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7° Congresso Mondiale della WCP (World Council for Psychotherapy).
Durban, South Africa, 25-29 Agosto 2014.
Title: Psychodynamic Psychotherapy for Borderline Patients: Significance of Therapeutic Alliance and Dreams of Initial Sessions.
Presenter: Michele Battuello.
Many patients present complex clinical features and symptoms that make difficult the evaluation for a psychodynamic psychotherapy.
Initial sessions are usually focused on exploring patients’ inner world, relations, history and psychopathology and the therapist tries at his best to understand what’s going wrong with that person.
No doubt that this is a good and valid clinical practice but we think that is only a partial knowledge of the patient. The therapist can decide to start a psychotherapy. basing only on dysfunctional aspects. This limits the possibility for a psychotherapy because the seriousness of symptoms and pathological dynamics is the distinctive element that allows to work with the patient or not.
So often “severe” situations are subjected to a psychiatric evaluation and to a pharmacotherapy and follow another clinical path while less severe patients can start a psychotherapy.
For what concerns complex patients in psychotherapy as borderline ones, instead of a nosographic and axial classification of mental diseases we agree with the definition of I. Ruggiero, 2012: “Patients who present an extremely variable mode of functioning in which the more neurotic aspects co-exist with areas of psychotic functioning, sometimes alternating in the same session. This is the mental functioning which characterizes those whom Donnet (1999) defines as ‘limit patients’, inasmuch as they alternate rapidly between neurotic and psychotic functioning, between recognition and negation of reality. With this type of mental functioning, which makes the constancy of the setting essential, we can expect breaks and unpredictable readjustments, which constitute what Roussillon (quoted in Donnet, 1999, p. 124), describes as ‘‘limit situations’’.
The heterogeneity of clinical aspects has made hard to evaluate and treat such complex patients as for those affected by bipolar disorder, so in clinical practice we can see many pharmacological and/or psychotherapeutic approaches, with failures in terms of recovery’s possibility.
The best outcomes are in the temporary resolution of severe and invalidating aspect of the pathology as anxious symptoms, working and social dysfunctions and suicidal behaviors. Different therapeutic approaches hardly obtain a stable resolution of pathology in long terms.
Psychotherapies focused mostly on psychoeducational, support and behavioral sides.
Just because we don’t work in groups with patients selected for pathology but we prefer an heterogeneous vision of human’s dynamics, we consider the possibility to work with “risky” patients as for all of our patients, after the two important steps of evaluation sessions and a period of individual therapy.
Just because we consider this initial phase of therapy so important, number of evaluation sessions can be variable up to 8 and more, as the patient’s answer requests. The efficacy of this method is evaluable soon.
The valid therapeutic alliance that appears as the answer to therapist’s proposition, represents the awareness of patients that we could call the “physiological” elements, the not destroyed ones, that are still present.
They can be covered by symptoms, by pathological dynamics, by severe illness, but they can be still present in traces and when patient can reach them, is an indication for beginning a P.P. and a positive predictor factor for recovery.
We think that psychotic aspects of risky patients are the ones that request the comprehension and the elaboration in individual therapy: in those patients the valid parts are still present but very fragile and covered by disruptive ones. The pathological dynamics are prevalent and the defense mechanisms activated to maintain the status quo. As everyone knows from his own clinical experience one step the therapy goes forward the next session maybe goes back.
During the first period of individual therapy is difficult to use interpretation of dreams as tool of the psychological work because risky patients can’t tolerate at all the interpretation of pathological dynamics as the presence of valid and functional parts for the tendency to disruption. It’s important at this time the role of a container of therapist with the initial distinction between what is valid and acceptable from what is not sane, pathological, to be transformed. The couple remains in the facts, in the symptoms and they are the great part of the relation: the goal is to increase the tolerance of the patient of a valid relation and the capacity to mentalize his problems.
If at this time patients could join the group there would not be the possibility of a valid work for the individual and the group as a whole: affective dynamics, elaboration dreams, recognition of functionality of elder members of the group could represent an intolerable enemy for risky patients that could try to force themselves against the group with acting out, symptoms and other activated disruptive elements.
