From: PERSON-CENTERED REVIEW,
Vol. 3 No.4, November 1988 442-462 ~ 1988 Sage Publications, Inc.

 


FOCUSING WITH A

BORDERLINE ADOLESCENT

Barend Santen

Psych.centrum De Mark

The Netherlands

 

Eugene Gendlin’s focusing method can be used with “borderline” adolescents. Typical experiences of these clients are described, with implications for the therapeutic relation­ships. This is followed by a brief outline of Gendlin’s conceptions of personality change. It is claimed that, in a situation where clients tend to experience both silence and talking as threatening, focusing may be a helpful therapeutic intervention. A case description of focusing with a 14-year-old girl illustrates this approach.

Barend Santen studied developmental psychology at the University of Amsterdam. He works as a client-centered/experiential psychotherapist at De Mark, a psychiatric clinic for children and adolescents (Medical centre Dc Klokkenberg, Breda). He is a focusing-teacher in private practice and the Area Coordinator of the Focusing Institute in the Netherlands.

Eugene Gendlin’s theory of. personality change (Gendlin, 1964), which forms the basis of the experiential branch of client-centered therapy, can also be a useful model for the child and adolescent psychotherapist (Neagu, 1986; Santen & Koopmans, 1975, 1980). Within this theoretical framework the focusing method (Gendlin, 1969, 1981; Santen & Gendlin, 1985) has been developed. Elsewhere I have shown that adolescents quickly develop the necessary capacity to learn focusing (Santen, 1986, 1987). The aim of this article is to show that borderline adolescents can profit from the use of this therapeutic approach.

THE BORDERLINE PERSONALITY DISORDER

The last decade there has been considerable discussion about defining the borderline syndrome, its predisposing factors in the individual’s development, and “the necessary and sufficient conditions for therapeutic change” (Rogers) in people diagnosed suffering from this personality disorder. Recently, the most essential feature that describes these clients is a “pervasive pattern of instability in their self-image, interpersonal relationships, and mood” (Diagnostic and Statistical Manual of Mental Disorders, 1987, p. 346). People diagnosed as borderline seem to have unstable and intense relationships. They tend to be impulsive in potentially self-damaging ways. While their moods and feeling may shift considerably, they report a persistent background feeling of emptiness or boredom. Outbursts of intense anger, self-mutilation, and suicidal tendencies are common. They are lacking a sense of identity, which manifests itself in uncertainties in many areas of life. Finally, their behavior seems to be strongly influenced by a persistent fear of abandonment.

Traditionally, clients with such characteristics were treated by psychoanalysts who adapted their techniques to the ways these clients perceive the therapeutic relationships (De Blecourt, 1980; Door et al., 1983; Kernberg, 1970; Masterson, 1972; Rohde-Dachser, 1979; Van Vreckem & Verhaest, 1984). During the last ten years, however, client-centered/experiential and Gestalt therapists explored ways of applying their methods of treatment to borderline clients (Bauer, 1979; De Haas, 1980; Grindler, 1982; Santen, 1987; Swildens, 1981). Though coming from different theoretical positions, the authors seem to share the conviction of the severity of the borderline pathology and’ its relatively poor prognosis. These clients also respond poorly to medical treatment. According to Horevitz (1987), tricyclic antidepressants don’t seem to have beneficial effects. A few of these clients are reported to profit from low doses of antipsychotics (Mellaril) or MAO inhibitors.

Initiating and establishing a psychotherapeutic relationship with a borderline client is difficult (De Blecourt, 1980; Rohde-Dachser, 1979). These clients find themselves in a thorny position. According to psychodynamic theory they seek treatment for symptoms that protect them from becoming psychotic (Kernberg, 1970).

Because of their chronic free-floating anxiety, these persons easily become panic stricken in the presence of others. Often they mention a mixture of phobic, obsessional, and/or depressive experiences and bodily symptoms that may result in psychic disintegration.

Psychodynamic theory holds that borderline clients have been immersed in a symbiotic mother-child relationship (Mahler, 1972). Because these persons were unable as small children to separate from their mother, their identity development has been disturbed. Later, as an adolescent or an adult, they keep struggling against merging with and separation from other persons. When engaging with others, their temptation to merge with the other person can intensify their latent fear of losing their identity. As a rule, a person with such experiences withdraws from contact. They may behave in such a self-alienated way that they experience themselves as being split into a true and a false self (Winnicott, 1965); a false self that “adapts” to the outside world and a true self of which even the clients themselves are only vaguely aware.

