#29 – “The Borderline States” – An Essay by Lloyd Ross, Ph.D., Therapist with 40 Years’ Experience Treating People Labeled BPD

I recently emailed Dr. Lloyd Ross, a clinical psychologist from New Jersey with 40 years’ experience treating individuals labeled borderline. I asked him for his views on the DSM model of BPD, the causes of borderline states, what is the best treatment for BPD, and can it be cured. Here are highlights of his responses, with my emphases in bold:

Highlights of Lloyd Ross’ Viewpoints on BPD, excerpted from his essay below:

On therapists who don’t want to work with people labeled BPD:

Lloyd Ross: “To avoid their own discomfort, poorly trained therapists describe borderline individuals as untreatable. Well trained therapists do not have that opinion. Well trained therapists have done well with these individuals, provided the therapist knows both what to expect and what he is doing.”

On good outcomes for people labeled “BPD”:

Lloyd Ross: “With proper insight oriented therapy, people labeled as borderline do go out in the world and function quite well in relationships, employment, etc. Like the rest of us, the goal is not to be cured from some non-existent disease, but to simply resolve the issues in our development that stop us from functioning in a relatively comfortable manner.”

On BPD as a medical diagnosis:

Lloyd Ross: “(As a medical diagnosis) the only “borderline states” that have any validity for me are on the border of Mexico or Canada… In addition, there is absolutely no real science behind any of the DSM/ICD diagnoses.”

On how the word borderline can be useful:

Lloyd Ross: “To use the term “borderline” from a developmental point of view is very different… Using the term “borderline developmental issues” enables us to go back in time and try to help the individual to undo, modify, and soften development that did not go smoothly the first time around.

On the developmental approach to working with people labeled BPD,

Lloyd Ross: “Using this model, the therapist works toward a stronger continuum of emotional development so that a person can function in a more whole way. Borderline states are not a disease or medical issue and therefore, nobody is “cured.” People just learn to handle various issues in their lives in a smoother, more comfortable manner for them.

On suicide prevention:

Lloyd Ross: “According to Bertram Karon, Ph.D., one of the world’s most prolific researchers on effective psychotherapy with patients labeled schizophrenic, suicidal, and borderline, ‘The best suicide prevention is effective psychotherapy.‘ ”

On the value of medication in treating people labeled BPD:

Lloyd Ross: “The medication approach (anti-depressants and/or anti-psychotics) is useless in people with borderline, suicidal, and PTSD symptoms. In fact, anti-depressants are probably one of the major causes of iatrogenic (doctor induced) suicide in this country in the past 15 years, especially with individuals labeled borderline.”

On trauma as the cause of borderline states:

Lloyd Ross: “The cause of “Borderline Personality Disorder” as with all of the “made-up” psychiatric diseases, is trauma at various times and stages in a person’s development… The failure of all-good and all-bad perceptions to fuse is the genesis of all pathologically borderline states.

My Interaction with Dr. Ross

So (this is Edward writing again) these were my favorite parts of what Dr. Ross said about BPD; for the full context, see his essay below. I had originally found Dr. Ross because he is a member of ISPS, the International Society for Psychological and Social Approaches to Psychosis, with which I’m also involved. In my first email, I asked Dr. Ross for detailed answers to my questions about what causes BPD, what best treats it, is it curable, and how best to understand Borderline Personality Disorder.  I wanted to see how much his viewpoints agreed with mine, and to share an informative and hopeful professional viewpoint on BPD with readers of this blog.

In response, Dr. Ross decided to write a single essay incorporating his responses to all the questions. That essay, “The Borderline States” forms the main part of this post. I highly recommend reading it to see how a psychologist who’s worked with over 100 people labeled BPD understands the condition. To Dr. Ross, thank you for taking the time and for giving me permission to post your essay here.

For anyone wanting to know more about Dr. Ross, he is a leading member of the International Society for Ethical Psychiatry and Psychology (ISEPP), and is listed halfway down this page: http://psychintegrity.org/isepp-leadership/


Lloyd Ross, Ph.D.

Dr. Ross also features in a Youtube interview about helping people labeled schizophrenic here: https://www.youtube.com/watch?v=wyL0jjI93OI . I want to note that Dr. Ross did not edit this video (the silly cartoonish elements, which in my opinion detract from its message, were added by the filmmaker Daniel Mackler). But you can see from the way Dr. Ross talks that he is an experienced, committed therapist.

Lastly, I want to note that Dr. Ross’ viewpoints appearing on my site does not mean that he endorses or agrees with everything else on this site. His viewpoints are his own. Here is his full essay:



By Lloyd Ross, Ph.D.

