Boston, Massachusetts. REFERENCE. 1. Gunderson JG, Chu JA. Treatment ... Belmont, Massachusetts. REFERENCE. 1. Herman JL, Schatzhow E. Recovery ...
TREATMENT IMPLICATIONS OF PAST TRAUMA IN BORDERLINE PERSONALITY DISORDER
To the Editor: At first glance the article on the implications of past trauma in borderline personality (BPD) in your July-August issue’ appears to offer a reasonable and fresh perspective on the clinical picture and treatment of a challenging clinical condition. However, given the imperious growth over the past decade of posttraumatic stress disorder and the controversy regarding the reliability of long-delayed reports, authors in academic publications have a special responsibility in their presentation of related hypotheses and hypothetically derived advice. Gunderson and Chu, respected authors in the fields under review, explicitly recommend the validation of past trauma to build up a therapeutic alliance. They also concede that “a significant [emphasis mine] minority of patients seem to develop BPD without evidence of childhood trauma,” and that it is the gross disruptions of familial attachments and the massive failure of adequate care and protection of the child that result in distortions of normal character development. At another point they comment that “the patient with BPD has an inherent [emphasis mine] vulnerability in terms of chronically unstable relatedness, intolerance of intense affect, and a tendency to flee into dysfunctional isolation and impulsive and self-destructive behavior.” On the basis of these concessions alone, if the reader is to understand the authors to mean that the long-delayed histories of early abuse (often nowadays actively sought by the therapist) should be validated by the therapist, they are on tenuous ground. According to Webster’s Dictionary,2 “valid” includes the following meaning: “(1)having legal force, properly executed and binding under the law, (2) sound; well grounded on principles or evidence; able to withstand criticism or objection, as an argument: opposed to invalid.” “Validate” is defined as “(1) to make binding under the law; to give legal force to; to declare legally valid, (2) to prove to be valid; to confirm the validity of.” How does one validate what is neither witnessed not corroborated? The question of the veridicality of the autobiographies of patients is evident in the earliest writings of Freud. I find it difficult to believe that, over this past decade and on the basis of a few clinical reports, we have made the final breakthrough and solved the riddle. If therapists are to validate histories of trauma without corroboration, and largely to establish a therapeutic relationship with the patient, what of their professional ethics and their obligations to the families and to society? It seems to me that the authors are more credible when they recommend that therapists should understand and validate the patient’s “sense
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[emphasis mine] of having been victimized,” which leaves room for dialogue and negotiation. This is not the same as validating the historical accuracy! Therapists cannot afford to ignore the influences of rage, envy, competitiveness,and other factors on the way in which personal events are experienced and reported. The complexities of these clinical issues challenge the current oftenexaggerated emphasis on a history of trauma, and the very notion of simply validating the facts without regard to family input or other corroboration.
Fred H . Frankel, MBChB, DPM Boston, Massachusetts
REFERENCE 1. Gunderson JG,Chu JA. Treatment implications of past trauma in borderline personality disorder. HARVARD REV PSYCHIATRY 1993;1:75-81. 2. Webster’s deluxe unabridged dictionary. 2nd ed. New York Simon and Schuster, 1979.
REPLY
To the Editor: Dr. Frankel’s letter concerning our article raises several valuable and interesting points. It is, of course, frequently impossible for a therapist to validate (in the sense of establishing proof) the remembered experiences of abuse by borderline patients, particularly because many past abusive events occurred in secrecy and there may be little or no objective evidence of their having occurred. It is, however, possible for therapists to validate such experiences in the sense of affirming that recollections of abuse have some important meaning including the possibility that they have substantial basis in historical fact. In addition to one study in the psychiatric literature,’ our clinical experience suggests that there is often substantial evidence supporting much of what our borderline patients recall about traumatic experiences. The more substantive issue raised by Dr. Frankel concerns the ethical and clinical hazards tied to therapists validating long-delayed reporting of childhood traumas. Dr. Frankel is correct in suggesting that the endorsement of such histories should be given carefully, particularly because our clinical experience is that many patients are unsure about the accuracy of their memories early in treatment. In our article we hoped to convey that such affirmation should not simply be an artifice used to form a good alliance, but should be offered only to the extent that a therapist has concluded that there is an essential truth in the patient’s
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report. Our emphasis on the value and role of validation was a deliberate effort to diminish the reflexive skepticism with which clinicians have traditionally responded to reports of childhood trauma. It is usually only over time that patients can resolve the complexities and contradictions of their remembered trauma in a way that enables them (and their therapists) to make sense of their past and current lives. The assessment of the validity of patients’ reports of past trauma should be based on therapists’ careful consideration of all the complex factors that contribute to delayed recall of past events. While we appreciate Dr. Frankel’s cautions about the need to pay attention to corroboration and family input, there are frequently clinical circumstances in which corroboration is impossible or clinically inadvisable and family input is conflicted or unreliable. Ultimately, assessing the validity of reGembered past trauma should occur as part
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of an extended process in which such memories either may or may not become part of a coherent and plausible life history consistent with known historical events, psychiatric symptomatology, and current patterns of adaptation.
John Gunderson, MD James A. Chu, MD Belmont, Massachusetts
REFERENCE
JL, Schatzhow E. Recovery and verification of memories of childhood sexual trauma. Psychoand Psycho1 1987;4:114.
1. Herman
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