A shaky equilibrium is the result. As a result of such incongruence, sometimes uncontrollable aggressive outbursts may break through. Such outbursts may reinforce the person’s fear of losing another person’s love and lead to forced “adapting.” There are also moments when psychotic experiences disturb contact with reality.

Borderline clients have the vague but inevitable fear that they might lose themselves and disintegrate in any relationship in which they engage. Painstakingly, they sway between inner confusion and loss of contact with reality on the one hand, and psychic integration and authentic contact on the other. Moreover, in a rapidly changing body the borderline must deal with tasks that are difficult even for the average adolescent.

IMPLICATIONS FOR THE THERAPEUTIC RELATIONSHIP

Giovacchini (1978) considers the above mentioned borderline qualities characteristic of the normal character development of the adolescent. Several authors (Masterson, 1972; Swildens, 1981) point out the correspondence between the therapeutic relationship with a borderline client and the relationship with many adolescents. Strong attachment to the therapist can abruptly give way to indifference, hostility, and the interruption or termination of that contact. The way in which the therapist is perceived may change drastically. The need to be independent may predominate, followed by the need for fusion with the therapist. The need for support from others conflicts with the desire to preserve one’s identity.

When one meets such a person in the therapeutic encounter, he or she cannot adequately experience himself or herself as a cohesive and integrated person. Owing to inner confusion and contradictory feelings, the borderline adolescent cannot easily respond to our verbalizations. For a moment, something totally different and incomprehensible may flash through his or her mind. The individual has lost track of what was being discussed and cannot speak clearly.

This inability to make him or herself understood can evoke fear in the client. But if the client could have expressed him or herself coherently, fear may still be evoked, since making oneself understood may result in fear of undesired obligations. Being understood can be experienced as having the other person gain control and being swallowed up in the contact. Consequently, speaking to and interacting with the therapist might intensify the client’s feelings of impotence and fear.

Working with clients with such experiences has influenced psychoanalytical, client-centered/ experiential, and Gestalt therapists (Bauer, 1979; De Blecourt, 1980; De Haas, 1980; Eigen, 1973; Grindler, 1982; Swildens, 1981; Rohde-Dachser, 1979; Santen, 1986, 1987) in at least two ways.

(1) They advocate providing borderline clients with more structure than with most other clients. They stress the importance of limit setting, awareness of boundaries, and of keeping the right distance emotionally. These responses derive from an understanding of the vulnerability and chaos that typifies such clients’ lives (Pines, 1978) and their inability to integrate inner conflicting tendencies. Therapists wish to prevent the client from getting overwhelmed by these conflicting thoughts and feelings and becoming disoriented and helpless. The provision of structure may also stem from therapist’s vulnerability. As Kernberg (1968) stated, therapists working with borderline clients can easily be ensnared by the strong emotional suction of these clients. This might alienate the therapist from his or her own natural reactions and disrupt congruency. To protect themselves against either colliding emotionally or detaching coldly, therapists often need more structure themselves to escape from debilitating “counter-transferance.”

(2) Therapists search for ways to enhance these clients’ ability to experience directly instead of being preoccupied with how they present themselves. For example, both psychoanalytic and Gestalt therapists (Bauer, 1979; Eigen, 1973) experimented with inducing trances in borderline clients. Commenting on the effectiveness of this approach, Bauer stated: “In a sense, the metaphor of going into trance to work on a particular experience or feeling allows the patient to set limits and boundaries on what will happen to him. He begins to see that the painful feelings can be touched upon and yet contained, and he is therefore more free to work with them” (p. 372). He adds, “Trance provides a ritual for the patient to give focus and defined expression to his chaotic and undefined experience” (p. 374). Client-centered/experiential work with borderline clients (Grindler, 1982; Santen, 1986, 1987) by means of focusing is based on the same kind of observations. Focusing with a borderline client helps provide needed structure and facilitates direct experiencing.

GENDLIN’S CONCEPTIONS OF PERSONALITY CHANGE

The basic concept used by Gendlin (1962, 1964) is “experiencing.” This is the reaction of one’s body to all that comes to it from either the outside or inner world. The body reacts to those stimuli with a constantly changing feeling quality that can be distinguished from emotions and sheer physiological reactions in

that it encompasses all felt aspects of a problem. Though this bodily felt process is important to our psychological functioning, one is usually not conscious of it. When in contact with bodily experience, one feels a vague but nevertheless clearly immediate feeling evoked by the situation one attends to. Gendlin calls this the felt sense of the problem or situation.

