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Treating Borderline: Frustration & Anger
 Borderline Personality Disorder: Treating Frustration & Anger - 10 CEUs

Manual of Articles Sections 15 - 28
Section 15
BPD: "Do I have a Right to Be Angry?"

Question 15 | Answer Booklet | Table of Contents | Borderline
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Helpless Victim Versus Guilty Perpetrator
This question represents a universal response to severe trauma and underlies the second core conflict of borderline personality disorder. Alternative ways that this question can be posed include, "was I unloved, beaten, neglected, or abandoned because my parents were hateful, or am I so evil as to be unlovable or even provoked attacks because of my bad behavior? Am I to blame or are they? Are my wants, needs, and opinions legitimate, or am I just a crazy person?" These questions are derived from an essentially different kind of conflict from that of diverging wishes, and instead are best described by metaphors of dissociative splitting of self and others into good and bad objects.

In his work with traumatized and delinquent children, Fairbairn ( 18) noted that they were unable to cognitively process traumatic experiences and needed to maintain an idealized image or fantasy of their parents as safe and loving, i.e. as a "good object." Traumatized children are prone to sacrifice their self-esteem in an attempt to maintain an unconscious fantasy of the idealized parent, i.e. the child becomes the "bad object" so as to maintain the fantasy of the parents as the "good object" ( 19). Among adults undergoing trauma, such as kidnap victims, this process of taking on excessive responsibility for the traumatic actions of one's perpetrator has been labeled Stockholm Syndrome ( 20).

In order to regain self-esteem, the negative self-image can become projected or repressed, but is nevertheless manifested by chronic dysphoria, suicidality, and self-destructiveness. Self-image and patterns of interactions become split between innocent victim versus guilty perpetrator. In the victim role the patient can appear helpless, passive and dependent, or enraged and self-righteous. In the perpetrator role, the patient is depressed, guilt-ridden, suicidal, or self-destructive.
Stage II tends to be a prolonged stage of treatment as patients repeatedly engage and disengage in traumatic relationships in an attempt to answer the question of whether they are victim or perpetrator. Self-destructive behaviors, dissociation, and suicide wishes become more clearly linked to traumatic experiences. It is easy for therapists to feel discouraged as their patients reenter traumatic relationships.

Freud was the first to observe this pattern of traumatic reenactment and labeled it the repetition compulsion ( 21). Freud also pointed out that this tendency towards traumatic reenactment plays out in the patient-therapist relationship. It is common for therapists during the first two stages to experience countertransference feelings of helplessness, guilt, hopelessness, and frustration, and to have wishes to rescue, direct, or control the patient. The most common trap for therapists is to infantilize patients by assuming they are helpless and totally incompetent and by giving excessive advice or reassurance ( 12). The therapist thereby creates a traumatic reenactment of loss of autonomy. Patients react to this approach with either an infantile regression or a passive-aggressive rebellion, e.g. sabotaging efforts to gain employment.
The following transcript illustrates how unconscious conflicts are enacted in relationships:

Janus: The person in the business office required all this I.D. before she would take my request seriously. I needed to prove to her that I was a legitimate person.
Therapist: Not really believing that you are a legitimate and competent person.
Janus: That's what I felt like. I don't think most people do see me that way. Even my friends sometimes say "God has one hand on Janus and one hand on the world."
Therapist: But you know, of course, your harshest critic?
Janus: Is moi?
Therapist: Yes, you can't believe your successes and competency either and that probably goes into why other people have a hard time taking you seriously.

Janus begins by describing a conflict with a person who is demeaning to her and then generalizes it to other relationships in her life. She is now in the helpless victim role. I provide an internalizing question to increase her awareness of the other side of her split self-image as a guilty perpetrator. The patient readily recognizes the internal conflict, stating "Is moi?"
In the following transcript, Janus starts out in the guilty perpetrator role with her sister, denigrating herself for being so jealous. She then switches into the victim role when talking about her mother and husband. She is particularly angry with her mother for favoring her sister. I make an integrating comment, attempting to bring both sides of the conflict of helpless victim versus guilty perpetrator into consciousness.

Janus: I don't know why I'm so jealous of my sister and am thinking it's really immature of me. I just need to get over this and find my place in this world regardless of my sister and all her fan club. It's just that I don't like the fact people don't acknowledge all I've gone through, but give sympathy and assistance to her. It makes me mad. At a party my mother was telling me, 'it's so awful what (my sister) went through with her husband.' And I was like, "what about what I'm going through with my husband!" And then she spoke of how my husband is on the worship team at Church and 'maybe he's changed.' I just wanted to deck her.

Therapist: It's definitely a sensitive spot, because that's exactly what you are struggling with. Is my husband just this nice earnest guy who is trying to reform? Is it just my attitude that's the problem? Do I have any right to be angry and any value in myself? And so, it's a very sore spot.
Janus: I think I'm coming to terms with it though.

Anger, guilt and self-destructive behaviors greatly diminish. Some patients describe, "finding a voice," as they become able to appropriately assert themselves to resolve day-to-day conflicts and problems. Importantly, by becoming more aware of her conflicts, Janus was finally able to successfully remove herself from the highly traumatic relationship with her husband and obtain a divorce.

An important landmark in treatment was the development of empathy. During the twin tower bombings, the patient was surprised to find tears on her face. She stated that it represented the first time she was able to cry for someone else, instead of for just herself. Even three weeks before that incident, she had stated in a session, "I feel like I exist for the first time in my life."
- Gregory, Robert; Thematic Stages of Recovery in the Treatment of Borderline Personality Disorder; American Journal of Psychotherapy, 2004, Vol. 58, Issue 3.

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about anger in the borderline client.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
According to Gregory, what is the most common trap for therapists with a borderline client? Record the letter of the correct answer the Answer Booklet.

 
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