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Gestlat Therapy and Borderline Personality Disorder

Gestlat Therapy and Borderline Personality Disorder

This writing came from self reflection. I am stuck at times when to asking in difficult situations whether a positive outcome can be achieved, or is it a utopian wish. In my journey, from a deeply shamed and damaged teenager leaving school and home at the age of fifteen years, there have been many times, when optimism and hope was my only resource. I cannot answer the question where did I get it from but I had it, most of the time. The BPD client has a wonderful resource of excitement and energy that I love. That wish, as I see it, to make contact in order to get their relational needs met seems almost indestructible. Like my own optimism, this energy can be harnessed into motivation to keep going with the undefeatable belief that it will lead somewhere. Somewhere that maybe we all look to reach. I believe, from my own evidence, if I can attain the ability to relate and be in the world in a somewhat healthy manner, after having discovered Gestalt Therapy, then it is open to nearly everyone. Whatever, the opportunity will remain, that the client and therapist can indeed get somewhere together along the journey. A place that makes being in the world less of a torment and more of a nourishment that contains aspects of spontaneity, connectedness and joy for the person with BPD.

Personality disorder is a comparatively new term or diagnosis. Psychosis and neurosis were the well documented diagnoses of the early 20th century before it was realised that these were far from adequate. Borderline became the 'in-between' category where individuals were seen as neither psychotic or particularly neurotic but somewhere in between. Narcissistic and schizoid personality disorders soon followed as diagnosis, which could indicate that some form of personality disorder is present in many forms of mental illness.

Here I wish to write more about BPD from my perspective of working with the issue and from those in the Gestalt world whom have written on the topic. Initially I will write regarding the experience of BPD. I will then look at it closely from a Gestalt perspective and then at how therapy can help.

Margherita Spagnuolo Lobb, the Gestalt psychotherapist and trainer, wrote of BPD (2013), 'Borderline personality disorder faces a human drama that is much more complex than that of the repression of the emotions and the consequent lack of autonomy. It pertains to a more delicate experiential field, in which uttering one's emotions leads to an expansion of the self which is always dramatically conflictual: a profound sense of split leads the sufferer to desire and at the same time loathe contact with the other.'

So what then is the experience of BPD? People with BPD traits usually connect with the extremes of emotional reactions. This is termed splitting (more on splitting later). They can be very energised, out-spoken, aggressive and demonstrative. Experiencing few boundaries in what they may do or say. I remember a client telling me when I asked what it would be like not experiencing this intensity replying ‘boring’. In the other extreme, connection is with the depressive aspect of life, - feelings of worthlessness, low self confidence, 'no one is there', - and deep experiences of guilt and very often shame occur. This is associated with a strong tendency to self-blame which is experienced along with acute painful feelings of abandonment, in turn leading to thoughts that the relationship must be recovered at all costs. The energy turns inward toward self harm or suicide.

It is very much these poles that are inhabited and that outline the traits of BPD. People with BPD have very little sense of alternative modes of being in life. This volatility is consistently very difficult for both the person experiencing these issues and also for those around them. Because of the volatility, BPD is sometimes diagnosed as Bipolar or diagnosed together with BPD. You can find more regarding the traits of BPD in Kernberg, (1968) Yontef, (1993) and Spanguolo Lobb, (2013).

I would like to spend more time in looking at what is behind these traits and how they arise, and by taking the high level of emotional excitement (experienced as one of the two polarities) as a starting point. It is worth outlining now, that within Gestalt Therapy excitement in perceived as that very behaviour that is the reaching out for contact and is no-way considered negative. Excitement and Growth... is, of course in the subtitle the of the book, Gestalt Therapy (Perls, et al 1951,). However, it is the 'Growth', a clear gestalt and of course assimilation of that growth that is missing in the BPD client.

