B&F Affect

1-25-07

copied from below, italics, etc. are mine:

“In this way the patient will experience the relationship as a place in which ideas can be played with.  In the transitional area thus created, thoughts, feelings, and ideas neither belong internally nor externally and so their power to overwhelm is lost – they are no longer either the therapist’s or the patient’s, but shared.  (Bateman/pbpd/205)”

Where in the world are they, then?  Where is this transitional area?  It’s not REAL but it is real?  This seems an “unsolvable paradox” to me.  If a person has a disorganized insecure attachment, then they cannot “experience the relationship” with anyone, and perhaps not with anything.

Today I believe that humans are not benevolent.  They/we are predators.

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Twilight Zone, here we come!

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Bateman has this in italics:

“There is a gap between the primary affective experience of the borderline patient and its symbolic representation.  This gap has to be bridged in therapy if the reflective process is to develop with a view to strengthening the secondary representational system. (Bateman/pbpd/205)”

TIME

“The core of psychological therapy with individuals with severe personality disorder (PD) is the enhancement of reflective processes.  The therapist must not only help the patient understand and label emotional states but also enable him to place them within a present context with a linking narrative to the recent and remote past.  The gap between inner experience and its representation engenders impulsivity.  The therapist needs to create a therapeutic milieu in which the experiences of the patient can be transformed from confusion to meaning, especially in terms of interpersonal understanding.  This is achieved not only by interpretations of moment-to-moment changes in the patient’s emotional stance but also by focusing the patient’s attention on the therapist’s experience.  This enables an exploration of a mind by a mind within an interpersonal context.  (Bateman/pbpd/205)”

“Interpreting a more complex psychological process, however accurate or inaccurate it may be, is likely to destabilize the patient who will become more and more uncertain and confused about himself as the contradictions and uncertainties are pointed out.  The result will be an attempt by the patient to adhere to a rigid, schematic representation of the relationship between patient and therapist….It is equally important not to focus on a patient’s conflicts and ambivalence (conscious or unconscious).  Change is generated in borderline patients by brief, specific interpretation and clear answers to questions.  (Bateman/pbpd/205)”

“The ever present danger in trying to ‘bridge the gap’ [gap between the primary affective experience of the borderline patient and its symbolic representation] is that when the therapeutic relationship intensifies through confrontation and complex interpretation, this highlights a patient’s difficulties in creating a distance between internal and external reality.  So, the therapist’s task is in some way analogous to that of the parents who first make the situation secure and then create a frame for creative play – except in this case it is thoughts and feelings that need to become accessible through the creation of such a transitional area.  In the move towards mentalization, the therapist must get used to working with its precursors, namely mind states in which internal is identical with external, ideas form no bridge between inner and outer reality, and feelings have no context. The task is the elaboration of teleological models into intentional ones, psychic equivalence into symbolic representation, and linking affects to representation.  Integrating the dissociated modes of the patient’s functioning where sometimes nothing feels real (certainly not words or ideas) and at other moments words and ideas carry unbelievable potency and destructiveness can seem an awesome task.  [I don’t think that previous sentence, the end of it anyway, makes sense] Yet progress is only conceivable if the therapist is able to become part of the patient’s pretended world, trying to make it real, while at the same time avoiding entanglement with the equation of thoughts and reality.  (Bateman/pbpd/206)”

ENTANGLEMENT – ENACTMENTS (ENMESHMENT)

“Entanglement leads to the activation of the inevitable destructiveness often found in borderline patients in relation to the therapeutic enterprise.  It is rarely adequately dealt with by confrontation or interpretation of aggressive intent.  Rather, comments are more helpfully aimed at the emotional antecedents of enactments – the emotions that cause confusion and disorganization.  The therapist has to remain calm under fire, whilst at the same time being able to demonstrate that words, thoughts, and discussion are eminently more expressive than behaviour.  In order to do this, the therapist may have to show something of himself [sic] at certain moments, for example through humour or irreverence.  (Bateman/pbpd/206)”

“In this way the patient will experience the relationship as a place in which ideas can be played with.  In the transitional area thus created, thoughts, feelings, and ideas neither belong internally nor externally and so their power to overwhelm is lost – they are no longer either the therapist’s or the patient’s, but shared.  (Bateman/pbpd/205)”

This is really interesting, but I don’t quite get it yet.  They keep using the word “play.”  It seems that these thoughts, feelings, ideas, intentions, etc. that we have – even from the beginning with our mothers, are not supposed to be SERIOUS!  They are supposed to be PLAYED WITH.  It makes me think of the nervous system development, opiod centerst, and how everything is supposed to be formed for us through some version of excitement, anticipation, joy and enjoyment – an always with healthy feelings of pride and a sense of accomplishment  in ourselves and in our abilities, even from being tiny people – filling those opiod centers of the brain and forming our nervous system so that joy is what excites us, and the rest is calm.

