by Kathi Stringer

July 19, 2002

[Revision N/A]

Special Thanks to Nicole for Inspiring Me to Write this Paper

The idea of writing this paper came up because after examining my own feelings and talking to individuals with borderline personality disorder, the issue seemed to come up frequently that their treater would threaten to ban them from the practice because of their primitive rage acted out in transference. 


Topographical Model

The material in this paper is based on the modern psychodynamic psychotherapy model embedded in object relations.


Abandonment and Rejection

The execution boundary and abandonment are one of the same in the mind of a borderline. That said, before we discuss the execution boundary, lets reflect on the borderline’s desperation to prevent separation and loss. Adler reflects the borderline wishes;

“Borderline patients talk vividly about their longings to be held and contained, and their panic about being dropped, abandoned and rejected (p.221).” 

Searles echoes Adler, “borderline personality-organization itself renders ever-present, for him, the danger of separation and loss (p.288)”

This basic intrinsic borderline pathology and its destructive power will be the theme for this paper. 


Using Transference in the Analytic Space

Since we are going to include transference in this discussion would be useful to review it’s basic fundamental significance.

Transference are feelings and attitudes from previous relationships of the past and brought into the present and directed toward the treater. Of course, transference is always a distortion but extremely useful to examine the internal structures of the borderline. Kernberg interprets transference in this way

“Transference is usually conceptualized as the transfer of love or hatred from the original object onto the therapist (p.156).”

For example a client may direct rage to the treater seen as the parental object since this rage is, in reality, rightfully at parents. Through this transference a client is able to work out this anger in the analytic space.

The analytic space is the realm where assigned roles are played out and examined to identify defenses and developmental organization of regressed individuals. 


Reassignment of Ego Strength

A frighten mistrustful borderline may attempt to devalue the therapist and reassign the treater’s ego as helpless, weak and insignificant. The unconscious dynamic that may play out is now the client is in the safe controlling role of parent, able to torment the child, aka the treater. To the borderline it gives a sense of being in a position of doing the rejecting instead of being rejected. The pseudo gain from the switch gives rise to the prominent idea that the treater cannot destroy the patient. Truly a paradox since most borderlines have infantile longings to be contained and nurtured and this exchange prevents exactly that. 


Lets talk about the Countertransference Hook

I think it is important to briefly touch on countertransference for a moment to see how it plays into the execution boundary. 

Countertransference is a term that describes a jointly created phenomenon between the treater and the client. In essence, countertransference is a reaction from the client’s transference combined with the unconscious unresolved issues of the treater. For example lets say a client brings past unresolved anger from a previous relationship and projects it onto the therapist. When this projection of anger from the client is combined with pressure, as if to force the treater to behave in line with the clients wishes, we call this projective identification, since the client is identifying with the treater to project the object (anger). Think of it as a client unconsciously pushing the hot buttons of the treater, as if the client is taking her anger out on the treater. In order for the client to take her anger out on the treater and get the desired reaction, the treater must have some sort of weakness that is identified by the client. Once identified, this becomes a countertransference hook, a hot button, which of course can hook the treater to behave in such a way as the client is projecting. One cannot project into a hollow shell. Like a small child may think, “I made mommy do what I wanted her to do.”

I think it is important to describe the countertransference hook as it relates to anger projected from the client in transference from previous relationships. Perhaps if the treater were aware of the dynamic he would be able to detach and not take the projected anger as personal. Which is difficult since the projection was custom tailored for the treater as identified by the client via his ego weaknesses. With practice and hyper diligence the treater may be able to contain the projection without retaliating. 


Projective Identification via the Hot Button

Some borderlines are so terrified of annihilation, of getting erased, of being thrown into the dark abyss that they will protect themselves by zeroing in on the countertransference hook of the treater.

Adler insightfully describes a borderlines fear;

“These patients are expert in perceiving aspects of the therapist’s personality that are problem areas for the therapist. Primitive patients probably develop this skill from their style of existence, in which every encounter with any person is so threatening that they must perceive his weaknesses in order to be prepared for the final battle for survival (p.180)”

Most borderlines seem to have a honing device that directs them to the therapist’s ego weakness. Once this weakness is identified, a borderline may push the treater’s hot buttons defined previously as a countertransference hook. Once the treater is hooked through projective identification, the client has now gained a sense of control, if and only if, the treater identifies with the projection. If the borderline is successful and the treater identifies with the projection, (anger in this case) then what we call projective counteridentification has taken place (Ogden 1982). In other words the treater now behaves characteristically similar to the internal drama of the borderline (Adler), as if an alien force has taken the treater over (Gabbard). Sometimes the projective counteridentification is so miserable for the treater that he may take this dilemma under consultation. Kernberg reminds us that,

“Under conditions of projective counteridentification the therapist may unreasonably feel unfit to treat the patient (p. 86).” 

Since the treater may feel unreasonably unfit to treat the patient, the treater may threaten the client with the execution boundary. However

In cases under supervision or by consultation, it is here where the opportunity of magic begins. The treater is now in a position to respond in a kinder way providing a new experience for the borderline to internalize. This is what we call an introject. The treater is now offering a positive introject to the borderline, and if accepted, it may be taken in and assimilated. This is referred to as introjective identification. Meaning the client has identified and accepted the new experience from the treater and is willing to take it in to be assimilated. The client is now able to see the world as a modified and newer place in which to live. 


Advantage of Acting out Anger in Transference

A therapist that prevents regressive developmental behaviors (anger) from being examined in the analytic space can fixate or prolong therapy since the dynamic that drives the pattern cannot be identified in the transference. The threat of an execution boundary for vocally expressing anger may be interpreted as the ultimate abandonment and rejection; a devastating borderline injury. The alternative as Adler so eloquently states;

“The therapist’s consistent, tactful, non-retaliatory handling of the patient’s rage allows the pathological defenses to be given up slowly and permits the patient to experience the therapist as the truly good object who can safely be intorjected (p176).” 

