struggles can result just as much from therapists’ reactions to their clients’ behaviors as from the clients’ intrapsychic extremes. How therapists react is largely determined by their understanding of what’s happening. The Internal Family Systems (IFS) approach, a model that I’ve developed over the past 30 years, offers an alternative to conventional ways of working with borderline clients. It can make the therapist’s task less intimidating and discouraging, and more hopeful and rewarding. From the IFS perspective, borderline personality disorder symptoms represent the emergence of different parts, or subpersonalities, of the client. These parts all carry extreme beliefs and emotions—what we call burdens—because of the terrible traumas and betrayals the client suffered as a child.

The central task of IFS therapy is to work with these parts in a way that allows the client’s undamaged core self to emerge and deep emotional healing to take place. If each part—even the most damaged and negative—is given the chance to reveal the origin of its burdens, it can show itself in its original valuable state, before it became so destructive in the client’s life.

Suppose that you were sexually molested, repeatedly, as a child by your stepfather and could never tell your mother. As an adult, you’ll probably be carrying parts of yourself stuck back in those scenes of abuse, isolation, and shame. Those parts remain young, scared, and desperate, and when they surface in your consciousness, you’re pulled back into those dreadful times. This cycle raises the same terrible memories, emotions, and sensations that you swore decades ago never to think about again. I call these parts your exiles because you try to keep them banished and locked away, deep inside. However, when not actively hurting, these parts are sensitive, trusting, playful, and imaginative, so suppressing them stifles some of your capacities for love and creativity.

Much of the time, these exiles remain hidden. They’re kept buried by protective parts, which use various strategies to prevent you from experiencing them. One strategy is to prevent the exiles from being triggered in the first place. These protectors organize your life so you avoid anyone who reminds you of the stepfather and remain at a safe distance from people in general. They constantly scold you, forcing you to strive for perfection to keep you from being criticized or rejected—which would bring up the feelings of shame, fear, and worthlessness carried by the exiles. Despite these protective efforts, however, not only does the world still manage to trigger your exiles, but the exiles themselves want to break out of their inner jail so that you’ll deal with them. Their breakout strategy comes in the form of flashbacks, nightmares, panic attacks, or less overwhelming but still intense and pervasive feelings of anxiety, shame, or desperation.

To escape the bad feelings generated by the exile states, other parts of you develop an arsenal of distracting activities, to be used as needed. You feel the urge to get drunk, or you abruptly go numb and find yourself feeling confused and flat. If those efforts don’t work, you may be both comforted and terrified by thoughts of suicide. If you qualify for the borderline personality disorder diagnosis, it’s likely that you also have two sets of protective parts that specialize in handling relationships: the recruiters and the distrusters.

Suppose your mind were a house with lots of children and no parents. The younger children are badly hurt and needy, and the older ones, overwhelmed with the task of caring for them, have locked them in the basement. Some of these older ones desperately want to find a grown-up to take care of these basement orphans. These are the recruiters. They search for likely prospects—therapists, spouses, acquaintances—and make use of your charm to recruit those people into the role of redeemer. However, these recruiter parts share with your exiles a sense that you’re basically worthless, that as soon as people see how vile you are, they’ll bolt. They believe you have to prove yourself special in some way or manipulate people so they’ll continue to play the redeemer role. The recruiters also believe that caring for your exiles is a full-time job, so they try to invade the life of whomever they target.

Among the older kids in this house of your mind is a faction that tries to protect the basement kids in a different way—by trusting no one and keeping them away from people who might falsely raise their hopes of liberation. These protectors have seen in the past what happens when the exiles attach too strongly to a potential redeemer. The exiles become infatuated with the supposed redeemer, who inevitably lets them down by never helping enough, or even by becoming repulsed by their neediness. The protectors have seen how the redeemer’s distaste and rejection devastates the basement children, so these “big brothers” make sure you remain isolated, detached, completely engrossed in work, and emotionally unavailable. They remind you that the redeemers flee because you’re truly repulsive—and that if others are allowed to get close enough to see you as you really are, they’ll be disgusted, too.