During my 40 years as a clinical psychologist, I have worked with approximately 100 to 150 people who would be considered to fall into the developmental framework of what psychiatry, in its simplistic and arbitrary way, views as borderline. These people were seen by me for at least one year or longer, some multiple times per week, and others once per week. Some were also seen at multiple times in their lives with months or years separating periods of therapy.

Before discussing this topic, I would like to make clear the issue of psychiatric diagnoses of “mental disorders.” I am a clinical psychologist who was psychoanalytically trained from an ego-developmental point of view. I have been in full time practice for almost 40 years and have always avoided psychiatric diagnoses, as I see the various recreations of the DSMs/ICDs as nothing more than an attempt to medicalize things that are not medical to begin with (human behavior, experience, and development). On that basis, the only “borderline states” that have any validity for me are on the border of Mexico or Canada.

In addition, there is absolutely no real science behind any of the DSM/ICD diagnoses. All of them were developed in committee rooms inhabited by mostly elderly white psychiatrists, many of whom represented the financial interests of the pharmaceutical industry. When I do write down a DSM or ICD diagnosis for a patient, and only at a patient’s request, it is usually because they need it to submit their claim to an insurance company (Unfortunately, that is the way things are in this society). The diagnosis I use is almost always “Post Traumatic Stress Disorder,” for several reasons:

  1. It is the closest thing to a real diagnosis in the entire list of diagnoses, in that anyone who is having enough emotional difficulties to seek help has had personal trauma of some sort as one of the factors that caused their difficulties.
  2. From a developmental point of view, the stage of development we are in or approaching when trauma occurs is a good predictor of how, when, and where it will manifest itself in a person’s life.
  3. The term itself, “Post traumatic stress disorder,” is sufficiently vague and innocuous to the public to make the term less of a problem for an individual than terms such as schizophrenia, psychopathic or sociopathic personality or borderline personality disorder, none of which have any real scientific meaning.

I approach human (not medical) diagnosis as a strictly developmental issue. This is because of the influence of Margaret Mahler on my training, with some influence from Donald Winnicott, Edith Jacobson, Anna Freud, Renee Spitz, Heinz Kohut, and Ruben and Gertrude Blanck. I come primarily from Mahler’s framework and was supervised by her. Therefore, any real diagnosis that I do comes from an ego-developmental point of view.

The Causes of Borderline States

When looking at a detailed history of people commonly diagnosed by others as “borderline personality,” I and others have found that these people have experienced emotional trauma at around the time in development when children make and solidify their attachment to the mother figure. To be a bit more specific, it is associated with trauma during that time frame and there is always deprivation around that time frame also. I am sorry for making it such a complicated thing, but when you don’t simply slap a diagnostic label on somebody, but are instead dealing with a real live very unique individual and their complex developmental problems, the issues are no longer simple. In addition, to perceive a human being as literally being a diagnostic category—a “Schizophrenic” or a “Borderline” –dehumanizes that person.

The cause of “Borderline Personality Disorder” as with all of the “made-up” psychiatric diseases, is trauma at various times and stages in a person’s development. That is why taking a carefully detailed history of that person’s development, events in his life, and memories in his life is so important. All extreme mental states, whether with someone diagnosed as schizophrenic, borderline, neurotic, etc. which are meaningless terms, are the result of things gone awry or not having been negotiated at various stages in development, resulting in trauma.

Even if a child seems to progress just fine, if and when trauma occurs, it lingers or appears dormant. When, even years later, that trauma is reactivated by another trauma, that person seems to exhibit or feel the original trauma again without ever connecting the two. That is why I use the diagnosis “Post Traumatic Stress Disorder” with insurance companies, for everyone, and not just those who come for help. There is no human being that I have met who has never experienced trauma, although the ramifications for some are more disturbing than for others.

A Personal Example of Trauma

I will give you a vivid example of trauma in myself. From the time I was five years old, until I was ten years old, I was ordered by my parents to come home from school immediately, without lingering with my friends, to babysit my grandmother because I left school at exactly 3:00 P.M. and the lady who took care of my elderly grandmother left at exactly 3:00 P.M. My grandmother was a very nice roly-poly lady who only spoke Polish and Yiddish, was blind except for being able to see shadows, and was able to walk from her chair to the bathroom to the bed by feeling along the wall. I, on the other hand, did not speak Polish or Yiddish.

