By Dr. Jason N. Camu
licensed clinical psychologist
“Oh, he makes a big deal about boundaries, he’s so serious he won’t even hug her, she’s an old woman for God’s sakes.” The snickers suggest that my reticence about hugging a patient on the unit is based in my own character deficits, namely that I’m mean or overly rigid.
My reasons for refraining from indulging that patient in a hug were based in a comprehensive diagnostic impression of that patient. I posited that hugging her actually interfered with her treatment, and I could describe why. This syrupy sweet and caring old woman used hugs to deny her own hostility and project responsibility and rage onto the recipient of the unwanted hug; the patient was malodorous, disheveled, and had head-lice, yet was exceedingly bright with a high functioning history. Rather than admit to repulsion and rage, clinicians colluded with the patient in a myriad of unspoken issues of anger, dependency, and helplessness.
Knowing what you are doing and why you believe treatment to be effective differentiates you the psychologist from any layperson offering emotional support.
Not all treatment is the same. Selecting which treatment is appropriate is based in diagnosis.
The borderline diagnosis is rich with a peculiar excitement for clinicians. It arouses what seems to be a pathologizing tendency that allows us to feel separate from and consequently healthy unlike our troubled patients, while simultaneously reveling in our own masochism as we suffer to help a noble savage. The DSM classification while useful in some ways, is a simple grouping of symptoms/behaviors etc. that are often confounded in a co-morbid mess with multiple other character and mood disorders, and does little to inform treatment.
For some treating professionals, grounding in theory provides a sound base for determining treatment modality—and perhaps even more importantly identifying the psychologist’s limitations in treatment.
For those who rely upon psychoanalytic or structural theory, the difference between borderline and neurotic is essential in shaping treatment. It is unfortunate that this basically simple theoretical approach has become synonymous with sex and cigar myths, not only in the lay community but now commonly infiltrating our field.
The distinction between borderline and neurotic sets the groundwork for selecting a treatment modality. Often attacked as effusive and narcissistic, analytic theory (structural theory) is very concrete in this regard and can organize a clinician’s approach to treatment. Said succinctly, differentiating patient pathology is what drives treatment and modality. An illustrative example is the fledgling therapist with the best of intentions who walks blindly into an exploration of trauma and affect with the borderline patient. The ensuing fallout can include a destructive deluge of rage, suicidality, or if lucky the calm before the storm with the exalted idealization.
The reason one might not use insight-oriented therapy is because the borderline patient lacks key Ego functions, namely he or she is incapable of self-reflection and has a profound difficulty managing affect. In my own work I have come to see this lack of self-reflection as a limitation in biology or genetics, not parental influence or environment. Consequently, I am unable to create or develop a self-reflective skill through treatment for the borderline patient. Similarly, a patient with developmental disability will reach an IQ ceiling defined by genetics even with extensive intervention.
Those patients demonstrating a reflective capacity, even if it is poorly developed, may be candidates for dynamic or insight oriented psychotherapy including the slow work of new compromises between drives for pleasure, and one’s conscious and unconscious prohibitions against those drives, e.g., telling a lie for personal gain and feeling guilty. Conflict resolution (a new compromise) might involve more comfort telling lies (challenging Superego and encouraging Id), or tighter control on the impulse to lie (strengthening the superego). Intelligence, attention span, affect tolerance, affect modulation and regulation, as well as other conceptual distinguishing features like a “sense of self,” are all key data that inform how or whether I will provide treatment.
In addition to a psychoanalytic practice, much of my work at present involves assessment for the international consulting and matchmaking organization Valenti International. As with all of my work, theory drives the diagnostic impression which then shapes evaluation. The written evaluation is read by the client. Thus, the very same diagnostic concepts must be considered. Only those who are self-reflective (can empathize via internalized object representations) can become clients. I must then consider how defended or protected this client is, so I may determine what is digestible for that client who will read his or her evaluation. The answers or hypotheses define what a client will be able to tolerate and hopefully use to develop, grow, and improve, making that person more prepared for a meaningful relationship.
It seems that a contemporary attitude about treatment is increasingly a blanket approach aimed at simply supporting a patient. Arguably empathy and caring are essential in treatment, but knowing how they facilitate cure or improvement should be readily explainable.
For example, mirroring a patient with a cohesive and articulated sense of self is patronizing and he or she will tell you so if you unnecessarily provide support (words) when something else was needed. Softening a Superego, supercharging Id, or supporting Ego functioning, or however one thinks about the mechanism of cure should not be mysterious at the time of intervention.
This commentary was provided as a sample of one clinician’s curiosity about treatment and how and why interventions are selected for each patient or client who has contact with a psychologist. Defining what we do can present a confusing picture of psychotherapy to most patients, it should not be so confusing to ourselves. To correspond regarding this or other articles, please contact me, Dr. Jason Camu via email at: firstname.lastname@example.org.