Whenever your recruiters override the distrusters and succeed in getting you close to someone, these distrusting protectors watch that person’s every move for signs that the person is false and dangerous. They scan everything about your therapist, for instance—from his taste in clothes and office furniture to perceived shifts in his mood or lengths of his vacation. They then use these imperfections as evidence that he doesn’t really care or is incompetent, especially if he ever does anything that reminds you of your perpetrator. If your therapist uses a similar phrase or wears a similar shirt, he becomes your stepfather. So your therapist innocently enters the house of your mind and quickly finds himself caught in the crossfire between these sets of protectors: one set will do almost anything to get him to stay, and the other set will do almost anything to get him kicked out. If the therapist lasts long enough, he’ll be subjected to the suffocating needs of your basement children and exposed to the disturbing methods the older children use to keep them contained. A therapist unprepared for this inner war or untrained in approaching these various internal factions will become embroiled in endless battles.

An Early Wake-Up Call

Early in my career, before developing IFS, I began seeing Pamela, an obese, 35-year-old office manager who came to the mental health center where I worked complaining of depression and compulsive eating. In our first session, she said she thought her dark moods might be related to having been sexually abused by a babysitter when she was 10 years old, but that she also felt alone in life and stuck in a job she hated. She liked that I was young and seemed kind, and wondered if she could come in twice a week. I, in turn, looked forward to working with her, appreciating how eager and articulate she was compared with the sullen adolescents who made up much of my caseload. For a number of sessions, I coached her as she debated leaving her job and developed an eating plan. I felt confident that her trust in me was growing, and I was enjoying the work, which seemed to be progressing nicely.

Then came the session when she began talking about the abuse. She became frightened and weepy and didn’t want to leave my office at the end of the hour. I extended the session until she seemed to recover and could leave. I was bewildered by this shift, but understood that we’d hit on an emotional subject.

In her next session, Pamela was apologetic and worried that I wouldn’t work with her anymore. I reassured her that I thought the last session had been the beginning of something important and that I was committed to helping her. She asked if she could come in three times a week, in part because she was having some suicidal thoughts. I agreed.

This pattern repeated in the following session: she began talking about the abuse, then became mute, started to cry, and seemed increasingly desperate. I tried to be empathically present, trusting my Rogerian instincts. The subsequent session began in the same way, and then someone knocked on my door. Although I ignored the knock and encouraged Pamela to continue, she erupted furiously, “How could you let that happen? What’s wrong with you?!”

I apologized for forgetting to put the in-session sign up, but she’d have none of it and bolted from the office. I tried futilely to reach her several times that week, grew increasingly panicked as she missed all her appointments, and was about to call the police when she showed up unannounced at my office, repentantly pleading for me to continue seeing her.

I did continue, but no longer with an open heart. Parts of me had felt powerless and frightened during the week she was missing, and other parts resented the way she’d treated me. I should have had the sign up, but her reaction was way over the top, I thought. I began resenting all her requests for more of my time.

I’m now certain that the work with Pamela didn’t go well in large part because she sensed this shift in me and my feelings about her. There were further suicidal episodes and escalating demands for reassurance and more time. She even began running into me on the street. I suspected she was stalking me—which made my skin crawl. Try as I might to hide it, I’m sure my exasperation and antipathy leaked out at times, making her recruiters more desperate to get me to care and her distrusters more invested in driving me away.

After about two years of working with her in this way, she died suddenly of a heart attack related to her obesity. I’m ashamed to admit that I mostly felt relief. I’d never developed any real awareness of my role in her downward spiral and had been feeling increasingly burdened by this “hopeless borderline.”

Advancing Self-Leadership

After many years of learning from clients like Pamela about their inner systems, my style of therapy has changed radically. From that experience with her, I understand why so many therapists retreat to their own inner fortresses, hiding their panic and anger behind a fa├žade of professional detachment. If you don’t have a systemic perspective on what’s going on, you’re faced with what seems like the wildly oscillating expressions of different, often contradictory, personalities.

