Long-Term Psychotherapy and BPD, Part 2: A Dialogue on Trust

Earn CE Credit

• Introduction: What We Did
• Cracking Ourselves Up: Enhancing Trust with Humour
• “Being Seen” through Creative Collaboration
• Mutually Revealing
• Epilogue: Returning to Embodiment—March 2021

Question: What do you call a homeless horse with a Borderline Personality Disorder?

Answer: Unstable.
 

Introduction: What We Did

In this, the second of a two-part essay, we (Anne, the client, and Trish, the therapist) seek to share multiple perspectives of our co-writing collaboration, a process that we developed to inform our long-term therapeutic relationship’s new focus on Anne’s diagnosis of borderline personality disorder (BPD). Following on from Part 1, in which we detail the ways in which long-term therapy with Trish has had a powerfully positive impact on Anne’s (treatment for) BPD, this second part—begun 5-6 months after the first—moves into the “how” of our co-authoring experience. Through collaborating, Anne is able to practice better interpersonal relationships, which we identified in Part 1 of this essay as crucial to “building a life worth living.” The epistolary dialogue format (as in Part 1) models the importance of trust in the therapist/client relationship, especially for those with BPD, which for us has been built in a range of ways through creative collaboration. In Part 2, we explore the risks and benefits of this dialogic trust-building collaboration, and recognise the investments of all parties involved in the treatment of those with BPD.

In mid-2020, in the midst of Australia’s COVID lockdown, Anne was asked by a friend who edits a psychotherapy journal to contribute an article on their recent diagnosis of Borderline Personality Disorder (BPD). That process is detailed in Part 1 of this essay. In Part 2, we unpack how collaborative writing is impacting our therapeutic relationship, and how humour has played a powerful role in building trust. Our creative collaboration has also raised a number of questions and negotiations, including: What risks were identified? How were these processed and resolved? How has maintaining our dual roles improved our therapeutic relationship?

We explore not only what has changed in our therapeutic relationship due to our creative collaboration, but also what has happened underneath the changes and how co-authoring (or other creative collaboration) might be useful to both therapist and client. We consider why we came to write together, the power of attuning and attending, and shifts in the therapeutic atmosphere that can result in increased trust—most powerfully, a more expansive view of each other that seems to enhance our work “in the room.” For us, humour is a “way in,” a way for us to extend the safe space of the therapeutic exchange into different kinds of relating, a movement that leads to increased trust.

We share memes and jokes about therapy, BPD, and any other topics that need to be decompressed, which establishes a common irreverent sense of humour that solidifies the trust built over time. Common factors theory suggests that the most important influence on therapeutic change is the strength of the alliance between therapist and client. Looking beyond technique and intervention, how does what happens in the room affect our co-authoring, and how does our co-authoring affect what happens for both of us in the room? As before, we use a dialogic approach to give voice to both perspectives.

Trish (she/her): I remember several months back, you had had a bad couple of days, and you were feeling particularly isolated. I wanted to reach out in some way, so I sent you a video clip showing Pepper (my therapy dog, who has been a part of our work together) magically being able to speak through a phone app, asking how you were feeling. I hesitated several times before I sent it but did it in the end. Ultimately I think it achieved what I hoped—a moment of connection through humour, extended by you, when you sent me a video of your dog replying. This happened before the idea of writing of our first article was even on the table, but there we were, extending our therapeutic alliance beyond the counselling room and into a creative/visual space.

Anne (they/them): Our psychotherapeutic relationship is predominantly a one-way listener relationship, framed by your professional training and the terms of our engagement. Is the incessant talking of the therapy client and the never-ending listening of the therapist a false centring of the client in a way the world doesn’t uphold? Like you said the other day, the few times your own selfness comes out in sessions, the client often overlooks it and is like, “Yeah, so anyway, back to me”—which, sadly, I can totally see myself doing! What if you were to say to me, in a session where I might do that, “Hey Anne! I just said something about myself, and you totally ignored it.” It might be hard for me to hear, but that is exactly what happens in real life. And what would that mean for you as a “therapist-ever-becoming” who considers what might be possible when a client is so caught up in their own woes that they miss the you-ness? A you-ness that might be able to push them further toward better interpersonal relationships?