To the extent that one is psychologically healthy, the direction of one’s experiencing is codetermined by symbols (e.g., words, gestures, images). The preconceptual experiencing is in con­tinuous interaction with this symbolization. In this interaction the felt sense can change and new facets of meaning can be sensed.

CURTAILMENT OF EXPERIENCING

Sometimes, however, experiencing can be structure-bound. The interaction between perceptions, thoughts, verbal utterances, actions, and their experiencing is disturbed. Certain cues repeatedly evoke the same feeling that is not influenced by the context of the moment. For example, closing your office door may evoke in your client a persistent feeling of being trapped in the therapy situation. If structure-boundness is extreme, these stereotypically recurring feelings and ideas tend not to be perceived as “owned.” Experience intrudes upon the person, like watching one’s own movie; As a result of the interruption of the feeling process a lack of one’s sense of self occurs. Just as occurrences in the outside world are not interpreted on the basis of bodily experiencing, this bodily felt process also lacks a relationship to the “self.”

FOCUSING

Focusing is the mental activity that leads to the reconstitution of experiencing. This subtle way of contacting one’s inner experiencing causes one’s problems to change in one’s body.

The use of the focusing method is based on the belief that the client can change if he or she learns to contact troublesome experiences in an accepting way. The client is guided in attending silently to the totality of bodily sensation: emotions and former experiences related to the problem and to experience this directly as a whole. Then, open-ended questions are posed to the felt sense of the problem. One can consider focusing a form of client-centered therapy in which one’s mind functions as the therapist while the body is the client. After open-ended questions are posed, the client then awaits his or her bodily reactions and checks to see if they fit the problem being addressed. In this way focusing is a dialogue without coercion in which the focuser formulates short verbal descriptions or images related to the felt quality of the problem. The validity of the response is determined by checking again and again with the bodily felt sense until the fit feels right.

This direct reference to experiencing can cause an unfolding of the feeling that is accompanied by a physical sense of relief. The problem begins to feel different and less cramped. Newly emerging descriptions of the problem will be more striking than previous ones. The changes in experiencing thus initiated affect the client’s behavior and the way the client experiences him or herself and the environment.

FOCUSING WITH A BORDERLINE ADOLESCENT

Focusing can be an effective approach to treating borderline adolescents. Before illustrating this, I want to mention some specifics that may contribute to its relative effectiveness with this type of client.

(1) During the focusing process the therapist remains in the background as much as possible. The therapist acts as a nonintrusive companion in an exercise designed to enhance more fluent interaction between the client’s feelings and thoughts. There is no necessity for the client to report to the therapist who facilitates an inner process instead of asking about content. This more professional-technical and nonintrusive style helps lessen the client’s fear of closeness.

(2) The opportunity provided to clients to close their eyes (if they want to) and attend to the middle of their body may also help lower their level of fear. Since many borderline clients are relatively unable to inhibit and select stimuli from their outer and inner world, the focusing process helps them avoid feeling overwhelmed. Focusing may also assist such clients by limiting stimuli from external and internal sources.

(3) Working with borderline clients requires a delicate balance between respecting and bypassing their defense mechanisms. Within the focusing structure, this balance is reached by alternatively allowing the client to maintain and then let go of ego control; a variation of relaxation and mental alertness (Gendlin, 1969; Miller, 1970). In this way, preconscious material comes into consciousness and is then used constructively by means of the client’s ego.

(4) Focusing helps the client to use words and/or images to give a more differentiated form to bodily felt but preconceptual experiences. For borderline clients, finding more ways to express themselves verbally is very important. If they do not succeed in finding a verbal means of expressing these experiences, they will remain structure-bound in a whirlpool of feelings and thoughts.

(5) Usually borderline clients can easily evoke visual images (Salzmann & Machover, 1952). Often these concern memories and fantasies; sometimes they have a hallucinatory character. By focusing on these images, emotional aspects connected to them can become recognized, and processed.

CASE STUDY

When 14-year-old Wanda and I met for the first therapy session, eleven months after she had entered our psychiatric clinic, she remained almost motionless. Wanda hid behind her hair. She was extremely inhibited, stiff, and constrained. Her diagnosis was “borderline syndrome.”