From the IFS perspective, however, the shifts in demeanor that signal the appearance of different subpersonalities aren’t bad news. Far from necessarily being evidence of extreme pathology on the client’s part or incompetence on the therapist’s part, the emergence of these subpersonalities signals that the client feels safe enough to let them out. In IFS land, things like flashbacks, dissociation, panic attacks, resistance, and transference are the tools used by the different parts and, as such, are useful signposts indicating what needs to happen in therapy.

If therapists understand borderline personality disorder in this way, they’re more comfortable with jarring shifts, personal attacks, desperate dependence, and apparent regression, as well as controlling and coercive behaviors. Because these behaviors aren’t signs of deep pathology, they shouldn’t be taken personally. They’re part of the territory. The attacks are coming from protective parts whose job it is to make you feel bad and force you to retreat. The regression isn’t a crossing of the border into psychosis: it’s a sign of progress because the system feels safe enough to release a hurting exile. The manipulation and coercion aren’t signs of resistance or character disorder: they’re just indications of fear. The self-harm and suicidal symptoms aren’t signals of scary pathology: they’re attempts to self-soothe.

This perspective can help you remain the “I” in the storm—grounded and compassionate in the face of your clients’ extremes. It’s like having X-ray vision. You can see the pain that drives the protectors—which helps you avoid overreacting to them. The more accepting and understanding you are of your clients’ parts when they emerge, the less your clients will judge or attack themselves or panic when they feel out of control. The better you get at passing the protectors’ tests, the more they can relax, allowing your clients’ calm, confident, mindful self to separate from the protectors and emerge.

A hallmark of IFS is the belief that beneath the surface of their parts, all clients have an undamaged, healing self. At the beginning of therapy, most borderline clients have no awareness of this inner self, so they feel completely unmoored. In the absence of self-leadership, parts become scared, rigid, and polarized, like the older kids in the parentless house. As the therapist perseveres with his or her calm, steady, compassionate self, clients’ parts will relax, and their self will begin to emerge spontaneously. At that point, clients will start to feel different, as if the stormy waves of life are more navigable.

Internal Family Systems in Action

I recently began work with a 42-year-old client named Colette, who’d been in and out of several treatment centers for an unresolved eating disorder and diagnosed by the last two centers with borderline personality disorder. Like so many borderline clients, she’d been sexually abused as a child—in her case, by a neighbor. However, her previous treatments had focused mainly on getting her to examine and correct her irrational cognitions around the eating disorder.

She told me she’d heard that I was good at helping people with their traumas. I said I could help her with the parts of her that had been hurt and were stuck in the past. I added that we wouldn’t visit those parts until we’d gotten to know them and received their permission to approach those emotions and memories. In subsequent sessions, I helped Colette talk to and reassure several different protectors, including her eating disorder, so they wouldn’t be afraid of our contacting her exiles.

Once she got tentative permission to proceed, I encouraged her to focus on the memory of the abuse. She saw herself as a curious 5-year-old girl who’d been lured to the neighbor’s house to play with his pet bunnies. Colette became able to witness the ensuing abuse scene with compassion for her younger self. In her mind’s eye, she could then enter the scene and bring the girl to safety. Her protectors were relieved to see that this part was no longer so vulnerable and said they were considering taking on new roles. As Colette left that session, she said she felt hopeful for the first time in a while. I was moved by the intensity of the work and grateful for the privilege of being allowed to share in her journey.

In the next session, however, Colette was distant and shut down. She said she had no memory of what we’d done in the previous session and that continuing to work with me wasn’t a good idea. She added that she’d come in just to say that this would be our last session. There was no talking her out of it.

Despite knowing better, there are still young parts of me that get disappointed by such sudden downturns and others that feel pouty when I work hard to help someone who doesn’t appreciate it. So at that point, one of my own protectors took over, and I said with cool, clinical detachment that I was really sorry to hear this news, but if she was certain, I’d be happy to give her referrals. As we chatted a little longer, I had a chance to notice the reactive part of my own personality that had been triggered. I reminded it through inner dialogue that it didn’t have to take over. I know you think she’s ungrateful, I told my reactive part, but it’s really just her own protective parts that are scared. Just relax a bit. Let me handle this and I’ll talk to you after the session.