At a very early age babies are born with needs, and by needs I mean not simply physiological needs, such as hunger, but needs of relationship. These needs include reaching out physically, looking, seeing and touching as well as being touched and held physically and emotionally. Frank (2001), has described how even the youngest of babies can move with relational contact in mind. Stern (1985) has also evidenced the movement from very young infants toward the mother showing early signs or recognition and getting what they need from a relationship. Buber (1996), encompasses this in the I/it, the relating that needs something from the other, and I/thou relationship, resting in the arms of the other experiencing the feeling of being loved. Feeding, as a basic initial need, is absolutely essential amongst these aspects of getting physiological nourishment, while also containing a very strong relational aspect from which nourishment is importantly experienced. Whether it be bottle or breast, babies will want feeding. The response of the provider within this process can take many forms. There is the healthy response that would consist of love, affection, validation, patience and soothing but there are also many other responses.

Take the response of frustration. Maybe if a baby is difficult to feed for whatever reason, or the care-giver has little time or patience, the response from the feeder could well be one of frustration or even anger. This in turn raises the level of excitement in the baby. The baby is frustrated and maybe hungry also. The levels of excitement and frustration rise in unison. The levels of excitement and more importantly the capacity for excitement regulation is fundamental to the growing baby or child. Feeding is the first relationship that occurs between child and adult, the process of relationship has started. In the case of a frustrated feeding experience a foundation of high emotional excitement is established within this early processes of relating.

The above is an example that enables us to see what may well be a pattern that is establishing or mode of contact that affects the way a child could grow and be in the world. It could well be that the attitude of the care-giver, for example impatience and frustration, is one used in many different ways of relating in their every day lives to the child. It is not difficult for me to imagine what this mode of relating offers: unhealthy, escalating levels of excitement and frustration, levels that in the case of BPD would raise in turn the levels of excitement in the child to similar levels to that of the care-giver. If the needs of the child are not met, which is very much the likely outcome, the needs of the child will not go away, see below. Frustration and anger will grow. This method of relating can often reach very high levels of emotionality and excitement. As a child grows, becomes older, and becomes acclimatised to this way of relating, it will be highly likely even greater extremes will be experienced. It is important to note (Stern 1987), that it is not one instant that causes pathology, but a sequence that can commence or become established at anytime in the child's life, and may well not necessarily start, at the very earliest moments of the experiencing of relating to the other.

Now I will turn to how Gestalt therapy could look at this process. From Ego, Hunger and Aggression (1947): Perls wrote 'the central conception is of the theory that the organism is striving for the maintenance of a balance which is continuously disturbed by its needs, and regained through their gratification or elimination'. Following from this conception and a central theme in Gestalt therapy is creative adjustment. This is the regulating part of self that regulates each encounter at contacting. This would be the case in the regulation of excitement. From Gestalt Therapy Perls et al., (1951): 'Suppose, for instance that an urge or appetite is not satisfied from the environment and the emergency function (tantrum, dream, blacking out etc.) cannot operate or are exhausted, then there will be readjustment of the physiology, an attempt to establish a new unaware equilibrium in the new

conditions.' Becoming aware of any bodily feelings, or, the inherent needs does not solve the problem, there remains a solution or creative adjustment to be lived out or fulfilled. If the social environment is still refractory to creative adjustment, and the client cannot adjust it to himself, then he must again adjust himself to it and keep his neurosis'.

How does the individual achieve this creative adjustment within BPD? The need is established, it is met with frustration and excitement, this in turn is met like-for-like, excitement raises, but the needs are still not met. The child is still not met. Within this process of relating the child could respond in different ways: with fear and withdrawal, or to meet the levels of excitement 'like for like' with the enduring motivation to get their needs met. The latter example, like for like, would be the case in BPD.

It is interesting to note what precipitates different responses or creative adjustments. I would contend that the level of excitement displayed by the parent is not at a level to induce fear in the child, but enough to allow or more importantly, even to encourage the child to follow their lead. There must also be that level from the child to meet that excitement and not back away quickly as a response. This is very much the response from the individual to the environment that is the creating of a relationship, emergent together (Philippson 2001), from the situation, (Robine, 2015). Kernberg (1967), has written regarding the dual nature of the response. This for him was very much the origin of BPD. The environmental and/or a genetic cause (dual nature), which could be a predisposition of the child toward high levels of excitement. However, from the gestalt perspective it is neither one or the other but the situation together, that is, the emotional nature of the care-giver and child. When the two meet together or collide in a destructive engagement, this results in a lack of actual meeting or contacting. I readily acknowledge that other variables could contribute to this response but these would, in my view, be less of an affect.