When Wanda was 23 months old, her sister was born. The birth of her sister frightened Wanda. She felt rejected by her mother, and clung to her skirts. Wanda became increasingly demanding. An ambivalent symbiotic tie developed between her and her mother.

At age 4 it appeared that Wanda was developing obsessive traits. In kindergarten she became upset unless objects stayed in their place. During her first years of elementary school she became increasingly perfectionistic, obsessive, and fearful. When she was 10 years old, Wanda’s separation anxiety increased so much that she became extremely fearful of leaving home. She feared crowds and shopping. Wanda was frightened of contamination and irregularity as well. At home she would spend hours in front of the mirror, parting her hair so harshly that bald spots appeared; if interrupted, Wanda became fearful and could burst into a rage. Wanda was jealous and demanding and tried to possess her mother as much as she could. When outside, Wanda shied away from contact with adults. Though she scrupulously tried to force herself to behave as sweetly and adaptively as she could, she often became overwhelmed by her inhibited aggressive feelings, most of which seemed to concern her mother.

Wanda reacted fearfully and suspiciously to efforts by therapists to relate with her. A year before she was sent to our clinic she was admitted by another clinic for several months and then treated individually as an outpatient. Family therapy and individual psychoanalytic therapy failed because of what was called her “negativistic attitude.” Medical treatment was attempted but periodically she refused to take her medicine.

During her therapy with me, Wanda would tell me how she had begun to feel conflicted as she grew up. As soon as a request was made of her, panic would grow into an inner chaos. As soon as she made a statement, she would doubt it. For many years she experienced great internal conflict and felt alienated from herself. It was as though her feeling weren’t real. She would sometimes be surprised to find herself acting aggressively without being aware of any anger inside. It was as though she wasn’t the one acting, or even really present. It took a long time, however, before Wanda could realize and verbalize these facts.

INITIAL PHASE OF THERAPY

During the initial phase of therapy Wanda and I met weekly. She said she didn’t know what to talk about and seemed to be afraid of verbal contact, but also couldn’t bear long silences. She wanted to start working yet was hesitant to do so. She indicated having all kinds of vague feelings and thoughts jumbled together that scattered as soon as I spoke to her. In reply to a question of mine, she explained:

Somewhere I know it, but I cannot put it into words. . . . It is a thought.. . . Is it, a thought?. . . It is certain that it is clear, but I cannot put it into words.

Utterances such as this led me, after four weeks, to propose to use the whole session to teach Wanda focusing. It was hard for Wanda to do this. Back then, she was still unable to identify a problem on which focusing would be possible. The direct naming of any problem at all was too threatening to her. Implicitly it would have indicated a willingness to change, which she seemed to experience as yielding to my control. Realizing this, I decided to ask her to start focusing on the immediate feeling that the therapy situation evoked in her. This seemed to lessen her fear of the situation. Several weeks later she was able to attend to bodily problems such as her headache and the fog she localized in her head. Focusing on these heightened her severely defective verbalizing ability. Asking her to imagine herself falling asleep and gradually beginning to dream seemed to lower her resistance and increased her capacity for visualization. Sometimes I asked her to visualize some of the words that arose in her and let them resonate with the evoked felt sense.

Since Wanda’s anticipatory fear of expressing herself (she seemed to think that she was obliged to tell me the words that came up in her) triggered her panic, I asked her to raise a finger as soon as something new arose in her that she wanted to communicate to me. This enabled her to retain control of her communication.

In those first weeks the extreme structure-boundness of Wanda’s inner world was broken. This constituted a threatening but necessary disturbance of her pathological equilibrium. From then on Wanda’s experiential process began to unfold.

The frozen character of Wanda’s inner world expressed itself strikingly during the second focusing session. Her flat and isolated “handle” words spoke for themselves: “cold”. . . “petrified”. . . “chilly”. . . “stuck”. . . “oppressed.” But while the structure-boundness was being verbalized, experiencing unfolded:

The vague image of a black corridor appeared. The corridor had a small white spot. This first felt shift was accompanied by a sense of relief. “It is as if something has left me,” Wanda said.

During the next session the words “sensitive,” “restless,” and “with lagging steps” arose. Wanda described the emergence, then the breaking off, of a feeling process. Though hard to follow, I quote it as she verbalized it.

