Bishop Gregory (hgr) wrote,
Bishop Gregory

borderline, some particular cases

p. 164
The suicidal patient
activates powerful countertransference reactions in the therapist. The therapist's
ability to process these reactions and use them constructively may be
the single most important factor in effective work with the suicidal borderline

p. 167
A number of signs alert the therapist to the likelihood of characterologically
based suicidality [vs. affective suicidality]. First, the presence of one of the personality disorders—especially
borderline proper, histrionic, sadomasochistic, infantile, narcissistic,
or antisocial—should raise suspicion of a strong characterological
component. Second, the finding of a severe suicidal preoccupation in disproportion
to the severity of the depression is an indicator of characterological
suicidality. Another suggestive finding is a history of preoccupation
with suicide or threats of suicide as a prominent theme throughout the patient's
life, especially when such preoccupations do not wax and wane with
episodes of affective illness. Suicidality that increases specifically in response
to interpersonal events is also suggestive of a strong characterological
component. Secondary gain from suicidality should also raise the
therapist's suspicion of a characterological source. Finally, for some patients
suicidality is such a constant theme that it has become woven into their way
of life. These patients' principal mode of relating may be as a victim to a
life-saver, and they may only be able to form friendships with those willing
to enter into such rescue relationships.

Furthermore, the borderline patient's use of
such defenses as omnipotent control and projective identification may induce
powerful feelings in the therapist or intensify already existing conflicts.
The therapist may feel hate for the patient as he projects his own
sadism and simultaneously provokes these feelings in the therapist. Hate in
the countertransference is an important complication in the treatment of
suicidal patients (Maltsberger and Buie 1974). Alternatively, the patient's
hopelessness and powerlessness may be activated in the therapist, and he
may become paralyzed into inaction. It is when such countertransference
feelings are unconscious that they are most apt to influence the therapist's
actions. It is helpful for the therapist to pay attention to his fantasies and
feeling states, particularly those that seem uncharacteristic or excessive.
Consultation with a colleague may be invaluable. Awareness of the countertransference
will aid the therapist in avoiding counterproductive enactments
and may help him to identify the self-object dyad activated in the
treatment at the moment. This knowledge will aid the therapist in formulating
his interpretive interventions around the suicidal themes.

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