Question: Can my neediness, strong attachment, and “borderline” traits repel my new and wonderful therapist? (Photo: Marina del Castell, Flickr, CC BY 2.0)
Answer: This is a tricky one because I can’t speak for all therapists, but I’ll share some thoughts. Technically speaking, parents should love all their children the same and professionals, who are paid adequately for their time, should give each client equally enthusiastic service. The problem is that humans are not robots and we experience each relationship differently.
Here is the good news:
The worries that seem most dire to you are probably not the ones that have the most impact on your therapist. For example, If a therapist responds well to early hints of neediness and attachment, then those qualities, which are so “disgusting” and “shameful” to the patient, are actually not a problem for the therapist. These feelings of disgust and shame reflect toxic attitudes that were internalized long ago from unloving and abusive caregivers. A therapist who felt that way about patients would probably not go into the profession and would certainly not last long doing in-depth psychotherapy.
But it is more complicated.
As has been chronicled so many times on these pages, there are therapists who can’t handle neediness and attachment. Most of those don’t present themselves as ready to do deep psychotherapy. They are more likely to identify as cognitive-behavioral therapists or to espouse a brand of therapy that does not emphasize a long-term deep relationship. Unfortunately, there have been cases of misunderstanding or mismatch where the patient couldn’t know that the therapist would reject or even punish attachment. This has happened more often with trainees, who might have the temperament to be able to handle a deep relationship, but the supervisor or the clinical director could not.
The best advice I know is to test the waters with a trial balloon or two to see what the reaction is. A therapist who competent will welcome a patient who wonders what is OK in the therapy. One who is ready to do the work will communicate willingness and encouragement. One caveat is that fear and shame sometimes cause patients to give such quiet hints that the therapist won’t notice or get what is being asked. It is important to be direct. I would recommend softening the question by using more abstract language. “I am wondering if this is a treatment that encourages talking about feelings towards the therapist?”
“Borderline Personality Disorder”
I don’t usually use that term or think well of it. Judith Herman wrote an important book, Trauma and Recovery, opening the field’s eyes to the fact that borderline usually means trauma. However, there are patients whose relationships tend to be chaotic and go from hot to cold very quickly. Often there are crises so frequent, intense, and dire that dealing with them distracts from the flow of the therapy. Perhaps most important, the therapist can be the best therapist one day and the worst the next.
Some therapists are more able to handle the crises and deal with the criticisms in an non-defensive way than others. Usually over time, therapists self-select away from this kind of patient if they have too much trouble. Here is where one of the therapist’s most important therapeutic roles is to be a “rock on the shore, battered by raging storms.” Simply by not being too reactive, the therapist brings calm and containment to a psyche in life-and-death turmoil.
One thing that makes a therapist able to do this is a perspective on what is happening. Understanding takes much of the threat out of the interaction. Another useful component is taking some pride in being able to help people who are not easy to help.
A Special Conundrum
I have written elsewhere about a special situation that happens sometimes. The patient chooses a therapist who has the qualities of acceptance and caring that were missing long ago. As the therapeutic relationship deepens, the patient begins to identify what seem to be negative intentions in the therapist that have been “transferred” from the past. In other words observations about the therapist are mis-perceived as sure evidence of say—of not caring. Now, this therapist does really care, and was chosen for that quality. Furthermore, the therapist takes a lot of pride in being a caring person. So when the patient begins to criticize the therapist for not caring, it is hard for the therapist not to feel offended and get defensive. After all, the criticism falls right where it hurts most. And, to make matters worse, the therapist’s involuntary defensiveness confirms the patient’s worst fears. Hopefully, before the investment both have put into this relationship is thrown overboard, the therapist figures out that this is all a misinterpretation and is able to help the patient see it.
When the work is taxing and difficult
Yes, there are times when every therapist has a “bad day in the office.” That is to be expected and it is why therapists need their own support system outside. And it is true that some patients are more “high maintenance” than others. It is the therapist’s job not to let any patient be the cause of “burn out.” That might mean restricting contact between sessions or not being willing to discount fees. It might mean, wisely, referring a patient out in the beginning of therapy. It might mean bringing in outside resources such as a day program or adjunctive therapy. Somehow, the balance of plusses and minuses in every therapeutic relationship will need to average out in the positive for both sides. If this balance is getting hard to maintain, it is the therapist’s job to bring this problem into the therapy and see that it gets solved. Something must be done to repair ongoing negativity. A therapist who dreads each session is as unworkable as a patient who dreads each session.
Two Basic Ethical Principles
The structure of therapy is that the patient pays for professional services that are for his or her benefit before and above all else. Within this framework, one ethical principle subsumes all others: Therapists should not make or imply promises they will not be willing or able to keep. Within these principles, is there room for therapists and patients to have a good time together? Absolutely. Laughter, warmth, enjoyment of mutual connection, pride in success, and even a feeling of power are all positive feelings that can happen for both participants, in a therapy that continues every session to meet these two ethical principles.