As we come into our own immediate state of authenticity with a patient, it can feel like the safety net is gone. It’s not dissimilar to the way that we feel the first time we realize our parents are fallible. Developmentally, that is often our first inkling that there are no absolutes. It is as seismic a shift in consciousness as the first inklings of the integration of the “bad mother.” So, as I feel myself coming into this place of maturity, how can I feel grounded as I move forward professionally? I am increasingly finding myself drawn to a model of narrative-emotional therapy that I am utilizing to work with patients who have borderline organization or borderline personality disorder (BPD).
A possible model for a narrative-emotional response loop in borderline patients might take the following route: The patient experiences something (“the story”) and has to make a lightning-fast series of choices leading to the way that the story of that experience is represented to herself narratively. This is the first step in being able to respond to the story, “speak” of it, categorize it, and file it away into the “portfolio” of the self, i.e., the historical identity and emotional memory that becomes a part of the master narrative of the self).
The initial task is to process the experience and assign a category to it that is congruent with the rest of her historical identity. This requires processing, containing and rejecting all of the other possible categories and interpretations. This necessitates a default because the possibilities for conceiving of this narrative are limitless. Sorting through other possible narratives is an overwhelming task for those with a borderline organization of the self. To compensate for this, the emotional response and consequent narrative result begin to develop a shortcut. In borderline patients, this shortcut is stuck at an early developmental place of un-integration.
This might partially explain the tangential organization and the labile affect that prevails when these patients try to relate or recount a narrative experience in a linear fashion. This also helps to explain the dramatically heightened awareness these patients have of the most minute shift in our own affective mirroring of patients’ narratives. The patients’ already-fractured identities are thus reinforced by their “reading’ or “misreading” of therapist responses. It is for this reason that the therapist or counselor must maintain a steady, neutral affect while simultaneously being empathic, warm and receptive.
Too much or too little affect will both be magnified by the patient’s subjectivity and cause the patient to either sense engulfment and retreat or sense an abandonment that will activate a depressive position. These patients have not yet developed the capacity to self-regulate their emotions. An important skill in working with these patients narratively involves bringing the patient back to the main narrative thread. This aids in affect-regulation and in the navigation of default behaviors these patients employ to avoid frightening emotional states.
As they move forward with their narratives, they become better able to tolerate negative affective states—as well as perceived negative affective states in the therapist. This ability to tolerate imperfections in the therapist and to express dissatisfaction with the therapist while maintaining the therapeutic bond is a strengthening exercise that begins to have a profound effect on patients’ lives outside of the therapeutic hour. Patients begin to have a sense of themselves as the center of their own agency. This in turn creates the ability to strengthen and eventually maintain boundaries, which are always highly permeable and fragile in patients with BPD.