Trish: You came in with your American swagger, already a devotee to New York style of psychotherapy, where not everyone there might have their very own barista (it’s a Melbourne thing), but they certainly have a therapist. You seemed to be willing to take a chance on me, despite some differences that might have gotten in the way. We seemed to click, conversation flowed and continued to flow in subsequent sessions. We discovered things that connected us in shared experiences in our lives apart from the mutual age bracket we found ourselves inhabiting, both having been high school teachers, both loving dogs in the same devotional kind of way. But maybe it was mostly that I really liked you as a person—your inquiring mind, your desire to make sense of things, your wry humour, your ability to narrate your life from the couch in such a way that I was drawn into the story and cared deeply about the author. Your paid work took you away on a regular basis, often for weeks or months at a time, but you would appear again at my office and we would resume. Before I knew it, we had been doing this for a couple of years and entering the realm of long-term therapy—not new to you, but not guaranteed for me, for two reasons: Australians are not so familiar with this way of receiving (long-term) psychological support, and for me as a therapist sitting outside of the Medicare system, there were no financial structures in place to subsidize the work, at times a disincentive for prospective clients. But it has always been my preferred way of working, as one who has found a fit with the relational emphasis of therapeutic work.

When therapists get together and wax lyrical about unconditional positive regard, they rarely see this as a reciprocal idea. It is considered as something bestowed on the client, flowing from a compassionate therapist. But when it is present in the therapeutic space in its fullest capacity, it emerges out of a mutual desire for the therapist and client to see each other as the best that they can be. I want to help you and I want to be seen as someone capable of that. You want help from me and need to believe that I will not let you down. I keep getting to show up again; I can say I won’t give up on you, and you give me the chance to do that through your own acceptance and trust of me. So is this shared unconditional positive regard?

Anne: I was not surprised to find out that you were a teacher—you remind me of the best teachers I knew during my 11 years teaching in high schools. I can see why the kids would be drawn to you: your sense of humor and down-to-earth vibe instantly put me at ease. Yet one thing I’m seeing in myself through the BPD diagnosis and range of treatments is how transactional I can be: i.e., you are my therapist, and because I pay you, you should be like x. Today when we were talking about you, it occurred to me that if we are talking about mutuality, it has to include a kind of benevolence in me for you, too. It doesn’t mean you have to disclose personal details as I do, but I think the interpersonal, relational mode I was talking about does mean our therapy sessions could be a space where I try out caring more about the other.

You are not just my therapist because you were there and I said yes. You also said yes. I have not just stayed—you have stayed. You have said that you feel you can help people and maybe there’s a question in there that goes beyond me just “feeling better.” I don’t literally affirm to you that you DO help me. You do. And I don’t think I affirm you or acknowledge that in the way that you do for me. What does that mean or look like coming from client to therapist? I think I would like to try some kind of “attending to” you in our next session, as a kind of practice of my learning better how to attend to others, in a non-transactional way. It feels freeing to think of improving my interpersonal skills through getting out of my own needs and trying to live more in others’ experiences or needs. I’m not sure exactly what that looks like in our therapy sessions, but I do think this is evolving in a direction in which I can practice caring for someone without it being based on my own needs, even in therapy. Which is still part of my growth in response to my BPD diagnosis.

But why did we keep writing together, and how has it increased each person’s feeling of “being seen” in a more fulsome manner? Initially, it made sense for Anne to ask Trish to co-write the article for the psychotherapy journal, given she is Anne’s therapist and had played such a profound role in Anne’s diagnostic journey. But what we found was something more than a narration of how long-term psychotherapy might help those with BPD.

Trish and Anne started co-writing online while maintaining fortnightly therapy sessions, as face-to-face sessions had been prohibited by home isolation. During this time Anne was also completing their Dialectical Behaviour Therapy (DBT) program remotely, which had life-changing effects. We also acknowledge that we are producing writing that is going to have a public audience, and that now that shapes our creative collaboration in important ways.