Now, thus far we have a high level of excitement established at the contact/boundary. There follows stronger breathing which in turn has nowhere to go, meeting and/or completion does not take place, there is no nourishment to assimilate. It is not possible for one method of excitement to be sustained for long periods in the absence of some compensation. Incorporated within Gestalt therapy there is holism and circuitry or circuits (Dewey 1896 in Kitzler 2006), and within this circuitry exists the compensation or creative adjustment the child needs to survive. The child holds the breath and anxiety ensues, 'Anxiety as an emotion is the dread of one's being' (Perls, 1951). The body therefore becomes figural -'it is an attempt of creative adjustment, working on the body instead of the environment'. However, in Gestalt therapy theory the initial needs or excitement remain, these cannot in themselves be repressed, only the manner of dealing with them or inhibiting them is the repression. Therefore, it is this repression that may well become part of the body in the form of tension or holding in. However, in BPD the level of excitement is high and the ability to regulate this excitement is low and further regulation is not encouraged or taught by example or role model. It is the body that becomes the resistance but more importantly the body becomes the resistance to the sense of being, that is the level of excitement. Still, importantly the basic need remains unmet, the excitement is still present, both remain and are both unmet, where can this energy go? It is turned inward; into the body. The energy remains, the same levels of emotionality and intensity that already exist has nowhere to go, therefore, is turned around as a compensation. This is the circuit towards a holistic integration, that enables a continued existence, albeit an unhealthy existence. This in turn will quickly lead the child or adult to feelings of guilt, shame, depression, feelings of abandonment, and lack of self esteem, all encompassed in the feelings of unmet relational needs, again with similar degrees of intensity or excitement but directionally different.

To underline, subsequent to such intense emotional encounters as above the child is still left with those unmet needs. As put in 'Gestalt Therapy' (Perls et al., 1951), 'it is the work of creative adjustment that heightens awareness of what one wants', and later in the book is the description of the process of interrupted 'excitements', needs not being met, and ...'in such a case the excitement becomes spectacularly disruptive of the organising self… this is not useful for learning anything' … however, and, ...'again there is nothing left to assimilate'. The breath is held and anxiety is felt which in turn leads to fear and more particularly the fear to reach out and make contact or fear of the raising level of excitement in the relationship, often to levels of extreme destructiveness. The world becomes something very different. There ensues feelings of being alone, abandoned and self blame, a very painful and distressing place to be. Life for the BPD client is very emotional, as to occupy one extreme consistently is impossible, yet, importantly needs remain unmet, the need for contact remains and the feelings resulting from not getting it also remain, although very likely, lost in the overall turmoil created within the environment of unmet needs.

So, from the above we see that the experiencing of emotional outpourings toward another get nowhere, and these feelings are then turned inward toward the body. The emotion remains but is turned around with the same intensity and extremes. The child or adult becomes a living intense, excited, emotional child in response to the care-giver and also to how life is within their family system into which they were born, (situation). However, often the world or life outside the family system is a very different place. Contact or relating, in the same manner, does not work and could well be shunned, ridiculed or even not unlikely, criminalised.

In many families of this nature, it could only be one parent involved, with little or no support or reflection from any one else. Maybe, the other care giver, if there is one, is rather absent or even, as I have seen in my work, to a degree supportive and encouraging of the child against the other parent, enjoying seeing the child engage in behaviours absent from themselves. Moreover, if there are other members of the family in the situation, they may well enter into the same 'communication style' in ways that exacerbate the situation. The overall outcome is typically one of chaos, where, healthy contact is not experienced by anyone and importantly chaos has become the norm.

