Letters to the Editor
Voice Mail as a Transitional Object in the Treatment of Borderline Personality Disorder
Dear Editor:
One of the psychodynamic theories related to borderline personality disorder (BPD) is that the patient was unable as a child to traverse the rapprochement subphase of the separation–individuation process described by Mahler. As a result, the patient was unable to develop a sense of emotional object constancy (1,2). Adler formulated such patient difficulties as an inability to maintain holding and soothing introjects when faced with separations (1). Winnicott described how children use transitional objects to help tolerate negative affects and aloneness until evocative memory is established (1). Psychiatric staff commonly observe an association between a diagnosis of BPD and the presence of transitional objects on the inpatient ward (3,4).
In therapy with patients having BPD, it is important to create a containing environment (1). This can help the patient manage anger and other painful feelings that are triggered by separations from the therapist and can lead to increasing suicidality (1). Adler describes the use of transitional objects to create a holding therapy environment (1). However, some therapists express concern that the use of transitional objects can be gratifying and promote regression and dependency.
As a junior resident working in therapy with a patient suffering from BPD, I was always unsettled by panicky phone calls. My patient, a First Nations woman who had experienced severe childhood abuse and neglect, sometimes called from a closet where she held a knife to her chest. I was surprised to find how little intervention it took to settle the situation: it seemed that just hearing my voice was enough. Later in therapy, I acquired voice mail. She confessed to me that she frequently called my voice mail between sessions to hear my voice and that this helped her. Since that experience, I have had several other patients with BPD who have used voice mail in this way. Some find the experience “grounding,” while others find that it reinforces my role as the caring therapist.
Voice mail is a standard way of receiving messages that can provide a personal message 24 hours daily, 7 days a week. It is not a gift for the patient, nor is it created especially for the patient. There is no limit to the length of the message left. Conversely, the caller can choose not to leave a message, and the receiver will be unaware of the call. Patients can be warned that there may be a variable delay before a call is returned, and other plans for access to immediate resources can be discussed, as appropriate. The use of voice mail by a patient with BPD in some ways mimics the rapprochement phase, because the patient can use the therapist’s voice as a way of checking back and “refuelling” between sessions. However, voice mail does not gratify the patient with the therapist’s presence. Moreover, use of voice mail can be explored within therapy sessions.
In therapy with patients having BPD, voice mail is a tool that can assist in containing, soothing, and holding strong emotions. With this tool, crisis phone calls, emergency room visits, and self-harming gestures may be reduced.
References
1. Adler G. The psychotherapy of core borderline psychopathology. Am J Psychother 1993;47:194–205.
2. Cohen CP, Sherwood VR. Becoming a constant object for the borderline patient. Bull Menninger Clin 1989;53:287–99.
3. Cardasis W, Hochman JA, Silk KR. Transitional objects and borderline personality disorder. Am J Psychiatry 1997;154:250–5.
4. Laporta LD. Borderline personality and transitional objects. Am J Psychiatry 1997;154:1484–5.
Susan J Finch, MD, CM, FRCPC
Kingston, Ontairo
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