We have tried writing separately and then sharing what we had written at a later point, as Irvin Yalom and his client “Ginny” did in Every Day Gets a Little Closer ⁽¹⁾, but ultimately returned to co-authoring in a shared Google doc that has a satisfying interactivity and vibrancy. One aspect of the collaboration that emerged from the beginning is the humorous banter that we both enjoy. It is present in our therapy sessions, too, but not to the extent that it has bloomed in our tracked comments while writing together. So alive was that back-and-forth that we tried to include the tracked comments in the final draft of that first article, but it didn’t feel right; the spontaneity was lost once the time stamps and overlaps in the marginalia were formalised into the body of the essay.

The fluidity of being able to write into the same document, and comment on each others’ and our own writing, seemed to form a big part of the energy of the shared work. Trish identified “rooftop moments” and other important insights that emerged in the writing. We both flagged passages that brought tears.

________________________
⁽¹⁾ Every Day Gets a Little Closer

Trish: Anne, you pose such interesting questions about this creative process and why it works. It takes me back to our earlier discussions as we explored the issue of the power dynamic in the client-therapist relationship. It is a strange beast because it seems like it is both needed and rebelled against simultaneously. Sometimes, as a client, you want me to firmly take the reins and show you the way, and at other times you are aware that as you bare your life to me, I keep mine under wraps. You step into a vulnerable space and I have a boundary that keeps me safe. And I want to offer support and guidance but reject labels like “expert” and get cosy with terms like Yalom’s “fellow travellers.” Do you think our writing together altered an established power dynamic? For in that space I saw you as the authority and looked to you to have the answers on how the work would come together. I completely trusted that you would take us to where we needed to be with our first article. How does it feel for us to exchange leadership roles as we move from one space to the other? I encourage you and affirm your resolute commitment to wellness, as you face the parts of you that still flare up at times and remind you of the hell that is other people. ⁽²⁾ Then you encourage me and applaud certain passages that I write. You take note of my hesitancy and respond with patience and curiosity, perhaps in a similar way to how you do with your own students. So we redefine the terms of engagement. We allow the spaces of therapy and writing to co-inform one another, as this most human of relationships draws on all of its strengths to bring out the best in each of us. As Yalom ⁽³⁾  reminds us:
 

This encounter, the very heart of psychotherapy, is a caring, deeply human meeting between two people, one (generally, but not always, the patient) more troubled than the other. Therapists have a dual role: they must both observe and participate in the lives of their patients. As observer, one must be sufficiently objective to provide necessary rudimentary guidance to the patient. As participant, one enters into the life of the patient and is affected and sometimes changed by the encounter. In choosing to enter fully into each patient’s life, I, the therapist, not only am exposed to the same existential issues as are my patients, I must assume that knowing is better than not knowing, venturing than not venturing, and that magic and illusion, however rich, however alluring, ultimately weaken the human spirit.

________________________
⁽²⁾ No Exit and Three Other Plays
⁽³⁾ Love’s Executioner and Other Tales of Psychotherapy

Trish: In a recent supervision session with my supervisee James, who works at an in-patient setting, we were reflecting on how patients there form a trusting alliance with the staff. James happens to be blessed with a benevolent warmth, and his presence is therapeutic before he even opens his mouth. He shared his thoughts about the negative impact on patients if they experience the mental health professionals as taking a position that is “above” them—whether that be in the way they dress or speak, or in the attitude that they convey—“I could never be in your shoes.” For James, what is important is the recognition that we can all find ourselves pushed beyond our capacity to cope and experience being unwell. That we need to have a willingness to “also see myself in their story.” Anne, it got me thinking about what you wrote in our first article—that BPD is a disorder of separation. And I wonder how it is possible to trust anyone if you feel so distant from them? As we grapple with understanding how our writing together built trust, it dawned on me that this process has been highlighting the ways in which we are similar rather than different.

Psychiatrist to his nurse: “Just say we’re very busy. Don’t keep saying, ‘It’s a madhouse.’”