Gunderson also advocates the tolerance of negative transference as a basic tenet; “The therapist must be able to withstand the borderline’s verbal assaults without either retaliating or withdrawing. By this process, the patient’s hostility can be examined and understood as part of a more general pattern of relating to important others.”

The Holding Environment and Modified Introjects

The analytic space created in the therapeutic framework is what Winnicott (1965) referred to as the ‘Holding Environment.’ This provides a safe environment for the borderline to establish trust in the treater as the good object. Applegate & Bonovitz suggest that;

“it is only when a sense of safety and trust finds solid footing in a secure clinical holding environment and ego relatedness with the clinician is established that clients can begin to risk testing the clinician’s durability.”

Once testing begins, consciously or unconsciously a treater can modify the projected hostilely and rage into a softer, soother objects and offer it back to the borderline as a modified positive introject. Apparently, since it took years to form the borderline personality, it will also take collaborative work, bit-by-bit, for the borderline to re-trust, relearn, and re-identify with something better then their terrifying internal objects. Some borderlines have burning determination to go back into the past via transference to the treater and resolve the anger that was emotionally fixated from an earlier period.

With most borderline personalities, trust is a funny thing. It reminds me of a tid-bit I remember that goes like this, “If the employee gets 1000 at-a-boys, then he shall receive the promotion as company president, but one ah-shit along the way, and the process starts all over again.” It is frustrating to a treater to start over because of a countertransference reaction caught by a receptive hypersensitive borderline. Perhaps the treater may reduce the at-a-boys toward a successful conclusion of treatment if the execution boundary did not constantly raise it’s ugly head and start the trusting process all over again. 

Further exploration in some cases may reveal an unconscious narcissist longing in the treater, rooted in countertransference, to encourage dependency from the borderline. Since setting the execution boundary with regular reminders may cause a borderline to become clingier, more frantic, desperate, anxious, and distressed, then this would seem to satisfy the treaters unconscious wish for dependency. The problem is, this may hinder trust in the therapeutic alliance and of particular discern, treatment may be extended over a longer duration rising out of what a primitive personality may perceive as exclusion from the family relationship. “I am still bad and I can be cast out, and you have been lying to me all along that you really care about me. See, I knew this would happen.”


Harmful Introjects

Most borderlines worst fears stem from abandonment and rejection ideation. This terrifying pathology drives them to unconsciously compare any interpretation, facial expression or gesture as clues to impending doom. This undifferentiatedness helps explain why the execution boundary acts as a cathexis to feed borderline fear and regressive behaviors, which causes at times resentment from the treater in the form of negative introjects. Searles adds,

“Much ‘self’-destructive behavior on the patient’s part consists in his having introjected some of this most primitive, “sickest” components of the analyst’s ego-functioning and, in the acting out, venting aggression upon this introject (p.323).” 

This describes the effect a negative introject can have on a client in the form of self-destruction. The execution boundary tossed into the therapeutic arena may certainly be a countertransference reaction from the treater to punish the client. The problem is, words are powerful and especially powerful when assimilated by the client from an idealized treater. The execution boundary is so powerful, so devastating, and so frightening, that the mere suggestion of it’s essence can set back treatment for months.


A Paradox

So it seems we have a sort of paradox here. The treater perceives that setting the execution boundary will limit acting out in rage; however, this capital boundary may fixate progress, impede the development of trust and hinder the formation of a constant object. Ironically the very rage the treater intended to emotionally restrict manifests in the borderline’s developmental defects giving rise to unwanted regressive symptoms. These regressive characteristics may take the form of dependency, neediness and self-destructive behavior since aggression is turn inward on self. On aggression, Catham explains,

“They have no way to modulate this aggression because they have not achieved the cognitive prerequisites for doing so (p.197).” 

In fundamental nature, setting a capital boundary to contain rage may also regress the borderlines internal structures leading to desperation. 


Conclusion

The mere oppression of the execution boundary can manifest in the form of regressive defensives in the borderline and prolong or destroy therapy all together. The borderline may prematurely terminate therapy in anticipation of getting terminated. This should be of primary concern for treaters that wish expedient recovery for their borderline patients. I recall a saying that when like this, “Violence is the last resort of the incompetent” Execution or a creditable threat in the mind of a borderline is just as devastating


References:

Effective Psychotherapy with Borderline Patients / Waldinger & Gunderson [1989]

Countertransference and Regression / Boyer [1999]

Borderline Psychopathology and Its Treatment / Adler [1985]

The Facilitating Partnership / Applegate & Bonovitz [1995]

The Psychiatric Annals Volume 32, Number 6 [2002]

The Narcissistic and Borderline Disorders / Masterson [1981]

Psychodynamic Psychotherapy of Borderline Patients / Kernberg [1989]

Intensive Psychotherapy of the Borderline Patient / Chessick [1983]

Borderline Personality Disorder / Gunderson [1984]

Management of Countertransference with Borderline Patients / Gabbard [1994]

Treatment of Patients in the Borderline Spectrum / Meissner [1995]

Borderline Personality Disorder, A Clinical Guide / Gunderson [2001]

My Work with Borderline Patients / Searles [1990]

Countertransference Issues in Psychiatric Treatment / Gabbard [1999]

Psychodynamic Psychiatry in Clinical Practice DSM-IV Ed. / Gabbard [1994]

Treatment of the Borderline Personality / Chatham [1985] 

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Compliments of Kathi Stringer © All Rights Reserved 7/19/2002
Kathi's Mental Health Review