With this in mind the nature of Attachment theory will be integrative in how a child meets the world and what patterns are set (Bowlby, (1969), and Ainsworth, (1970). Secure attachment is the healthy aspect of a child's upbringing. It has been exemplified in the relationship of a typical BPD client that this does not take place. Feeling safe and secure is very much what a child needs. The Boston Change Process Study Group (2010), a group made up of Daniel Stern amongst others, have shown the ongoing need for ‘intersubjectivity’. This need, that arises at birth (see above), does not diminish or disappear. Looking for intersubjectivity is such an important ingredient in therapy and life. The search or longing is usually with excitement and energy, which when not met with acceptance becomes feelings of insecurity, felt with similar intensity. To attempt to live with these feelings are inconceivable. Therefore, consequences could well be the extreme feelings of depression and abandonment that occur so frequently in BPD, so much so that the wish to return and experience a safe secure base becomes paramount, to repair the primary relationship with the other at all costs.

These are the traits of a typical BPD diagnosis. There is no between, or middle mode (Perles et al 1951) this again in Perls 1951 is termed splitting. There is little or no contact of the in between state, the child learns to live in the intense extremes or polarities. As the child gets older and these experiences continue these situations become hardened, deepened and entrenched. There appears to be no choice (ego) or a sense of responsibility. Importantly the ability to relax is a distant thought and life is full of emotion and conflict within the self or with another, hence life is very difficult to live effectively and relationships difficult to sustain or enjoy. Splitting is not uncommon and can be seen elsewhere for example in inhabiting the positive or negative polarities. However, what remains in BPD is the sense of the emotional excitement that will push the other person away and the emotional depressive state that will attempt to pull them in. Each is a state that is not available for the actual completion of the contact process that the client is looking for, this is because of the emotional desperation in evidence will not be productive. The client becomes unreachable through the emotion, they are shut away within the creative adjustments that become their norm, and what is more obvious, is the losing of their sense, which may have been present in the distant past, of what the child actually needed originally, clear healthy gestalt's that result in assimilation and growth. Sadly the lack of ever having experienced the full contact or intersubjectivity that is the need.

This is the outline of the primary historical relationship that exists in the background of BPD. When the person has the opportunity to experience a different relationship maybe as they grow up these traits will be present and entrenched, behaviour patterns will follow that replicate those experienced within the initial primary relationship. Feelings of abandonment and depression or emotional outbursts when needs are perceived as not being met, splitting.

BPD is a disorder of the self, that is, it is the process of behaviour, usually not helpful, that a person engages in certain situations. However, individuals do have a choice and within that choice there is empowerment. Within certain aspects of BPD there appears to be action into the extremes without choice, this then is the splitting. The part of therapy, particularly Gestalt therapy, is to find the awareness that the individual has indeed a choice (ego, see below), then to subsequently embody that choice and finally to act in ways that represents that choice in healthy ways. Consequently, utilising the process of the self in a manner that enables the individual to engage in relationships that can nourish and sustain.

In Gestalt therapy the self is emergent (Philippson, 2009). A passage from Perls et al Gestalt Therapy (1951), 'The complex system of contacts necessary for adjustment in the difficult field we call the 'self'. Self may be regarded as of the boundary of the organism, but the boundary is not itself isolated from the environment; it belongs to both, environment and organism. Contact is touch touching something. The self is not to be thought of as a fixed institution; it exists wherever and whenever there is in fact a boundary interaction', contacting.

As we have seen throughout this writing self forms from relation to the other. Self responds to the environment and acts, hopefully according to appropriate healthy reactions. In Gestalt, the self has three aspects. The id... the resting relaxed stage, the aspects of self are relaxed and at rest. No firm sense of who we are is felt. The ego... boundary aspect, rising from rest, becoming interested, making choices, selecting and alienation. The aspect of self is waking up and becoming interested, this could be because of internal or external sensations. Finally, the Personality stage, integration takes place, becoming who we are from our history and principals in relation to the environment. The position of being able to explain ourselves. This process is not linier but are ‘functions of self’ that operate together in any sequence. This process is healthy contact that the BPD client is usually missing out on.

The missing function of self in BPD behaviour is the ego or choice function. Splitting is occurring as a defence and creative adjustment this action not only leaves behind the aspect of the person making a choice but also a sense of responsibility in what choice they make. That sense of self within BPD, has been creatively adjusted into polarities. It is within therapeutic relationship that a sense of choice, responsibility and being nourished can be established. Consequently, relating becomes a different experience, with the awareness of what the client is and has been looking for by way of needs, and these actually being met.