When psychotherapy has an interpersonal focus, it can be described as paying attention to the interactions between client and therapist, as well as providing an opportunity for practising a more satisfying relationship that then gets taken into the real world of the client. So what is going on in our writing process, including in the comments? We agree it’s an alternative form of “the real world,” organically appearing out of the mutuality of the co-creative work. Through the collaboration, Anne starts to see Trish as a “fuller human being” with her own wants, needs, ideas, resulting in more trust of Trish. Trish reports seeing Anne also as a fuller person, in their element, strength and power, a kind of agency. We both express how the increased interactions are not necessarily about more stories of our personal lives, but rather an experience of “a different me.” For us both, we have an increased sense of how the other is with other people.

Anne asks Trish questions like, “How does it feel to be a subject with a client? To take up space?”

We both ask, “How much is too much?”

Trish has been thinking a lot about this in the last couple of days, about self disclosure as the therapist, and bringing more of the “real self” into therapy. She says,
 

I thought about your saying that you saw me as a ‘fuller human being’ through the writing process and it made us wonder what that would look like, i.e. to have Trish the fuller human being in the therapy sessions. There is always a risk that something may not work out the way you want it to. Including this collaboration.

For Trish there is tension about whether Anne could still trust her to help them in the therapy space if they see her vulnerable and feeling out of her depth in the writing space. This feels risky but also highly challenging to how she sees herself as a therapist. Trish’s previous self-image as being authentic and honest is tempering with the recognition that there are parts still held back. This important self-examination leads Trish to grapple with the boundary of what becomes known, foregrounding always that whatever she offers of herself still needs to be of therapeutic value. The added role of “collaborator” has both personal and therapeutic benefits for Anne. A healthy intimate relationship means both can safely be vulnerable with the other and know it can be held and ultimately strengthen the relationship, not damage it. The therapeutic potential is that if this happens with Trish, it can strengthen with others in Anne’s life.


Anne: I find it challenging to trust people who remain “distant,” as a therapist may appear, because it feels like rejection and elicits feelings of vulnerability. Navigating these secondary co-creative roles is tricky but feels reassuring to me, and the trust between us seems to increase. In therapy sessions, I am the one with issues, difficult feelings, vulnerability, who looks for support and understanding. You are the one who listens and focuses on how best to meet the needs that I express. So how is it that despite us writing about the therapy, our roles still shift? I often take the lead in the co-authoring, which is not surprising given my professional expertise. I am able to share information with you, Trish, around the process of writing together and send you co-written autoethnographic articles as examples—a classic example of table-turning, you tell me, when we reflect on the times you have sent me articles of a psychological nature in relation to our therapeutic work.

Psychotherapy is often described in the person-centred school as a respectful, collaborative, teamwork-like approach. In this way, the client-therapist team builds their alliance and works together, but—and this is a major distinction—it is all in the service of the growth of the client. And fair enough, given there is a fee attached. But it would be a deception to suggest that the therapist does not grow as well, or, as Yalom says, is not changed or affected by the work, or doesn’t think about the client beyond the therapy hour. How much of this knowledge is—or should be—available to the client? Do they even want to know?

Trish: Anne, you made a comment about not realising how much was going on “behind the scenes” in our sessions. This was probably in response to my talking about a certain approach I might take with a certain goal in mind. Do you think it is helpful for a client to know that what their therapist is doing is reparenting them, or providing empathic attunement, or providing a secure base that was lacking in childhood? I just can’t imagine a client caring about the what, as long as it works, but when I think about talking with other therapists about this work and leaving my clients out of the conversation, it seems ridiculous! I find myself imagining a conversation with fellow therapists:

Me: “Hey therapist colleagues, let me tell you about this great intervention I did the other day in a session…”

Therapist colleagues: “Oh cool...but how do you know it was great? Did you ask the client?”

Me: “Well… no… but, it’s in this book I read.”

Therapist colleagues: ‘“Yeah but how do you know it actually helped the client?”

Me: “Um… well, they probably don’t know it helped them… but… oh, shut up.”