And that ruptures are supposed to be repaired.

Not over excited, but stimulated and challenged when we were infants, and as we continue to develop over the lifespan.  That these things, as per above, do not belong to us!!  I want to understand!

TRANSTIONS – TRANSITIONAL AREA

“Failure in the transitional area in borderline patients receives some support from attachment theory which has stressed the common characteristic, shared by the ambivalently attached/pre-occupied [makes me think of mother keeping her eye on me in the rear view mirror!] and borderline groups, ‘to check for proximity, signalling [sic] to establish contact by pleading or other calls for attention or help, and clinging behaviours’ (Gunderson 1996).  All these phenomena imply a difficulty in maintaining a stable representation of the other and the need to use the therapist as a transitional object, an extension of the patient who lacks separate identity and feelings (Modell 1963).  The importance (Bateman/ pbpd/206) [italics mine] of transitional relatedness in these patients is also demonstrated by striking histories of using transitional objects (Morris et al. 1986) as well as bringing such objects to hospital more frequently than patients with other psychiatric disorders (Cardasis et al. 1997).  Bateman/ pbpd/207)”

transitional relatedness – transitional area or space – transitions between states – transitional object because the “patient” uses these objects or people because as an extension of themselves because they lack “separate identity and feelings.”

Is it also like Ernie’s huge house, as an extension of himself as powerful and WORTHY, and his women as extension of his virility?  We are extensions of his “self” –

I still need to look at that brain research on how the brain processes information on people vs. objects!

That we have not “identified and felt” ALL of our self!

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transference – he italicizes this:

“With borderline patients, transference is not used in the clinical situation as a simple repetition of the past or as a displacement and should not be interpreted in this way.  Transference is experienced as real, accurate, and current by the borderline patient and needs to be accepted by the treatment team in that way.  (Bateman/ pbpd/207)”

“Interpretation in a direct manner simply makes the borderline patient feel that whatever is happening in therapy is unreal.  This leads to a dissociative experience and a sense that their own experience is invalid.  If such transference interpretations are made, the patient is immediately thrown into a pretend mode and gradually patient and therapist may elaborate a world, which however detailed and complex, has little experiential contact with reality.  Alternatively, the patient either angrily and contemptuously drops our of therapy feeling that their problems have not been understood, or mentally withdraws from treatment, or establishes a false treatment which looks like therapy but is in fact two individuals talking to themselves.  (Bateman/ pbpd/208)”

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two individuals talking to themselves:  this is not mentalizing!  I feel this way all of the time!

Maybe it’s like two cars being able to park in the same parking spot!!  It must be able to happen because mentalizing is not “real” and it is evidently not “pretend,” either.  It has something to do with that “feeling felt.”  It is some kind of resonance that is NOT merging – but has to happen in infancy and childhood when the caregivers are REAL PEOPLE and the children are, too.  Otherwise, no-body is talking to no-body!

two individuals talking to themselves — false treatment:  That IS a lonely feeling – and I know it.

Is that why Ernie and I can talk with one another – not to one another as both of us probably do the rest of the time – because we both suffer from the same disability!!  We both talk to ourselves – we both are extensions of the other – our centers are in each other through extension!  We are each only able to see our self reflected in the other – as transitional objects?!?!  This is all getting very strange!

So what if we cannot love ourselves because we were so hated and maltreated, traumatized and abused that we cannot find our goodness?  Then we must use projective identification and externalize this part of our self, also?  Do we find our transitional objects to carry and represent that part of us?  That person would REPRESENT us!  Be our representative at some “congress of nations.”  “I will love in you what I cannot love inside myself – or about myself.”  I actually put the LOVE I have out there.

But on some level, does everyone do this?  I guess not the securely attached.  They can actually love someone separate from them with love that is centered within themselves.  Like “talking to themselves” it can change into “loving to themselves.”  Two people with the same disability, doing this dance with each other – like Ernie and I!!  No wonder we feel so “connected.”  (Well, speaking for myself, but the connection is there.)  He loves himself in me and I love myself in him!  Only he has to do it in multiples!

How strange.  How sad!

Twilight Zone, here we come!

So it IS true that we can do this with other than only the hated parts of ourselves!!  We can put the goodness out there, too!!  OUR goodness, not just our badness!  Do these experts talk about this???