It has previously been thought in the UK that therapy consequently change for BPD was not possible in terms of a movement toward healthy responses. A Gestalt therapist has the advantage of not having to respond to a client with a diagnosis but of being with most clients all in very similar ways, as unique human beings. Experiencing contact and healthy relating are seen as the keys to unlocking responsibility and choice in responses. Attitudes of being in the world, accepting differences, and the consequent nourishment that hopefully occurs are integrative to the Gestalt therapeutic process.

We are now at the point where Spanguolo Lobb (2013) puts so well 'For Gestalt therapy, the suffering of the borderline patient is a Gestalt of socio-cultural, genetic and primary relational aspects, and the way the patient lives the therapeutic relationship re-proposes a suffering that has remained open in fundamental relationships. Hence, the task posed to the therapist is to complete, in as relaxed a manner as possible, the intentionality that was interrupted in the primary relationships, which now brings suffering'. This sense of what is needed, the intentionality, can sometimes be overlooked within the therapeutic process.

Many clients may well experience a sense of being lost, having the realisation of something missing in life but never solidly connecting to what that actually is. This can be a real difficulty within therapy, the finding out what that means for the client, and also in finding the fulfilment and how to fulfil that need can often be difficult. This longing is not limited to the BPD client. The BPD client’s sense of being nourished and fulfilled through contact is initially a long way off, usually hidden deeply by the actual methods that have been established in the attempts to get what they need. The pain and loss is only too apparent, as is the lack of any ability to connect healthily and ever assimilating and experiencing nourishment from the contacting they make.

Now at this stage being with a BPD client, who is in this state of deep suffering, and is looking for something which they are not sure what it is, looking for it in a manner, that realistically ensures that they are not going to get it, is not easy for the therapist or the client.

With this in mind, there is within the therapeutic relationship with the BPD client the objective to greatly reduce or get beyond cathartic release quickly, which is in essence, the very excitement that the BPD client is exhibiting and are the very blockages that are getting in the way of healthy contacting that has become a part of their existence. A circle of cathartic release engagements are not what is needed. If the therapist has narcissistic or defensive reaction to the BPD client in the extreme of excitement, this will best be replaced with looking at what the client is attempting to convey, anger is indeed a form of contacting (Spagnuolo-Lobb 2013). So instead of 'feel the emotion', it is more about looking at what the client wants from the engagement. The deep respect for the client that will need to be exhibited in this process is not only difficult to convey but also for the therapist likely to be difficult to sustain. There will undoubtedly be emotional attacks on others and may well be the same against the therapist, it is in these situations that the therapist is better served in holding on to that sense of what the client needs from this exchange and gradually being able to convey that the client can recognise and then establish the fulfilment of their needs. The incredible durability of the human in not giving up, but to sustain the longing and the seeking. This is the beautiful motivation that is so frequently seen within the BPD client and it is that motivation which needs to be respected and even appreciated.

To return to the child and look at the intentionality of contact, we return to the needs that were and still are primary although out of awareness: the need is for contacting and more importantly the subsequent nourishment that is hopefully integral to the contact. The important aspects in all that has gone before is namely the excitement, the splitting which are the creative adjustment. There then follows, the lack of choice and responsibility. The contact has never been adequately established, the satisfaction never experienced. Whereas, within healthy contact, satisfaction and growth occurs which is the nourishment. Subsequently the withdrawal, rest and a return to the id. It is very much that it is this process outlined above that is missing from the life of a BPD sufferer. Life is lived at the extremes without the rest and relaxation, that sense of being at ease and contented. Resting in the arms of the parent or a loved one feeling nourished, loved, attuned, validated and fulfilled. These moments that Buber, (1947), describes as the I/thou moment escapes the BPD child and later in life the BPD adult.