There is something, and yet there is nothing.. . a strange feeling, a restless feeling.. . . Thinking becomes more vivid, and everything that has something to do with it... . It has something to do with that vagueness, that everything is always that vague.. .. It is a train of thought, thinking. . and something very queer, a snapping off.

Evidence that Wanda’s sense of self was being recovered emerged in the images, which now arose more clearly. Her feelings of liveliness announced themselves as well. When Wanda uttered the word “will-less,” this evoked in her the image of a doll’s face. Sometimes it had animated features, though at the same time it was not really alive.

It seems to become a real face. . . . At least it almost laughed... The form also changed. . . . It does not really laugh. Those eyes, yes, they don’t look... . Oh, they are becoming deeper.

Step by step Wanda approached the moment when, in her own imagination, she could take over the leading part played by the doll. During the sixth focusing session she could visualize herself for the first time. The next week the doll disappeared almost completely. When present it took the shape of other persons.

In this period progress was made that ended in a wish-fulfilling image of closeness between mother and child:

-The doll strikingly resembled a doll Wanda possessed.

-This doll was given an (changing) age.

-It changed into a human being without identity (trunk and legs visible, face invisible).

-It then changed again into a “queer, strange” doll, this time in a place where Wanda had sometimes been herself.

-Thereupon Wanda saw herself standing there, 6 or 7 years old.

-Then the doll (“my own doll”) approached her; they held each other tight and walked away together.

-Wanda then changed into a 25-year-old mother, the doll into a 1½ to 2-year-old child.

-A peaceful and wishful image of closeness appeared: the mother lifted up the child, and they cheerfully walked on together.

The act of searching for words that referred to her feelings often isolated Wanda from those feelings. She still expressed herself most easily in images. For the moment I used this medium as an important vehicle to bring her into contact with her feelings.

Wanda began to experience words and images more and more as manifestations of her own inner life. Affectively colored images of the past arose. After evoking the felt quality of the therapy situation in her, I alternatively asked Wanda to match those arising images with her feeling. I had her repeat the handle words and resonate them with the felt sense, and asked her to pose questions to her body concerning the feeling. Now and then I asked her to talk briefly about those memories. Also, I regularly repeated out loud one of Wanda’s handle words to let it resonate with her feeling.

Wanda began to experience more connections between these images and words, which first tended to appear as isolated, fragmented units. Excessive attention either to those images or to the feeling could have destroyed this developing coherence. Most likely, this would have caused a sequence of images without feeling or a strengthening of affect without a felt process (Prouty, 1977).

What had at first been called “cold” was now described as “stiffening with fright.” Wanda visualized herself back in the clinic where she had stayed two years ago. The psychiatrist appeared again. He posed his questions. Wanda reexperienced this situation as an intrusion that frightened her. Focusing on this feeling initiated a chain of felt shifts. She was overwhelmed by associations, long forgotten memories, and so on, which related to this feeling of intrusion. It confused her and frightened her. However, she started sharing these feelings for the first time with one of the nurses in our clinic. In her therapy sessions, she began to share with amazement that, when in the other clinic, she hadn’t felt the fright she experienced during this scene while focusing.

The sheer experiencing of being carried passively along by others decreased in these weeks. Along with a sequence of new images and partly verbalized feelings, the awareness of feeling “suppressed” and of wanting to resist loomed up. Again Wanda was astonished. She saw herself resisting the psychiatrist and trying to get released from that clinic while reliving a situation in which she willingly let herself be abducted.

During the ninth focusing session, Wanda visualized herself as split into two persons. She saw herself in front of a glass wall looking at a sham, seemingly docile, part of herself that was sitting at a table in front of a nurse. Knocking at the glass wall, she saw that the sham Wanda was being dragged away. Alternatively two images appeared. The one showed her in her sham docility, the other in her fearful resistance. That this resistance concerned me, since I engaged her in this therapeutic process, Wanda would realize only some time later.

After the ninth session, the historical character of the images disappeared. Increasingly, they began to refer to the reality of the present situation that until this time had been so “unreal.” Wanda’s dreamlike inner world, full of images that had appeared rather free-floating and dreamlike to her, was disturbed. A critical phase in the therapeutic process had begun. By allowing this focusing process, Wanda risked the old and “safe” pathological equilibrium. As she commented:

It is as if someone enters, in order to hold me. . . . But then usually I hide under my arms. But in some way he already holds me, and if I withdraw I cannot get away. In fact he doesn’t hold me, and yet I’m caught. . . Jesus Christ! . . . But sometimes I think, “just let him.”