No wonder we don’t want to let go of these “dysfunctional” relationships.  We would lose sight of all that is good and loved and lovable in ourselves!

And it’s not about “boundaries” in any of the way I’ve seen the concept applied.  It is not about a boundary issue or violation between Ernie and me.  Neither of us has an intact, whole self because we were too damaged and to hurt to get one in the first place.  We lack “separate identity and feelings.” This is NOT something we have a choice about, nor is it something that has been made clear to any of us.  We have inadequate boundaries BECAUSE we DO NOT HAVE THEM nor have we EVER had them.  For me, it has been this way from the moment I was born.  I remained UNFORMED and truly unborn and uniformed of this fact! For some, those others with less severe forms of insecure attachment, they were partially formed.  They are like the man was in the fairy tale movie, The Princess Bride, “mostly dead.”  Or varying degrees of the same….

And it isn’t that I have to in any way take away the love I have placed in Ernie.  I just have to “bridge the gap” somehow so that I can stand in that circle of light and love with him, and feel all that within MY SELF!  But HOW?

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When I read that an expert says something that I resonate with, even something simple like “talking to themselves,” I feel felt.  I know that I know what he is saying, and I know he knows that I know what he is saying.  He just doesn’t know the second part:  I know that I know.  I THINK that part of it is within me only.

I can even feel the feeling of what it is like to feel felt.  And like the other day with Ernie when he was leaving the hospital, and I said, “I imagine you are crabby and restless as hell,” and he responded, “God!  Yes!”  And I knew for that split second what “feeling felt” and giving that “feeling felt” feeling to someone else meant and felt like.

And to think that people with secure attachment histories can do that all the time, and never even notice.  What a glorious gift they have to cherish and value!  They have the human birth right, and the rest of us don’t.

I know that you know that I know that you know…

Mirrors reflecting mirrors – the Mobius strip – the infinity sign.

And I suspect that what blocks this, on some deep and fundamental brain and nervous system level, is threat, not safe:  terror and/or despair.

“…reference to different perspectives and internal influences that may be driving them should be simple and to the point.  There is no place for complex statements implying a veridical [truthful, voracious; genuine – word related in roots to diction] truth as seen by the therapist.  Both patient and therapist have to start from a position of ‘not knowing’ but trying to understand. [How nicely put!!)   (Bateman/pbpd/208)”

“The therapist has not focused on the destructive component in relation to the therapeutic enterprise by confrontation or interpretation of aggressive intent.  The patient’s actions and dismissal are best understood as self-protective and interpretation is aimed at the emotional antecedents of the enactment and the emotions that cause confusion and disorganization.  (Bateman/pbpd/209)”

++  they are looking for themes and patterns from the past that will, I would say always, reappear in the present/future

++  need for stable internal representations to be established  [Are these representations, then, like the building blocks of thoughts?  Like they call it in computer software terms, “packets” of information that we can move around and drop into place in different ways within ourselves to build our beliefs, intentions, desires, hopes, etc?  Kind of like the ‘old fashioned’ stereo systems where you had to buy the separate components.]

++  need later, through an “incremental” process that “moves from distance to near depending on the patient’s level of anxiety”, to “explore different perspectives” later in the treatment once the relationship between patient and therapist has been established (Bateman/pbpd/210) – [the relationship, then, being where the “transitional area” is that makes this safe to do?]

RETAINING MENTAL CLOSENESS

His italics:

“Retaining mental closeness is akin to the process by which the caregiver’s empathic response provides the infant with feedback on his or her emotional state to enable developmental progress.  The task of the therapist is to represent accurately the feeling state of the patient and its accompanying internal representations.  (Bateman/pbpd/210)”

“…concept of ‘mirroring’…[is] a crucial interpersonal interchange within an attachment context.  It is through this process that the child acquires a sensitivity to self-states [this is down the road from where and when it first begins!] and eventually the states of others.  This sensitivity is an essential element in the development of the representational system and is dependent on the internalization of the caregiver’s mirroring response to the infant’s distress [as well as upon the response to all the other feeling states the infant has, as well!] – the caregiver’s empathic response provides the infant with feedback on his or her emotional state, and as long as it is marked as representing the child’s mental state and is reasonably accurate, it leads to [neurobiological brain and nervous system] developmental progress.  Retaining mental closeness is akin to this process and the task of the therapist is to represent accurately the feeling state of the patient and its accompanying internal representations.  [Because I am so craving this necessary “first step” I cannot tolerate people in my life feeding me back THEIR opinions and perceptions of what THEY think of how I live or how I feel if they don’t first take the time to let me know they understand how I feel – which I don’t think they do.]  In addition, the therapist must be able to distinguish between his own experiences and those of the patient and be able to demonstrate this distinction to the patient – marking (see p. 66).  Fortunately for the therapist, the accuracy of the identification of the patient’s feeling state need only be ‘good enough’.  A slight mismatch or discrepancy between the representation of the patient’s state by the therapist and actual state of the patient may be a main driver of psychological development. A mismatch completes patients and therapists to examine their own internal states further and to find different ways of expressing them if communication is to continue.   In addition, the therapist has to be able to examine his own internal states and be able to show that they can change according to further understanding of the patient’s state.  In this respect countertransference is crucial.  (Bateman/pbpd/210)”