Anne: I wonder at the disjunct between therapists’ acknowledgement that clients need to feel that you are not “above” us, are not inherently different from us, versus how infrequently clients seem to feel this sense of equality, accessibility, or sameness. As in James’ commentary above, I recognise the commitment in you, Trish, and others, to convey a sense of solidarity with clients; I also recognise what you have suggested many times, that clients do need that sense of being held, that the therapist is “holding things together” so that we can be vulnerable. Where is the balance between feeling this as hierarchical, and feeling in it together?

Trish: Anne, you are right that the balance is hard to find, particularly if there isn’t a dialogue between client and therapist about what is actually happening in the space together. As Yalom and others have often noted, it can be hard to know what helps in therapy, and I think quite often a therapist will have a different idea to the client about what was helpful, useful, or powerful in any given session. Sometimes a client will say to me, “When you said that thing last week, I found that really helpful.” And often I think, “Well actually, I didn’t quite say it like that, and it’s not what I meant, but OK. But didn’t you like it when I said this bit? You don’t remember that? Damn, I thought that was the good part…”

Cracking Ourselves Up: Enhancing Trust with Humour

Question: How many psychotherapists does it take to change a light bulb?

Answer: Probably just one, as long as it takes responsibility for its own change. This could be called having “a light bulb moment.”

Laughter has always been part of our therapeutic relationship, and we wonder as we go along what doorway this has opened to increasing trust. Our joking in the document is more frequent, but also a bit different in nature: more feeding off of one another, whereas in the room it’s a bit more measured. We are curious about the many roles humour seems to play between us in our dual roles. We discuss how—in the room—humour can also be a mechanism for deflecting, or keeping things on a more superficial level, and in this way is not always welcome. Nevertheless, once we begin our online interaction, the spontaneous humour grows. Trish writes of a time when she took a holiday and arranged for another staff member at the agency where she worked to see her clients if needed. The audacity of counsellors leaving clients in order to have some leisure time doesn’t go unnoticed by Anne in our track comments in the first article:

[Anne: how dare you LOL]

[Trish: How very BPD of you :)]

[Anne: LOL GUFFAW I think we may have a stand up routine by the end of this.]

[Trish: I know right? The side comments are almost as interesting as the article!!]


In this exchange, our shared humour strikes at the heart of the very condition that has caused Anne such anguish, and yet creates a moment of freedom as the heaviness of the label is discarded, all the while noticing that humour and pathos are indeed good friends. We agree that one reason both our irreverent humour and the creative collaboration work well is because it has emerged out of our pre-existing therapeutic relationship of almost six years. The trust and foundations were there before we altered our relationship, and Anne notes that widespread perceptions of BPD make it likely that such humour about the disorder would be hard to share with a therapist in a less established relationship.

One wall we have mutually hit together is a feeling of “too much”ness after the first essay, when we decided to continue writing together as well as still maintaining therapy sessions. The dual roles and time commitments of both soon felt too demanding, and we were able to talk about that openly and put some boundaries around it.


Trish: Anne, I recall that experience of “too much”ness was precipitated by your writing into our shared document about a dream you had had about me. I commented on how much was in the dream to be examined, but it seemed to be therapeutically, not creatively, relevant. Back then I wondered whether the writing together was blurring the therapeutic line in a confusing way. But now I think we see the line and we choose to walk along it courageously. I see an image of a tightrope walker, holding a long pole for balance. I wonder what the pole is representative of in our work together?

This experience caused us to recognise that we needed careful negotiation around how much and when we enact both roles: for example, do we collaborate while Anne is still a client? Do we have writing sessions and therapy sessions in the same week/month? After a time, we started to realise that they were folding back into one another in an iterative process that was becoming productive for both the writing and therapy, but we continue to monitor the efficacy of maintaining both roles simultaneously.

“Being Seen” through Creative Collaboration

Through humour especially, we both express a powerful feeling of being seen by the other, in deeper if not new ways. The feeling of “being seen” is, of course, a major part of the value of psychotherapy to a client, and was a strong part of Anne’s experience of therapy with Trish before the co-writing started. We decide to explore bringing some of this “whole person” or more interactive dynamic back into our therapy sessions, admitting that neither of us are quite sure what this will look like. We discuss how we might chip away at the “one-wayness,” the illusion of the therapist having no needs, feelings, investment. We consider questions like:

Is Trish always therapist Trish, even when we are co-writing?