My grandmother was alone for the five minutes it took me to get home and I would run all the way because I was told that if anything happened to her, it would be my fault, a rather heavy burden for a five year old. I would sit with her in a second floor apartment with very little communication and stop her from trying to cook. I would lead her to the bathroom and to the bed so that she didn’t fall, and sometimes would make her tea, watching that she didn’t spill it on herself. Either my aunt or my parents would come home between 5:00 P.M. and 6:00 P.M., but quite often, they went shopping first or had something else they had to do, and I would be stuck with my elderly grandmother for two to five hours. Also, since she couldn’t see, she kept all the lights off to save money so the apartment was usually dark.

When I turned ten years old, I was offered a part-time job and because work was so important to everyone in the family, when I got the job, my babysitting for my grandmother was over. What I remember most about the babysitting was that everything was always dark and boring. One day, I was very bored, and I could hear my friends playing ball in the street below. I opened the window and sat on the ledge, playing catch with a friend who was in the street. Someone called the police because they thought I was a jumper and they yelled and screamed at me.

After getting three advanced degrees, and spending a year in a horrific war, I came home and met my wife to be. I was always relaxed, mellow and calm, yet at the same time I could be cutting and sarcastic, all of which I admired in myself. After getting married, several days per week I would work late and come home when it was dark. When the lights were on in my house, there was never a problem, but if I came home to a dark house, I would feel enraged and walk in complaining, arguing, and finding fault with everything.

Since I was in my own training analysis at the time, I brought it up, thinking it had something to do with my time in Vietnam. I finally made the connection between the rage that I felt when forced to stay in a dark house watching my grandmother, and the rage I felt when I approached my house with the lights off. Having made that connection, I no longer became enraged when the lights were off, but I didn’t feel wonderful either. My wife and I discussed it and she kept the lights on for me, just like motel 6. Another point is that learning the connections don’t necessarily take away all the feelings but they do put you in much better control of those feelings.

That is a relatively minor cause of Post-Traumatic Stress Disorder. Who is a victim of it? Everyone, unless their childhood was just perfect, wonderful and magnificent, and so far, I haven’t met anyone who falls into that category, although I never met Donald Trump.

Understanding Borderline States Developmentally

I would like to discuss development at this point because most of the people seen by psychotherapists fall into this particular phase, including those with the arbitrary junk-science diagnosis of borderline personality. In normal development, when a child approaches the end of the first year or year-and-a-half of life, he/she begins to recognize that he is not one with his mother, but is really a separate person. This infantile recognition marks the beginning of the end of the “symbiotic” phase of human development and the very beginnings of the “practicing” sub-phase, sometimes better known as “the Terrible Twos.”

The practicing sub-phase is an early part of what we often refer to as the “separation-individuation” phase of development, which is so critical to our development that Margaret Mahler describes it as “the psychological birth of the human being.” In fact, she wrote a classic book just about that phase of human development. During the practicing sub-phase, the child’s mission in life is to prove that he is a separate, autonomous human being, while at the same time not losing his mother. He does this by exploring his world, by trying to do things independently from his mother, and by oppositional behavior, (saying “NO”.)

Sometimes, this phase of development can seem like a battle against parental figures, hence the name “terrible twos.” Problems that develop in the early parts of this phase of development which a child is unable to successfully negotiate often result in what they call “borderline issues” because they develop during the beginnings of the quest for reality on the part of the child, which occurs right on the border of these two stages. Let me go on with a description of the next part of the child’s emotional development.

The Identification Process, Splitting and Fusion in Childhood Development

While beginning the Separation-Individuation phase of development, the child begins to identify himself with others. This is also the beginnings of object-relationships. Since the primary object for all of us is mother (whoever mothers us, which could be the actual mother or a mother-substitute) a child will view his mother in very black and white terms as he begins the identification process. Mother in her nurturing role is seen as “good mother.” However, when mother says no to the child, restrains him in some way or frustrates him, mother is then seen as “bad mother.”

From a child’s point of view, “good mother” and “bad mother” are really two different people. This view occurs because of the absolute black and whiteness of the child’s thinking process at this age and is a normal age appropriate distortion of reality. The process is called “splitting.” When mother gives me what I want, she is “good mother” but when she doesn’t give me what I want, she is “bad mother.” These are totally two different people to the child.

Over the next year or two, depending upon intervening variables as well as the child’s developmental progress, the image of the “good mother” and “bad mother” slowly start to come together in a merging process. At a certain point, these objects “fuse” and we no longer see our mothers as a split object, one mother good and the other mother bad. When these objects fuse into one object, one mother, we begin to entertain a different, more sophisticated perception of mother. Now, mother is seen as basically “good mother” who sometimes is not so good. However, both the good and the bad are housed in the same person.