[STATES seems to be a word all these writers use in common – yet I’m not sure anyone defines it – perhaps Siegel does.]

“Countertransferences are generally considered as emotions that arise within the therapist as a result of the patient’s treatment of him as an object of one of the patient’s earlier relationships.  However, other countertransferences are different and akin to empathic responses, based on the analyst’s resonances with his patient rather than resulting from an evocation of earlier object relationships.  These ‘concordant’ countertransferences (Racker 1968) are extremely common in treatment of patients with PD and link with affective attunement (Stern 1985), empathy, mirroring, and a perspective that aspects of all relationships are based on emotional identifications between individuals.  The therapist ‘reads’ the patient’s behaviour and responds in a complementary manner, which is in turn ‘read’ by the patient.  One feeling state has been knowable to another and both sense that the transaction has taken place without the use of language.  In our terms this is ‘implicit’ mentalizing [unconscious or preconscious] with clear marking of the experience by the therapist, which will be met by an equally ‘implicit’ response on the part of the patient.  (Bateman/pbpd/211)”

“In order to retain a mental closeness, the therapist has to maintain a benign split within himself to allow a constant interplay between thinking and feeling,  [left and right brain] between himself and the patient, between his experience and the events the patient is talking about.  Sandler (193) used the term ‘primary identification’ for an equivalent process and regards it as similar to automatic mirroring.  Thus, if the therapist has a direct emotional reaction to a patient’s actions or behaviour, and this reaction is not one that he is being unconsciously pushed into, then this should be seen as primary identification.  If such identifications stimulate unresolved unconscious wishes within the therapist, conflict arises, which results in the mobilization of defences [sic], the formation of blind-spots within therapy, and a distancing of the therapeutic relationship.  (Bateman/pbpd/211)”

“…retaining mental closeness has its dangers and yet is necessary if therapy is to be effective.  (Bateman/pbpd/211)”

++  therapists need supervision so that they “do not become ‘entangled…..there is no doubt that borderline patients may suddenly evoke strong feelings which, if unprocessed, can lead to a mental collapse in the therapist.  (Bateman/pbpd/212)”

WORKING WITH CURRENT MENTAL STATES

Italics are authors’

“There can be little therapeutic gain from continually focusing in the past.  The focus needs to be on the present state and how it remains influenced by events of the past rather than on the past itself.  If the patient persistently returns to the past, the therapist needs to link back to the present, move therapy into the ‘here and now’, and consider the present experience.  (Bateman/pbpd/212)”

“Anger and other strong emotions about the past have to be re-oriented towards the present.  Most people bring anger and other feelings about earlier situations into their present life and in therapy it is necessary to look for the target of the feeling in the present rather than leave it hanging in the past.  (Bateman/pbpd/213)”

“In order to work closely with the current mental state it is always necessary to consider which elements of the patient are projected, which are not, and whether, at any particular time, the therapist is maintaining a mentalizing stance and able to consider their own mental state as well as that of the patients.  [sic]  (Bateman/pbpd/213)”

“…the exploration of the patient’s perspective and its discrepancy with that of others needs to be repeatedly reconsidered within many other current contexts before both patient and therapist can be confident about show feeling is whose.  Only when this aspect is clear can the therapist begin to address the dispositional aspects of the psychological process.  (Bateman/pbpd/213)”

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METAPHOR

“In working with current mental states it is essential to avoid using metaphor as the primary discourse with a patient.  Borderline patients have a poorly-developed ability to use secondary representation and limited symbolic binding of internally-experienced affects so the use of metaphor is relatively meaningless to the patient.  Rather than heightening the underlying meaning of the discourse, use of metaphor is likely to induce bewilderment and incomprehension.  (Bateman/pbpd/213)”

++  actual physical outcomes important to BPD

“Borderline patients cannot easily hold more than one idea, desire, or wish in mind at a time and have little access to alternative states.  (Bateman/pbpd/214)”