As my protective part receded, I sensed returning feelings of empathy and care for Colette and gained a clearer perspective on why she was being so distant. I interrupted our conversation and said, “I owe you an apology. Your wanting to stop surprised and disappointed me. I’ve been feeling really good about the work we’ve been doing and want to keep going. I get that our last session upset some parts of you that maybe we need to hear from, and I’m totally open to that.”

Colette thanked me for my time and said she appreciated my honesty, but she still wanted to stop. Then, during the week, she called to ask if we could meet again. At that next session, she said that my telling her that I wanted to keep going had meant a lot to her and she’d already negotiated with the part that had fired me to give me another chance. I told her I was glad for the second chance, but that I wasn’t sure what I’d done to be fired in the first place. She said she wasn’t sure either, so I told her to focus on the part that had pink-slipped me and ask it why. When she did, she said the part refused to answer and started swearing at her instead. I had her ask the part if it was willing to talk to me directly. The answer was yes.
Dick Schwartz: Are you there?
Colette’s Protector, in a harsh voice: Yes. What do you want?
DS: So you’re the part that fired me. Is that right?
CP: That’s right! She doesn’t need this bullshit. And you’re such an asshole!
(There’s a part of me that reacts reflexively to being called names. I had to ask this part to relax so that I could stay curious.)
DS: I appreciate your willingness to talk to me. I want to know more about why you think what we’ve been doing is bullshit or why you don’t like me.
CP: You’re no different than the last two loser therapists. You all get her hopes up and then shit on her.
(I sensed a part of me wanting to argue with her protector and convince it that I’m different, that I’m safe and won’t hurt her. I reminded it that this approach doesn’t work.)
DS: I get that you have no reason to trust me. She’s been betrayed by lots of people who told her to trust them, and she’s gotten her hopes up and been disappointed lots of times. I also get that you’re determined to keep those things from happening again, and you have a lot of power to do that. You’re the boss, and we’re not going to do anything more with her traumas without your permission.
CP: You’re an asshole! I know what you’re doing right now with this caring therapist bullshit. I see through you, asshole!
(Now a part of me was saying that this was a pointless and tiresome waste of time and it was sick of being insulted. I asked it to step back.)
DS: OK. As I said, I don’t expect you to trust me until I’ve proven myself to be trustworthy. I do appreciate that you let her continue to see me even though you have these feelings about me, and I want to check in with you frequently to see how we’re doing. Now I’d like to talk to Colette again. Are you there, Colette?
Colette: Yeah. That was weird! He’s always been so mean to me that I never realized that he’s trying to help me. While he was talking to you, I could feel his sadness.
DS: So how does that make you feel toward him?
C: I feel sorry that he has to act so tough when he’s so sad himself.
DS: Can you let him know that? See how he reacts?
C: (after a pause) He seems softer. He’s not saying anything, and just seems sad.
As Colette listened to me talk to her protector, she got a different sense of that part. When I asked how she felt toward it afterward, it was clear that her self was more present. Her voice was calm, and she exhibited a confidence and compassion that had been missing in earlier discussions about this part.

She still felt sorry for that protector in the next session, so I had her convey her new compassion to the part through inner dialogue. Initially it reacted with the same kind of contempt for her that it had shown toward me, telling her that she was a worthless fool to trust me. But as I helped her keep her heart open to it, the part disclosed that it liked that she’d finally realized it had been trying to help her.

Later in the therapy, after Colette had unburdened many more exiles, she began with my support to make big changes in her life. She stopped bingeing and purging and left a relationship in which she’d been recreating some of the original abuse patterns. I’d become fond of her and reveled in her growth and in my ability to help her. Then one day, I got a phone message from her that gave me chills. The voice on the message was deep and menacing. “You can’t have her. She’s mine!” it said, and then hung up.

I called back and got no response. Suddenly I felt a knot of panic in my belly similar to the one I’d felt with Pamela. Here was a client who might be in danger, and I couldn’t reach her. Fortunately, I had a few days to work with my distress before our next session. I asked a colleague to help me with a part of me related to a time in my early life when I felt powerless to help someone. This work turned out to be revealing and valuable.