For therapy the objective is very much contacting these feelings and the appreciation of the feelings and to create an in between that has a relaxed open perspective. Or, what I hear in this is close to ‘creative indifference’ (Friedlander 1918) which Perls writes about in detail within Ego, Hunger and Aggression. Creative Indifference can be experienced in relation to the situation by maybe finding that safe place within the world or within the body, creating a sense of ground or groundedness. Spagnuolo-Lobb (2016) writes regarding the need today of looking more at the ground of the client and not so much the figure. These needs she goes on to say, come from society today lacking these ingredients where times are so uncertain. So a sense of the body and feeling that sense of id is so important. The position can also be achieved in the relationship within the therapy. Peter Philippson, (2001), brings this together so well, he wrote 'We do not primarily look either inwards — at drives, introspection, self-awareness — nor outwards — towards a stimulus ‘causing’ a response, sociology, the demands of the environment ‘making’ us be a certain way. What we explore is the process of the person relating to their environment on the basis of organismic needs, demands from the environment, and our choices and interests'.

The question is, how can that feeling of nourishment and connection, the creative indifference, sense of id or the I/thou moment be created in an adult, especially when there has been very little experience of this as a child and excitement and longing is so high. In addition, to a large degree the very being of the borderline client is a stronger almost impenetrable barrier, to experiencing the need, let alone getting the need met. How can a BPD client achieve the contact that they need and deserve when they exhibit such high levels of excitement that intensity when experienced in relationship is most likely to push away a person or therapist whom is able to offer and fulfil the required needs. Can we as therapists imagine that this is possible? Could I imagine a healthy life for myself as a teenager?

With this in mind it is important to state maybe the obvious. When working with BPD traits it is important to outline the necessary grounds for hopefully successful therapy. To start there needs to be commitment from the client and the therapist. Sessions could get difficult, clients may leave a session and not want to return, this is something that could well need talking over when therapy commences. The therapist needs to be ready for that return. Finding new ways to work through difficulties is an essential part of therapy certainly for the BPD client and maybe the therapist also. Therapy to have an affect, will often take many sessions, there needs to be commitment to stay around and arrive at sessions whatever, and work through whatever. The client may feel abandoned, but hopeful will not be abandoned.

The overall default position in BPD is as we have seen one of high excitement, and underlying this out of awareness is of a need not being met and of the need for it to be met. For the need to be met there needs to be some sense of allowing that connection between two people, that level of engagement. It is this that encompasses the dialogical relationship or contacting that Yontef, (1994), has described as '... a specialized form of this mutual contacting. In dialogic contacting the figure of interest for both is the interaction with the other person as person...'. This is the sense of being heard, of being seen, of being understood, of being accepted, of not being judged or having to be someone different. Acceptance in who we are, and validated in that place. Equally importantly is to establish the wide aspect of what it is that we want and how are we going to get it. This is connecting with another, these are the unmet needs that the client will become aware of in the process of opening to a wider sense of who they are within a relationship and/or therapy.

To reach the above connection with a BPD client is can be a slow process. I remember well an occasion when a young 22 year old female client, slight in build and pretty entered a session after around 7 months of therapy. She burst through the door slamming it behind her. She then threw her keys across the floor, followed by her phone then her coat. She looked at me and while still standing shouted, ‘that f***ing doctor is a f***ing ****’. The intense anger was palpable. How to connect with her in this? Not by matching, not by being critical, not by disrespecting her but remaining open to the next. I wait, I feel no fear, only awe and respect. I would love this ability and willingness to express how she is. This wish to be seen and heard which as a child was far too dangerous for me. I have no wish for her to loose this sense of total expression. She slows, her breathing deepens, she looks at my face, we meet. ‘What do you want from me’?, I ask. She retains the look, I am not sure what she is seeing, but this moment is something different, something new. Can she maintain this and what will come next. I am aware of my anxiety with this question but I remain open and willing to wait. Her breathing deepens some more, tears come slowly and quietly. She speaks, ‘I want someone to see and hear me’, I pause, ‘do you feel you are’ I respond, holding back my tears, or trying to.

It was the mother of this client who initially contacted me. She was very concern about her daughter as a potential suicide risk. She was self harming, had taken time away from university and had a very emotional split from her boyfriend. I learnt much from this client and also loved the way she could be at times, while appreciating her suffering in this. During the two years she saw ne she started a new relationship and broke it off and she returned to university. She often spoke about being surprised at how aware she had become while noting that ‘doing something about it was more difficult’.