At that moment, Wanda was no longer merely experiencing herself as split, because by symbolizing this splitness and by imagining it in the waiting room, she had become able to remove herself one small step from it. The next step was unknown and threatening, however. The whirlpool of experiences (symbolized by handle worlds such as “floating” and “whirling”), which she was not yet sufficiently capable of integrating, waxed too quickly. Wanda agreed to take medication prescribed by our psychiatrist to mitigate her fears.

From the tenth to the fifteenth session, focusing led to additional unraveling. The quality of the initially very vague feeling was shifting. A global feeling of being enclosed and stuck came forward. Gradually this was replaced by a feeling of desperation. Wanda’s aggressive feelings began to crystallize followed by feelings of being caught, caged. The dawning awareness of feeling caged had a liberating effect. For the first time, after 5 months of therapy, Wanda had more positive or neutral memories.

MIDPHASE OF THERAPY

Wanda found herself in a state of transition. Hesitantly she reestablished contact with the outside world. During the twentyfirst therapy session she opened her eyes. Sometimes stammering, but with increasing fluency, she began to talk during and outside the focusing work. For example, she described how she observed the outside world from her glass bell through a little window.

Before falling asleep I got an image: it was the inner side of something round. . . . There was a door in it. There I was standing, yes, and then I fell out of it. . . I kept falling, but yet I held myself tight.

Meanwhile Wanda actually opened herself more to the world. She talked more about what the proximity of others evoked in her.

Sometimes it occurs when somebody touches me, or holds me or something like that. . . I don’t know what happens but I withdraw. Those boys this afternoon, I don’t know if they held me tight, but I just wanted to quit.. . I don’t know whether I beat them or not, but anyhow I wanted to be off.

As I mentioned before, in this midphase of therapy Wanda began to give extensive descriptions of self-alienation and the feeling of not really being present. She indicated how much she had withdrawn from the outside world in which she “behaved” but didn’t really feel.

After about 25 therapy sessions, focusing was employed within a broader therapeutic strategy. Now that Wanda began to speak more fluently, other techniques (empathic listening and paraphrasing, some tentative interpretation, a single Gestalt exercise) also contributed to the therapeutic process.

While Wanda engaged in a closer relationship with me, she revealed something of the self-protection she needed within that same relationship.

You ask a question, and then I must answer. Mostly I give an answer, but then I don’t know if I really mean what I say. Then I just say something to get rid of it.

Several weeks later Wanda explored more deeply how she tended to scatter in such a threatening situation.

Wanda: I think I must be able to give an answer immediately, but if I start thinking, mostly I wander away, or I don’t know the question anymore.

Therapist: It seems as if you become panicky then. . . slight panic, but I don’t know if that fits.

Wanda: Yes, then it is as if I have lost my grip.

Therapist: Just as if you’ve lost the bottom under your feet, as if you have nothing to stand on?

Wanda: Yes, sometimes it is as if I am in quicksand, and there’s nothing I can catch hold of any longer.

Therapist: Nothing you can catch hold of, as if you might be swallowed?

Wanda: Yes. . . sinking away, falling. Then I see myself really in quicksand.

In the beginning of most of these sessions, focusing seemed to remain necessary initially. After such a beginning, Wanda was more and more able to start talking herself, and develop initiative in our contact. As a consequence of her inner conflictedness and her profound fear of independence, however, it was generally still very difficult for her “to be able to want” anything. Between the thirtieth and the fortieth therapy session Wanda regularly used the word “I.” Repeatedly she muttered the words “own will,” as if to try out a discovery. Though she feared contact with others who had more willpower than she, it seemed that her sense of self had been strengthened. At least, she was able to explore her fearful experiences in new ways now, which turned out to have a crucial impact.

 

TERMINAL PHASE OF THERAPY

After a year of therapy Wanda started to focus directly on her conflicting impulses, which had paralyzed her so much up to now. As she acknowledged:

Whenever I say “yes” there is always something inside me that says “no” too.

