Awakening the Rescuer
The risks of working with BPD for the therapist are many and varied. The natural propensity of those in the helping professions to slip into rescuer mode is especially heightened when working with BPD individuals. Boundary-setting is imperative. The great Kleinian analyst Otto Kernberg, for example, sets boundaries through establishing contracts with these clients, so that when the contracts are violated, the therapist has a neutral place from which to operate. The split in the rescuer is aroused, and the ability to tolerate being disliked or hated is severely tested.
My experiences working as a psychoanalytically trained clinician at a methadone clinic threw into bold relief the absence in my awareness of the social stratification inherent in the mental health system. Trained to practice analytically-informed talk therapy with educated clients, I was suddenly confronted with patients—this was a medical facility—on an almost industrial scale. I certainly hard to operate in an industrial model: top-down authority; 30-minute sessions; screening tools and paperwork; crisis management; case management; and coordination of care that was not just medical and social, but legal in nature, as well.
Additionally, I was cast in the role of gatekeeper to the methadone, which created an intense power differential with these patients—whose very problems stemmed, in large part, from institutionalized power differentials, often several generations in the making. This left very little time to connect with my patients in a way that would be truly generative and healing. It was triage. Like many who do “agency” work, I found myself saving the “mundane” parts of the job for post-session time. That meant that I was connecting to my patients but having to stay hours afterwards in order to catch up on paperwork. In my own way, I became “addicted” to the high-stakes intensity of working with such a desperate and imperiled population of patients.
Coming as I do from an intensively self-psychological and attachment-oriented background, I have learned that the theoretical framework in which I was trained for a full decade has very much become who I am as a practitioner. What you “do” in terms of actively working patients can start to become invisible to you. After a certain number of years in this profession, you begin, as Kohutian psychoanalyst Louisa Livingston once said in a training analysis, to “recognize this stuff” (Livingstone, 2006). “This stuff” refers to patterns of dysfunction, probable behaviors that can be extrapolated from these patterns. The stuff also refers to the probable familial structures from which these patterns emerged and continue to persist into adulthood. It refers to the likely emotional responses to the behaviors and interactions generated by these dysfunctional patterns that perpetuate the cycle. All of this stuff constitutes the “presenting problem.” Like forensic reconstruction, there are a limited number of factors on each spectrum that will lead to a limited number of intersections in global spheres of functioning. Any psychoanalytic or psychodynamic theory will engage with an array of these possible intersections.
