Customer Reviews

Treating Borderline States in Marriage: Dealing with Oppositionalism, Ruthless Aggression, and Severe Resistance (The Library of Object Relations)

5 star:		(5)
4 star:		(0)
3 star:		(0)
2 star:		(0)
1 star:		(0)

 

 

If one is bold enough to attempt couples' therapy one lesson soon emerges: there are couples, and there are couples. The normal/neurotic couple incorporates communicative-interactive tips and interventions directed towards effective communication, conflict resolution, problem solving and enhanced intimacy. The personality-disordered marriage, even when managed with strategic skill and therapeutic acumen, too often seems impervious to change. The therapist is frequently left floundering and "at a loss." Charles McCormack navigates the reader around the reefs and through the doldrums that typically wreck or stall therapy with these couples. In doing so he also sheds light on the soft human underbelly of ALL marriages, reflecting , as they do, some degree of early trauma or impingement - now well-met in a partner. McCormack starts with the therapist's capacity to play and takes us on a journey of vigilance and courage to the recognition that, in working with borderline states in marital therapy, it is likely to be the THREAPIST'S resistance to understanding which may forestall - and then foreclose - the therapeutic process. McCormack uses exquisitely drawn vignettes which render the words as well as the "music" of sessions with these couples, transmitting the "feel" AND the "sense" of the sessions. In these couples we hear the echoes of their dreams and see the omnipresence of their nightmares wedded in their coupling. Each individual unabashedly - ruthlessly - uses the other as a self-object. Through resistance and oppositionalism the couple works to use the therapist as a self-object, too. McCormack makes the confusion in working with these couples clear. Using concepts derived from object relations, psychodynamics, self psychology and Ogden's theories of modes of human experience, McCormack sheds light on a unique treatment approach for working with borderline and other personality-disordered marriages. This light dawns gradually and not in a rushing flash of epiphany. What is unknown might not be unknowable; there may be a psycho-logic underlying what seems so "irrational." Therapy begins in the mind of the therapist. Through separate individual interactions within the dyadic context, Mr. McCormack works first to change each partner's relationship with the therapist, and THEN their relationship with one another. Sequential interactions with each member of the couple provide not only "role modeling," but create psychological space in the treatment room, allowing for the development of "thirdness," where the "Other" and "We" can come more fully into being. McCormack offers a myriad of techniques - such as the "deniable interpretation," the challenge to certainty, and teasing out and surfacing inconsistencies in narrative - all of which add to the therapist's armamentarium in this difficult but potentially rewarding process. A world that may seem unintelligible at the beginning of this book - the scorned world of the personality-disordered marriage - is made knowable by the end. Interventions rooted in "being" a therapist with a couple of Beings supplant the panicked urgency of "doing something, anything" about the couple's plight. McCormack's techniques create a pathway towards repair instead of annihilation, all the while reassuring us that "therapists are human, too." McCormack's book helps to bridge the obstacles impeding therapeutic work with these troubled and troubling couples. He lets us know, when we find ourselves "at wit's end," that this is a very good place to begin our work.

This book is a labor of love and the labor of my lifetime to this point. It's genesis dates from a time when society provided better for those in psychiatric distress, when long-term therapy wasn't a bad word. As a clinician I had received three years of formal training in structural and strategic family therapy. However, as my career passed through methadone maintenance clinic, to partial hospitalization, to long-term inpatient treatment, I found these approaches inadequate in helping me to help these patients with the difficulties they encountered. Nor, were these approaches any more helpful in helping me to understand the plight of individuals in spouse abuse and sexual abuse treatment programs for which I worked on a part-time basis. It was while working on a psychoanalytically oriented long-term inpatient unit that I was driven to the medical library in the attempt to develop a more in-depth understanding of the poignant plight of these individuals. I discovered Winnicott, Fairbairn, Sullivan, Balint, and others who had spent their lives considering just such questions. Slowly, very slowly, I gained bits and pieces of clinically useful understandings (the only kind that mattered to me) in the context of the continuing treatment of such patients. Gradually these moments of lucidity cohered into a greater whole. This book is the outcome of that quest for understanding. To my surprise, now it seems so naïve of me, my journey to understand also shed light on the difficulties encountered during regressive states (borderline states) in more normal/neurotic individuals and their relationships. I discovered that there is a personality-disordered self within each of us. The difference is that while some of us visit such mental states and skewed ways of organizing perception, others of us dwell there. I have always found the study of psychology helpful in shedding light on myself and my relationships. I often wondered why therapists didn't share their theoretical understandings more actively with their patients. After all, if we as therapists find them helpful why wouldn't our patients? In fact, many of us have been patients. With this in mind I took great pains to write this book in a way that will challenge and inform the most seasoned of therapists, while ensuring that it remained accessible to the lay person who has inclination to work his or her way through it. To this end, several of my readers were not psychoanalytically oriented. It was their job to ensure that I wrote in plain speak and in a way that made sense to them. In addition, I intentionally wrote this book in a way so as to induce within the reader some of the experience of working with individuals who are ensnared in borderline ways of being and relating. The book gradually induces within the reader the rawness of working with personality disordered patients. From initial enthusiasm, to the confusion of being confronted by the patients or their seeming impossible difficulties, to the therapist's use of his personal experience as it arises in the context of the sessions to better understand and work with the patient(s) in the collaborative effort that is therapy. The book then moves on to reach beyond common thinking, introducing such concepts as separate dyadic interactions, the use of deniable interpretations, the importance of "Not-Knowing," and of therapy as a full-contact endeavor of the therapist. I introduce such ideas as the importance of the therapist's use of aggression, the idea that the couple initially exists only in the mind of the therapist, and that the spouses first meet in the mind of the therapist. Finally, I speak to therapy as a recurring process, an upward spiral from the simple to the complex, from primitive development to whole relationship to self and other. Illustrative vignettes, often written in a manner that reveals the therapist's feeling and thinking, both spoken and unspoken, are liberally used throughout the text. Far from being the presentation of perfect sessions, these vignettes repeatedly reveal the therapist's flaws, biases, and mistakes, for I propose that it is exactly these human foibles that allows the therapist to be available to the patient and it is through our willingness to address our mistakes as therapists that we become available to and invite our patients to join us in real relationship and treatment alliance. Fortuitously, it is also the way through which the therapist's developmental capacities, particularly that of the capacity to make repair, become available for internalization by the patient. I sincerely hope that you, the reader, be you patient or therapist, gain at least a fraction of the benefit from reading this book as I did in writing it. Charles McCormack.