Experiencing the new contacting and subsequent feelings can be the very new beginning that leads to deeper connections and awareness of being with another person. New meetings are created in the situation of two humans. Out of this can come nourishment and assimilation by needs being met.

The engagement therapy can offer where the therapist stays well below the level of excitement that the client will probably present, undoubtedly offers a different way of being. The therapist must not be pulled to match the levels of excitement that the client exhibits. It could well be a shock for the client, the therapist reacting in such a different manner from the 'norm'. Interventions such as 'what do you need right now', 'what do you need from me right now', or 'take a breath and tell me what you feel in your body and is there something that you want'. Such interventions are intended to bring to the clients awareness what they are looking for, or have been missing out. In turn lowering the excitement levels or if the client is in the depressive polarity the interventions give the client the opportunity to look outward toward the other and the process of meeting the other. Broadening the sense of choice within the client, ego functions.

So, instead of feel the emotion, it is more about looking at what the client wants from the engagement. The deep respect that will need to be exhibited in this process is not only difficult to convey but also for the therapist difficult to sustain in the face of the extremes. As previously stated, there will undoubtedly be emotional attacks on others and there may well be the same against the therapist. It is in these situations, that the therapeutic relationship (Hycner and Jacobs 1995), is better served with establishing that sense of what the client needs from this exchange and in being able to convey that the client can connect with their needs and can establish the fulfilment of their needs. Bit by bit, the discovery occurs that there is a relaxed way of being that is actually possible in this and other relationships, and that this indeed leads to contact and connection. This is the in between the 'missing link', or ‘middle mode’, that is not reached with the typical BPD traits. Friedlaender’s Creative Indifference (Frambach 2002) to which Perls heavily referred to in Ego, Hunger and Agression (1947) is a beautiful example of this. To relax, challenges the very existence of the client. I have had a client express how 'boring' feeling that way is, or 'I am so used to the excitement'. To just to go home and relax is so difficult, and this has always seemed counter-intuitive to getting needs met to the BPD client. Here also The Paradoxical Theory of Change (Beisser 1970) comes to mind.

However, the therapist can bring attention to the connecting as a process, those available moments when it can be asked do you feel seen, heard or acknowledged. The validation that was, and is so important to the BPD client. The sense within the client of the needthat are so longed for coming into awareness, and the gradual sense of them being met in ways, most likely, previously unimagined, will, undoubtedly make a difference. This is achieved within the here and now of the session, not in the stories or re-enactment of events or scenarios but in the process of being with another, and the feelings, that can beestablished, a place where the client can learn to relax, feel safe and feel at home, without the need for excitement but a sense of nourishment. These are new feelings and emotions, that have been lost or never experienced, but that are so important to the aspects of being and humanity. In Gestalt terms this is the establishment of an id, mentioned above. The client will hopefully gain a sense of responsibility, in being able to make a choice, rather than reacting impulsively into excitement of the polarities or of splitting. Gradually, there becomes available aspects of choice and agency along with hopefully a sense of empowerment. This in turn will result in a very different sense of who the client is and a sense of self confidence growing out of healthy relationships.

Gestalt therapy offers this level of challenge that presents the client with the frustration of not engaging in the manner which they have become accustomed. That almost seductive level of excitement, that is easily met head on and that appears, so important within the life of a BPD client. With the usual path not open, and the client confronted with looking at what it is they wish for from the other, new paths are opened up and created. Relaxation follows as one of the few alternatives, a relaxation that is very much bodily felt in a manner again not previously experienced, (the id). This opens the client to contact, nourishment and healthy engagement. The choice to move away from impulsive reactions (the ego), that are more about habits and subsequently the availability of spontaneously and being creative in the world, presenting new social and relational aspects of the self, (personality-function).

All this I am sure does not sound easy, and nor is it. Like my journey, it has been life long, a silly statement but very true. Certainly when I was 15, survival was uppermost in my mind. However, I remember the a strong wish to be loved. I did not know what this meant but it was present. The journey has been to find what it does means and then to find love and loving, or maybe they rise together in relationship.

References: tbc