When Colette came to the next session, she looked downtrodden and reported that she was back to square one, bingeing again and attempting to reignite the relationship she’d left. She was having suicidal thoughts for the first time in years. She remembered calling me, but couldn’t recall what she’d said. Because I’d gotten so excited by her progress, I sensed my heart drop and a familiar inner voice question whether we’d achieved anything at all in our work together. I asked this part to let me stay present. I connected to her and felt the shift toward more spaciousness that comes when my self is more embodied.

I told her to focus on the suicidal impulse and ask the part of her that feared it to step back, allowing her to simply be curious. Then she was able to ask the other part why it wanted her to die. The scary voice from the phone message replied that its job was “to take her down.” I got my own nervous parts to step back and helped her stay curious about why that part wanted to do that. It told her that she deserved to die, and it was going to make sure she did. Colette looked at me and said that it seemed like pure evil. I told her to just stay calm and curious so she could talk to it and we could see if that was true.
Colette: Why do you think I deserve to die?
Suicidal Part: You just do, and it’s my job to make sure you do.
C: What are you afraid would happen if I didn’t die?
SP: I’m not afraid of anything!
Dick Schwartz: Ask it what would be good about your death.
C: OK then, why would it be good if I died?
SP: You wouldn’t keep feeling good about yourself.
C: So you don’t want me to feel good about myself?
SP: Yes, because you’re a worthless piece of shit and a waste of space!
C: What’s so bad about me feeling good?
SP: (after a long silence) Because then you try.
C: And what’s bad about trying?
SP: You keep getting hurt.
Ultimately, the part revealed that it couldn’t stand another failure: it would rather have her dead than disappointed yet again. Colette showed the part appreciation for trying to protect her from that outcome, and we asked for its permission to heal the parts of her that had been devastated in the past by disappointment.

Fortunately, Colette’s story has a happier ending than Pamela’s. She realized that this wasn’t a suicidal part per se, but another, tougher extreme protector part that had been a major player in her life. Because of its belief that pain and suffering were her destiny and any good thing coming her way had to be false and delusory, it had limited the amount of confidence or happiness she was allowed to experience and had resorted to sabotage when it felt things were going too well. Without the unconscious constraint of this saboteur, the trajectory of healing went steadily upward.

The difference in outcomes between Pamela and Colette was related to my differing perspectives on borderline personality disorder. What helped even more was my ability to notice the parts of myself that were triggered by Colette, work with them in the moment, and then return to self-leadership. Regardless of your orientation as a therapist, this ability to monitor the openness of your heart and quickly recover from a “part attack” is especially crucial when treating borderline clients. As my experiences have shown, clients’ distrusting protectors are monitoring your heart, and they’ll test and torment you or terminate therapy the moment they sense it closing.

One of life’s great inequities is that so many people traumatized as children are reinjured throughout their lives because the original hurt has left them raw and reactive. It’s inevitable that borderline clients will, from time to time, trigger feelings of fear, resentment, and suffocation in their therapists. Your recognition of what’s happening inside you and authentic attempt to reconnect can become a turning point in the therapy. Many borderline clients have had little validation in their lives. When they’ve been in conflict with someone, they’ve typically been shamed and rejected for being too sensitive, emotional, or impulsive. As a result, they often carry the sense that they’re doomed to be alone along with a battery of unusually reactive and extreme protectors.

These clients deserve to be in relationship with someone who, after initially being triggered, can regain perspective and see behind the explosive rage, icy withdrawal, or manipulative controlling to the pain that drives those behaviors. As you become aware of the parts that try to protect you from these clients and get them to let your inner self shine through, not only will these “difficult” clients become some of your most rewarding, but your level of self-leadership and compassionate presence will increase.

~ Richard Schwartz, Ph.D., director of the Center for Self Leadership and the originator of the Internal Family Systems model, is the author of Internal Family Systems Therapy and You Are the One You've Been Waiting For: Bringing Courageous Love to Intimate Relationships.

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