What in that therapy space is different or the same?


It is confusing for us both at times, often in different ways.

Trish: I wonder, “Well what IS bringing more into the room?” I believe that my emotional responses are already an act of bringing myself. It is my standard practice to share things like “I’m aware that I’m feeling quite sad as you tell me this.”

We wonder together: what if we were writing a novel instead, or painting a picture? We are writing about our therapy, not something else, so it reinforces the therapeutic relationship. We reflect on the fact that Trish is also a teacher and practice supervisor, and in those roles she encourages her students to be prepared to walk the talk, to consider the ethics of asking clients to go further than they’ll go themselves. We begin to acknowledge our investment in each other.

Of course, our creative collaboration presents challenges as well as benefits. What if it dissolves, runs out of steam, or there is a creative rupture? We discuss the value of this changed way of working, despite the risks. We discuss whether writing about this will be of benefit to other client/therapist teams, and, if this multi-directionality in our sessions doesn’t work for all clients, whether it is still a worthy experiment to share publicly.

Anne: One reason why I have this trust of you is because you have hung in there, not rejecting me, through so many difficult times. And why wasn’t my treatment of you as challenging as so many others in my life? My hard behaviour, I think, is triggered by feeling rejected or judged. But rejection and judging is part of life. So how does unconditional acceptance (“unconditional positive regard”) by you help me handle rejection in the real world? One of the ways I’m suggesting is to regard you with care as a whole person, not just a “therapist.” That is, not just “there for me.” In thinking about this over the last little while, I believe the improvement in much of my behaviour comes from my starting to regard others as whole human beings with their own needs and validity, whether they reject me or not, meet my needs or not. How can I increase my ability to put myself aside and regard others in a less transactional way? If I were to do this with you in our sessions, what does that look like? Certainly not your therapy, or therapy about you. But maybe it’s more like, “How does it feel to you when I just talk the whole session?” or “Do I hurt your feelings?” or “Am I boring you right now?” Maybe attending to you (and others) is holding the dialectic of “My feelings are hurt right now, but I can also attend to your hurt feelings at the same time, or even first.” Part of improving my interpersonal relationships, I think, is being able to perceive my impact on people.

Trish: The process of writing the article with you has provoked me to re-examine the firmly boundaried position of this understood one-way process. No person-centred therapist wants to be a blank screen, and I have always believed I bring my genuine self to the therapy process with clients. Being willing to be more explicit about my internal responses to things you might say to me, rather than hold some therapeutic high ground as I bracket them off, seems like an important way forward.

We agree that it should be as intentional as setting some ground rules for the experiment. Trish suggests regular check-ins, like asking “How is this going right now?” Anne wonders how productive setting ground rules or negotiating terms of relationships might have been in other relationships or friendships, too; maybe with such agreements those relationships would have gone better. Trish suggests to Anne, “See? You are now connecting what we are doing in therapy to your life in the real world, i.e. negotiating with people around the types of interactions you have—what works for both. So here is therapy on the page.”

Mutually Revealing

One day after a co-writing session, Trish scribbles some notes, including:

Explore in what ways (even without Anne knowing) the relationship between us has been therapeutic:

• Corrective emotional experience
• Being there
• Not abandoning
• Staying with

…and that these things build trust.

Trish: I believe that so much of what a therapist does with clients is to provide a corrective emotional experience. When there is abuse or neglect or misattunement early in life, the therapy of care and unconditional positive regard gives the client the feeling of what it is like to be held. So for you, Anne, maybe some of that was to not have to listen to someone else and validate them (in the way you did for your adoptive mother) in order to feel worthy. That you get to have the experience of this for yourself. In some ways, it is not so important that it isn’t the “real world” but the world of the therapy room. The emotions are real. That I attend to you is real. And you don’t have to be “good” (thanks, Mary Oliver) in order to feel this. And feeling this with me might then motivate you to know that it is possible, and that maybe you can also feel it in your “real” life.

