Working in the Flame. Conversational Model Psychotherapy with the Narcissistic Borderline Client

The purpose of this paper is to explore how the deep theoretical underpinnings and nuanced relational processes of the Conversational Model (CM) provide the therapist with the knowledge (capacity to understand intersubjective experience of the dyad) and skills (interpersonal responsiveness and ability to stay with) necessary to work with clients who suffer from disorders of self, such as Pathological Narcissism and Borderline Personality Disorder. The CM is based on the belief that relationally based psychopathology needs a relationally based treatment; the disordered self develops in relationship with others and a particular type of relationship can heal pathologies of the self.

The creators of the CM recognised that these clients are often stigmatised within the health system because of the tremendously difficult and often frightening behaviours they can exhibit. Without deep understanding around the effects of relational trauma on the developing brain, body and mind systems, it is impossible to make sense of the behaviours exhibited by this type of client; extremes of rage, contempt, paranoia, depression, anxiety, aloneness, emptiness and suicidality, underpinned by a core of shame and the annihilating terror of abandonment. I will use session vignettes to demonstrate both the intensity of these affects and their effect on the therapy and therapist, and ways that the CM informs therapist development, skills and knowledge.

The therapy room provides the space and time to witness the consequences of the trauma of the infant whose needs for attuned connection, intimacy, safety, stability and nurture were repeatedly unmet and misunderstood. The therapist has the opportunity to provide a different type of relationship; one where different types of responses are possible, perhaps for the first time. This can be the beginnings of a different way of being for the client, where the impossibility of relationships is challenged.

Finally, I wish to stress the vital guiding and restorative role that clinical supervision and the therapist’s own therapy play in complex therapies of this type. The countertransference experienced by clinicians when working with the pathologically Narcissistic and BPD clients can be unbearable; the therapist’s own traumatic past may inadvertently play out in the therapeutic relationship. Supervision provides a space for reflective understanding and creative thinking around another way to be with the client. Our supervisors and therapists help us come back to ourselves and the present, so we do not unconsciously complete painful re-enactments in the therapeutic relationship; rather we embody another way to be.