Using the Gestalt empty-chair technique (Greenberg, 1984), Wanda initiated a dialogue between those conflicting impulses. Aditionally, she focused (on a third chair in between) on how it felt to have this dialogue going on. At this point her desperate sad feelings broke through:

During the whole day I am busy not to think about it. It keeps me restless. It makes you so tired.

Having said this, Wanda began to cry. She hadn’t cried for years. “I think I’d given up years ago,” she sobbed, “everything goes wrong. I never can do any good.” These were weeks of distress, in which Wanda permitted me to support her silently by holding her shoulder. Her fear of proximity had largely disappeared. She now explained that, many times, she hadn’t wanted to live any longer. Exploring these recurrent death wishes, it appeared that this had to do with her feeling that whatever she did, however hard she tried, she could never do well. For the first time she began to talk about her mother. She felt rejected by her.

Wanda began to talk openly about her hostile feelings toward her mother, and also expressed them directly toward her. “I wish I could hate you,” she told her. “Then it would be much easier for me to leave you. You don’t understand me.” She openly blamed her parents for sending her to the clinics. Initially at Christmas she refused to go home. “I’d rather go roaming about,” she said. When her mother described her own feelings, Wanda replied: “The way you feel now, I always felt, in inner struggle.”

After approximately one and a half years of therapy, Wanda’s inner struggle diminished. She developed a more energetic, self-accepting attitude. Her mother mentioned that for the first time in many years she saw Wanda strive for something. In relationships, Wanda sometimes felt that she could still behave with forced exuberance in order to hold off unwelcome feelings; yet she experienced the increased contact with others as easier and more pleasant. She shared intimate experiences with her little sister and with her first real girlfriend. She fell in love, and was able to speak about the intense feelings and dilemmas this evoked.

After two years of therapy (three years after admission to the clinic) Wanda left the clinic. She continued therapy with me as an outpatient for over a year. While making contact with other people could still frighten her, she was able to explore that with me.

About three years after we met for the first time, Wanda-who lived far away from the clinic at the time-decided to terminate therapy. Shortly after that, the interpersonal tensions at home escalated to such an extent that she moved to live with another family and stayed there. In spite of that, I believe that she had developed sufficiently into a separate and integrated person to be able to cope with life more adequately than before.

DISCUSSION AND CONCLUSION

Wanda’s therapy raises the question of why focusing did not cause disintegration. An obsessive girl-fearful of any change and loss of control-was asked to allow unpredictability. One might have expected this to increase her pervasive fears and inner chaos. Instead the danger of deterioration diminished.

One of the main factors restraining the danger of deterioration was that the framework of the focusing method allowed me to respect Wanda in several ways: It provided the pace, the emotional distance, and the structure and amount of self-control she needed. I rarely encouraged her to go into the contents of her problems. In this way, her fear of having to talk about her “bad stuff” was diminished since she was able to mention only what emerged. All this happened at Wanda’s own pace, which made the process safe enough to allow experiencing to occur. Additionally, the process was facilitated because the focusing approach allowed me to respect Wanda’s fear of merging with me by becoming a more technically oriented guide. This relatively safe atmosphere enabled Wanda to trust herself in a structured and empathic relationship. As I provided her a stable environment, she became able to contain and process her fearful and painful experiences. As long as the therapeutic method used enables the therapist to refrain from being pushy and to provide structure in a firm but sensitive way, borderline adolescents can be helped to develop therapeutically. In my view, focusing is one of those methods specifically suitable to provide this occasion.

There are other clients, however, who are too detached from reality, or who cannot experience themselves enough as the locus of their own experience, to allow the basic contact with the therapist needed to make focusing possible. For these clients other therapeutic approaches are needed that are sensitive to their severely defective communicative abilities. Inspired by Carl Rogers and other client-centered therapists who worked with schizophrenic clients (Rogers, 1967), Prouty has refined Rogers’s reflection technique for hallucinating psychotic clients (Prouty, 1977). These techniques can help such clients to assimilate and integrate hallucinations that are experienced in an alienated way. Prouty beautifully illustrates how these persons can learn to recognize bodily felt aspects of experiencing that are basic to their hallucinatory experiences.

I will end by quoting Wanda one last time. “Most of all I saw you as human being, only in the second place as a therapist,” she once said. If she hadn’t experienced me in that way, I think the therapeutic process would not have taken place. It was not just technical experience with focusing that made the situation safe enough. It was rather the totally undemanding way in which it was done. Both technical skill and genuine care are needed.

REFERENCES

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