I have been thinking about this quite a bit over the last few days, and I have formed the belief that we needed to do this work (i.e. corrective emotional experience) before we could move into a space of being more overtly interpersonal. Trust is needed for that. I have often wanted to challenge some of my other clients with Borderline features to have a look at certain aspects of themselves and their behaviour that might impact other people, or even me, negatively, but I have found that there is a risk of their fragmenting. If someone already has a fragile sense of self, a suggestion that they could do something differently can be experienced as “I am a bad person.” So it is interesting that we are contemplating this experiment of giving the space between us more attention. Perhaps you feel secure enough in our relationship now to let me challenge you. If I let you see that I have reactions to what you do or say, that it actually affects me, I believe that you can hold this information and stay intact.

Anne: I have been thinking a lot for the past five days about my saying to you to “get over it.” One thing I’ve noticed with myself (is it the BPD?) is that sometimes I don’t intend to, but I am still quite harsh. I have always laughed this off as my New Yorker brusqueness. But is that an excuse for rudeness and not wanting to change? I’m sorry, Trish, that I spoke to you in that way. This is my being accountable interpersonally, even in a therapy session. I meant to encourage you. And I do think you are fearless in going to these places that are not the norm in the Australian context, and I love that and was trying to encourage you, but it came out in a rude and insulting way.

Trish: Twice now you have thought you might have offended me or been rude to me, and twice I have not felt offended or hurt. I wonder what you saw to think that you hurt me? An expression on my face, perhaps? Something in my response? Actually, I feel that on both occasions you were suggesting that maybe I could be more—an invitation to think big. And yet you think you were being dismissive or hurtful. I remember your saying recently that sometimes you find it hard to tell whether some communication between you and others is rude/aggressive or not. And then you might have to backtrack and check it out. I promise if you are nasty to me, I will tell you at the time and we can work out whether you meant it or not. You were witnessing my own discomfort with ambition. You didn’t cause it, you’re not the bad guy in this scenario. I am noticing and appreciating how you are thinking about the impact your words may have had on me.

Anne: I think it’s important to me that both of us acknowledge that there is fear perhaps around my BPD, because it is not only a disorder of separation, it is also a disorder of dysregulated emotions and behaviours. Through our work together and the safety of that, I am becoming more able to acknowledge the harms I have done to others and myself, harms that I can now feel regret and sadness about. That includes times I have hurt you in our work together, too, Trish. This doesn’t mean I won’t lash out (again). And as safe as I feel with you, we both know I have lashed out most often against those who are closest to me. So I recognise the courage it takes for you to continue to show up when you have witnessed so many of my hurtful behaviours to others, and sometimes experienced them yourself. That is brave, and I recognise the risk to you.

It is good and important to work together to improve my ability to calibrate my impact on others—to perceive it more clearly, perhaps—but also to model to other therapists that someone with BPD may be frightening or erratic, yes, but we can also be deeply reflective, resilient, empathic, courageous, and hungry to change. And we can care about you, even when we are mired in our own pain. And that this care for you can provide an important window to re-engaging with a world that is sometimes overwhelming for us.

Trish: You talk about acknowledging our fear around your BPD, and I wonder if it is the same for us both? You fear that you will still injure others, including me, despite how far you have come. I also fear that you could hurt me, too, might lash out at me despite the safety of our relationship. And as our therapeutic connection deepens, I take my place as someone at risk of being hurt by you. So how do we hold this fear in a way that makes sense? It brings to mind the dialectic of the work. Where there is fear, there is also bravery; where there is safety, there is also risk. And of course, as always, there is the knowing and the not knowing. It is inevitable that we hurt or disappoint the people who mean the most to us. We will do wrong, it is the nature of the imperfect relationships in which we all engage. And that brings us back to trust. With trust we are able to stay in touch with the resilience and perseverance that we see in one another, which makes repair and recovery possible. So when you care for me, and for others in their turn, know that what you are doing is an ongoing process of recreating a secure base that is at the very heart of what we all yearn for when we love and feel loved in return.