Interpretation of dreams: C., Female, 40 y.o., precedent diagnosis of Bipolar D. and/or Borderline Personality Disorder, second evaluation’s session:
“She returns in the house were she lived since 11 to 24 years, that hates and hated. She takes a look at it and thinks that she had needed to go away to understand how beautiful it was. So she opens windows and on the terrace meets a man that tells her that is a good place and there it will be possible to organize many parties”.
the interpretation of this dream concerned what I was just talking about before: personal history and family dynamics especially with the mother were really conflictual; a mother completely non affective, a family system completely based on material and practical aspects. When during first sessions I proposed her to see what in this terrible mess was her strength, her spontaneous activity of loving her family anyway as the human potential of every baby, she had let emerge this image. It concerns also with another basic assumption of our methodology: the necessity of separation from what didn’t work as pathological dynamics, to activate the unconscious skills. These are represented as a beautiful place to share with a man and with friends.
Fifth evaluation’s session:
“In a shop there are many clothes for her very beautiful but too expensive. She thinks that she can buy only the baby’s ones (3-4 y.o.) for her baby that is coming or will come soon.”
this dream confirms the fact that even if she can’t find her identity, she unconsciously understood that the base for its reconstruction is in the time where she was completely intact. Her awareness emerged as the answer to my proposition: the goal of our therapy will be the realization of the human potential of the 3-4 y.o. baby she is waiting for. We call this period the psychic weaning process.
M., male 36y.o., precedent diagnosis of Bipolar D. and/or Borderline Personality Disorder, second evaluation’s session:
“He works as a barman in a private yacht, he’s happy to meet an old girfriend of primary school’s period. She has a small black dog funny. Clients leave for him 5 euro’s tip and he’s happy because it’s money he can spend for himself.”
the patient tries to go back to find in his memory an affective relation of the past, and this allows him to find unconscious money for himself to work in psychotherapy.
Eight evaluation’s session:
“He’s swimming in Venice’s lagoon with many turtles. Turtles sometimes breath out of the sea as he does. He sees on the seaside his girlfriend with two children (6-8 y.o.) that play with turtles.”
even if his pathological issues are severe as symptoms, he finds the possibility to move between conscious and unconscious easily, and this allows him to find his valid, affective and functional parts.
S., female, 18 y.o., with a structured personality of rigorousness, very practice and material, high mind functionality, one day completely stopped her studies with consequently depression, anguish, fear. She was sent to me from a colleague with who she had one session.
2nd evaluation session:
“she was on the terrace of a small house and in the ground she sees a beautiful, big horse. She’s on the stairs and she finds in her hand a leaf and she has to decide if giving it to the horse or not” (she will explain that the leaf is the same of the plant of my studio).
During the 1st session, I explained to her that my interest was not to resolve immediately her symptoms and her fears because now they’re an important skill to say that something’s going wrong and maybe must be changed. And this was the unconscious emerged sign of a good therapeutic alliance.
3rd evaluation session:
“she arrives in a high building with her friend, she has to come in the apartment of a woman to show her friend the wonderful terrace of that woman. But while she’s going in, she finds an upper floor and they go there. There lives her professor, serious, a bit strange, but she likes him and he has a great house and also a wonderful terrace. She brings her friend to the terrace also because it was a good place to see the terrace of the woman and while she tries to show it to her friends, when she turns to her, she transforms in a rook and flies away”.
“she wants to exit from a building, and outside meets her friend with her mother and her sister. Her friend has long, thick and maybe sick, legs and she’s astonished of that”.
These two dreams represent the unconscious awareness of patient that found something special in the similar proposition of the 2 therapists but at the same time, where she understood that she found the great terraces where the rook can fly away, she finds the trust to offer her pathological dynamics to the therapy.
So this explicit proposition to patients of looking for the human potential creates a spontaneous answer of a valid therapeutic alliance represented by a strong relation and dreams. When this potential emerge as the trace of what has not been destroyed but kept valid we can be sure to start a psychotherapy and consider it as a good predictor factor of recovery.
In conclusion, for what we have called “risky” patients the possibility for a psychodynamic psychotherapy that contains the goal of recovery is possible not stopping at the diagnosis and at the clinical issues but exploring the valid and affective part left into the patients, his human potential.
The initial period of individual therapy is important to contain what became impossible to be contained by patients and also to redefine problems in terms of facts and relations to allow him to access to his inner world, to find an insight to proceed with the interpretation of dreams and of the relation.
Then the therapy extend personal dynamics and conflicts of single patient to the group the best skill for “risky” patient to come out his circular world in which he continuously lost himself and open again to the interplay between humans.
Donnet JL (1999) Patients limites, situations limites. [Limit patients, limit situations] In: Andre J, Chabert C, Donnet JL, Fedida P, Green A and Widlocher D (eds), Les états limites. Paris: PUF.
Ruggiero I (2012) The unreachable object? Difficulties and paradoxes in the analytical relationship with Borderline patients. Int J Psychoanal 93:585-606.