How Client with Borderline Personality Disorder Copes with Self Threat: Single Case Study

Aim of the study Aim of the study was to examine how a woman diagnosed with borderline personality disorder (BPD) manages moments when her self is threatened during an initial couple-therapy consultation, using an interactional, multimodal perspective. Subject or material and methods We examined a video-recorded initial session with a heterosexual couple, sampled from a larger corpus of couple-therapy consultations in a medical setting. Using multimodal conversation analysis, three analysts repeatedly viewed and sequentially analyzed the interaction to identify “self-threatening sequences”, where the patient’s moral, epistemic, or relational self was challenged and then either repaired or further pursued by the participants. Results The analysis shows that self-threat is jointly produced and managed by patient, partner and therapist. The patient alternates between starkly self-pathologizing and self-defending formulations, using laughter, hesitations and embodied conduct (gaze, posture, self-touch) to regulate exposure and arousal. The partner’s categorizations and complaints variably escalate, renegotiate or close self-threatening trajectories, while the therapist’s questions and formulations selectively take up or soften different self-descriptions. Discussion Identity disturbance in BPD patients emerge here as context-dependent and interactionally accomplished rather than a fixed intrapsychic deficit. Conclusions The study illustrates how detailed analysis of couple-therapy interaction can illuminate how threats to self are produced, resisted and absorbed in real time in interaction dynamics with BPD patient, and suggests that therapists should attend not only to what is said about the self but also to who says it, in response to what, and with which embodied displays.