Epilogue: Returning to Embodiment—March 2021

Anne: I’m glad I came to your office today. It has been a long time since we have shared space, and so much has happened in the interim, with COVID and multiple lockdowns. I was aware of you again as a changing human person, and the affective intensity of proximity. I think one reason I felt moved today was not just about the content we were discussing, but about the relationship and the exchange. It is, as Tara Brach would say, sacred ground, where people feel seen and heard. It’s so powerful. That room is a powerful sacred space for me.

Do I have anxiety about going backward, now that my DBT has finished? Disappointing you? Being disappointed by you? Of course! That’s every relationship, surely. Today I just felt moved by the proximity, the laughing—so much laughter!—the attending, the eye contact, the ambient noises, the longevity, the commitment, and the hope, even when I can’t find exactly who I am. And also the power of the room itself. That familiar room—the white blinds, your desk, cup, computer. The little table by the couch, the bin. Pepper had died during lockdown, and I felt his absence so strongly in the room. The environment matters, and I can see it now as another expression of you, of another way of your “bringing yourself” to your clients.

Trish: Yes, it was pretty powerful being together in person today. There was a certain energy which may well have been about how long it has been since we took up the chair and the couch, or perhaps about the added layer of the creative space that we are sharing as we write, knowing that our words on screen find calibration with the ones we speak to one another. Were you more aware of me than you have been in the past? You have said you wanted to be able to hold space for others while you navigate your own emotional space. I think I noticed a subtle shift—while you certainly wanted some thoughts from me about what was going on for you, there was something different, more of an ease in you and a space created for me. And somehow I felt that even though I didn’t really have a clear answer for you, I was still offering you something, and you saw that (and subsequently wrote about it). This work together is making me examine myself in the most profound way, and if I want you to do it, then I will, too. Maybe I am also trying to find out exactly who I am when I am in a therapeutic encounter with you. I know one thing, I will trust the journey.

Anne: I was more aware of wondering what techniques you may have been using, and why. That relational aspect that I had never really thought much about before our co-authoring. I assumed the therapist just showed up and it was a one-way thing. I’m enjoying this change in my awareness: not only in terms of acknowledging what you are bringing, but also for me, thinking relationally about you. You exist. You are thinking and feeling things, not just absorbing. I also think we had a lot more eye contact yesterday than usual, that was something I was aware of. And also the laughing… Why do you think we laughed more yesterday than usual? My perspective is that it was just a bit of happiness to see you again, and also I felt you laughed more than usual and that felt like a kind of openness from you.
 

***
 

As recently as 2015, at the end of Creatures of a Day, Yalom  ⁽⁴⁾ reminds us that even in the United States, these kinds of relational accounts are all too rare and
 

not generally available in contemporary curricula. Most training programs today (often under pressure by accreditation boards or insurance companies) offer instruction only in brief, “empirically validated” therapies that consist of highly specific techniques addressing discrete diagnostic categories... I worry that this current focus in education will ultimately result in losing sight of the whole person and that the humanistic, holistic approach I used with these ten patients may soon become extinct. Though research on effective psychotherapy continually shows that the most important factor determining outcome is the therapeutic relationship, the texture, the creation, and the evolution of this relationship are rarely a focus of training in graduate programs.

For Trish and Anne, this focus on our creative collaboration allows a deepening of trust and strengthening of our relational dynamics. Trish (and sometimes both of us now) uses many of the suggestions Yalom offers for calling attention to the bond between patient and therapist including: doing process checks, inquiring about the state of the encounter during the session, Trish’s asking if Anne has questions for her. Through creative collaboration, trusting in the here and now becomes multi-modal and multi-directional in ways that can offer new forms of corrective emotional experience. It has also firmly established a secure base, the core purpose of strong and trusting client-therapist relationships, never more important (and challenging) than with clients with Borderline Personality Disorder.
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⁽⁴⁾ Creatures of a Day and Other Tales of Psychotherapy

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