This book shows therapists how to help borderline couples begin to reflect on their feelings rather than act them out. The author uses clinical examples to show how clarification and confrontation of projections can help patients see each other, not just their fantasies. These patients often equate a spouse with a fantasy they have of the spouse; hence, they tend to be concrete and not curious. "No. That's not just how I see him. That's how he is!" McCormack shows how we can help these couples become less concrete, more reflective, and, as a result, more intimate. He talks honestly about how a therapist may 'drown' in the destructive feelings evoked in couples therapy. He shows how this happens, why, and how to work with that reality. The clinical examples he uses are raw, true to life, and, as a result, very useful. He is uncommonly honest and forthright in his discussion of when to share countertransference reactions with patients. He clearly does not see himself as an emotionally detached therapist. He likens work with borderline couples to psychological mud wrestling. His is a model of an emotionally engaged and relentless healer who tries to be as honest with himself as he is with his patients. As such, the book exemplifies the best of the existentialist and psychodynamic traditions.

McCormack (2000)illuminates the techiques of a mature and seaoned psychotherapist in his beautifully written book. He demonstrates an intimate understanding of working with both defensively sophisticated and unsophisticated patients. His wonderful use of language, empathic understanding, and unique ability to "marinate in piss" is repeatedly demonstrated in emotionally charged and captivating vignettes that support the thesis of the book. This book is a must read for both seasoned and new practicioners.

While =TBSIM= smacks here and there of therapist rescuing and codependence, it also provides solutions for the problems of enmeshment and boundary diffusion that occur when one is working with "mysteriously enmeshed" couples. This book is valuable for any therapist who climbs into the shark-infested waters with PD patients in =any= setting. I don't do MFT; I work with substance & process abusers, AMaCs and PTSDs. I don't see anything here I can't use with those people.

McCormack's insights into What Really Works are "gold standard," even if you think you're a "cognitive-behavioral," "dialectical-behavior" or "acceptance-and-committment" therapist who wouldn't crack a psychodynamic text if your life depended on it. His five "self-instructions" alone are worth the price of admission:

1) Give them room to spill their guts and spray their understandable rage without taking it personally; 2) sit still and feel what you feel without denying you've been "had;" 3) be the good-enough, attuning mother the patient didn't have and hasn't yet found or developed in himself; 4) show, rather than tell, how the therapeutic process works; and 5) behave according to the values you state. Mighty stuff.

McCormack gets down with ideas like "survival, not fulfillment," the pre-cognitive installation of distrust, "evolving rather than revolving," "the =feel= of the familiar," the autistic defense structure, the high value of floundering, the depressive mode as a therapeutic target, the borderline's belief system, and how "thirdness" overcomes "either-or" and orthographic appraisal. Moreover, you'll get material on non-defensive countertransference management and helping others to make amends and reparations the likes of which I've never run into before.

The author knows his Wilfred Bion, Ronald Fairbairn, Otto Kernberg, Melanie Klein, Heinz Kohut, William Meissner, Harold Searles and Donald Winnicott as well as anyone, but this is not another head-in-the-clouds-of-theory deal. This guy's been =in= the trenches, and he's developed a nifty way of letting go of his schizoid defenses in the face of projected threat that is at least as good as anything I've ever encountered in the last 35 years at this.

I =am=, btw, a DBT/ACT practitioner, but I'm not smug (or dumb) enough to think I can't learn plenty from the object relations people. Their language may seem opaque at times to behaviorists and rationalists, but when you come to understand it, you can see how much it clarifies the connections between unprocessed affects, cognitive schemas and behavioral presentation. Some OR people do this better than others. McCormack is surely one of them.