Therapists Conflate Performance and Ability

 A few years ago I did a blog post (July 22 2013) about movies that purport to be about someone with borderline personality disorder, and mentioned that the two most accurate portrayals came in the movies Thirteen and Frances.

Recently I came across the clip from the latter movie which dramatically illustrates why clients with this disorder are so unpopular with therapists who don't know how to handle interactions like the one in the clip.

Frances with Jessica Lange came out in 1982. As I wrote in the previous post, it was highly fictionalized but inspired by the true story of a minor movie star named Frances Farmer who ended up in a mental hospital. In the clip, Frances cunningly makes her psychiatrist break into a cold sweat by zeroing in on his insecurities.

Check it out at the link below. Try to imagine how uncomfortable you would be if you were in the therapist's position. 

When I first treated someone with the disorder as a psychiatric trainee, my very first patient had the disorder - and it wasn't even yet in psychiatric diagnostic manual, the DSM. She had been seeing another resident, who had moved on in the residency program. She described this woman as a Goddess - except for the fact that she had abandoned the patient and stuck her with me. She spent the first two or three sessions doing nothing but insulting or attacking me - mostly for my inexperience, of course. Then she went to my supervisor to complain about me, and asked to be transferred to a different therapist. Luckily, he was one of the few therapists at the time that was on to people like her, and  told her she was stuck with me and to give me more time.

"Splitting:" the belief some therapists have that these patients see others as all good or all bad with nothing in between. There is strong evidence that this behavior is more of a strategy for eliciting certain reactions and is part of a "false self: or persona which is meant to stabilize a dysfunctional family of origin. But a lot of therapists don't seem to really understand the difference between innate ability and performance.

At the time, of course, I didn't know anything about any of that. Very few in psychiatrists in those days knew much of anything at all about family systems theory . I began wondering what on earth had made me decide to go into this line of work. But somehow I had managed to stay cool during the ordeal. The patient settled down and stayed with me weekly for the entire academic year.

I still had no real ideas about why she had been so hostile at the beginning, but at the end of treatment she made a confession that really peaked my interest in BPD. She said what she had been thinking at the time she had been attacking me - not in hindsight but at the time. She was secretly telling herself, "This guy is amazing. He's not throwing me out of the office." What she had been doing was literally all an act, and that in fact, she was secretly admiring me. Now why would anyone act like that?

https://www.google.com/search?q=lane+smith+and+jessica+lange+in+Frances&sca_esv=fbc3f32290323a31&sxsrf=ANbL-n4wub5Y-I9FiDbpMECVt3J9s_kFsw%3A1780024592766&ei=EAUZaua7LuOjqtsP5ZyPqQY&biw=1279&bih=758&ved=0ahUKEwjmg6ysxN2UAxXjkWoFHWXOI2UQ4dUDCBA&uact=5&oq=lane+smith+and+jessica+lange+in+Frances&gs_lp=Egxnd3Mtd2l6LXNlcnAiJ2xhbmUgc21pdGggYW5kIGplc3NpY2EgbGFuZ2UgaW4gRnJhbmNlczIFECEYoAEyBRAhGKABMgUQIRigATIFECEYqwJI8XxQsQdY0WFwAngBkAEAmAFioAHQCaoBAjE1uAEDyAEA-AEBmAIPoAKUCcICChAAGLADGNYEGEfCAg4QABiwAxjkAhjWBNgBAcICFxAuGLADGLgGGNgCGMgDGNoGGNwG2AEBwgIFEAAY7wXCAggQABiABBiiBMICCBAAGKIEGIkFwgIKECEYoAEYwwQYCsICBBAhGArCAggQIRigARjDBJgDAIgGAZAGD7oGBggBEAEYCZIHBDE0LjGgB8M2sgcEMTIuMbgHhAnCBwcwLjguNS4yyAc8gAgA&sclient=gws-wiz-serp#fpstate=ive&vld=cid:da6f290f,vid:X701amn7SmU,st:0

 

Self Actualization and Why It may be So Difficult

 

Walking Reflection jpg by Tomascastelazo, creative commons attribution share alike 4.0

This post will continue on from my posts (2/24, 3/19 and 4/14) summarizing how I incorporated ideas from from fields outside of mental health into my psychotherapy model, as well as how I tried to fit together seemingly contradictory theoretical aspects of several other psychotherapy schools, I discussed how families operate by rules mostly set by the prevailing culture, and  how those rules change and how families may not be able to keep up, leading members to share intrapsychic conflicts.

But how does this all manifest itself inside the brains and minds of individuals, and why they do they feel they have to sacrifice aspects of themselves in order to stabilize the family? Why can’t they just go ahead and do whatever they really want to? I mean, if we’d like to believe in free will (and I do), why do they make this choice?

The answer boils down to how the rules of interpersonal engagement are laid down in the brain during  childhood, and how individuals generally feel when they ignore the rules.

Babies come into the universe knowing absolutely nothing about how the universe works and how they can best adjust to their circumstances. They literally do not even know their own body parts can be controlled. We are programmed to learn about our universe through interactions with primary attachment figures. As children spontaneously emit various behaviors (including expressing thoughts that occur to them) that parent find acceptable, the attachment figures  do something called mirroring (first described psychoanalyst Heinz Kohut) - they validate, affirm, and reflect back to the child creating sense of value, grandiosity, and self-worth. That allows a person to build healthy self-esteem and a stable internal identity.

The rate of the creation of synaptic pathways in the brain through this process, particularly in infancy, is phenomenal (less useful pathways are later “pruned” through a process called neural plasticity).

When babies grow older, and throughout much of their lives, they continue to emit new self-generated behavior. When that behavior is grossly at odds with their self image and for which they had not received validation, the evolutionary process that created kin selection kicks in, and they get very uncomfortable. If they are actively invalidated by parents and the rest of the family system when they do or experience something, it creates a sense of existential terror that psychotherapists called groundlessness or anomie. It’s like they don’t know who they are any more. The worse that attachment figures attack ideas and behaviors that don’t jibe with the family homeostasis (as are many efforts at self-actualization), the worse a person’s terror.

People do have the ability to persist in new thought and behavior patterns despite this feeling, and if they stick to them, the feeling of groundlessness eventually dissipates. It’s also often the case that the attachment figures are themselves ambivalent about the behavior in question, but refuse to talk about this for fear of being invalidated by their own attachment figures. They then give children mixed messages about what is expected of them. How I believe children read these contradictory messages will be summarized in the last post in this series.