This is a much more benevolent view of mother and allows for imperfection. Since mother is the “primary object,” the first person that a child identifies with, his perception of mother is vital to his perception of himself. Once the good and bad objects are fused, the extreme view of the child is softened. He now also looks at himself and is able to perceive that: “I’m basically a good child, but sometimes I do bad things. Even so, I’m basically a good child.” This benevolent perception does two things. First, it brings us in closer contact with reality, and secondly, it softens out perfectionism both toward ourselves and toward others.

When Fusion Doesn’t Take Place, or What Causes BPD

The failure of all-good and all-bad perceptions to fuse is the genesis of all pathologically borderline states. Please be aware also that I am using the word pathology to simply indicate development gone awry or developmental stages that were not properly negotiated by the child for multiple reasons.

Sometimes, due to external issues that limit or skew a child’s development, or because of internal developmental issues, a child is unable to fuse the good and bad objects into one unified whole. In that case, the split object remains and the child continues to perceive dual mothers; one totally good and one totally bad. Under such conditions, when the child identifies with the primary object (the mother or mother substitute) and then looks in the mirror, he sees either a totally good person or a totally bad person with no redeemable good qualities, a rather harsh view of oneself. Under the above conditions, the child’s development makes him a potential candidate for suicidal thoughts, feelings, and actions as well as borderline personality issues.

In the so-called “borderline personality, the core issues precede the problematic object relations and there are also introjective insufficiency problems with good and bad objects. Most people dealing with this issue feel an “annihilation panic” based upon the relative absence of positive introjects that pretty much explain the “borderline” person’s feeling that he is existentially at risk.

In other words, in the so-called “borderline personality, it isn’t just the all-good, all-bad splitting that is a problem, but the paucity or insufficiency of positive introjects. Therefore, in people who are labeled borderline, the negative introjects predominate. Also, in come cases, they are able to solve the introject problem by, in a sense, becoming their own object or mother, thereby being able to comfort themselves without the need for anyone else. In the psychiatric establishment, these individuals are referred to as “psychopathic” or “sociopathic” personalities. They don’t need mothering because they can self-comfort.

Let’s go back for a moment to clarify what the mother-introject is. In normal development, the child internalizes a mental representation of the mother figure and the way in which she makes the child feel. Negative introjects always come from abuse that has taken place at around this time. (Sorry if I am blaming the mother figure but that is the way it goes.)

Gerald Adler, also a student of the ego-developmental model, extends this work further. He describes ideal treatment as an attempt to establish and maintain a dialectic therapeutic relationship in which the therapist can be used over time by the patient to develop insight into adequately holding onto positive introjects. In this manner, the arrested developmental process is set in motion to correct the original developmental failure. This is called the “Deficit Model” in that the focus is on what is missing in that person’s development. Therefore, the core of borderline issues precede the destructive internal object relations. The issues involve abuse, the absence of a positive introject, and an overwhelming constant feeling of being at risk, primarily due to the insufficiency of positive introjects.

Treatment for the Borderline, Suicidal or PTSD individual:

In this section, I would like to consider a number of treatments for these people and then the treatment of choice.

Electroconvulsive Shock; (ECT):

ECT, in short, involves placing two electrodes on the skull over the frontal area of the brain and then administering voltage that is comparable to being hit by lightening. This does several things. First, it causes a brain seizure which is not very pretty to observe. To avoid looking like a scene out of the movie “One Flew Over The Cuckoo’s Nest,” psychiatrists first administer sedative drugs to mute the external manifestations of the electric shock such as thrashing, broken bones, etc.

However, when they do this, to cosmetically improve the look of the treatment, they also have to increase the voltage, thereby creating greater cell damage and cell death in the brain, flatness of personality and affect, and slower thinking processes. This damage is similar to what occurs as a result of long-term heavy alcohol use, only more rapidly and in more focused areas, particularly the frontal lobes of the cortex or the cognitive and feeling areas of the brain. Keep in mind that ECT is similar to a motorcyclist head injury or explosion in that it is a “traumatic head injury,” only it is being caused by a physician. One of the side effects of killing off brain tissue in the frontal lobes is apathy, flatness of personality and affect, and slower thinking processes.

As a result of all this brain damage, suicidal thoughts (all other thoughts as well) are deferred and drastically slowed up. Therefore, ECT may temporarily defer suicide or soften the borderline issues, but it does not prevent it and when a person slowly and partially recovers from the shock, he may realize the lesser functioning he is left with permanently, an even greater motivation for suicide. ECT also significantly and drastically disrupts any psychotherapeutic process that is being carried on. Earnest Hemingway was “cured” of suicidal tendencies by ECT.

Bio-psychiatric Treatments:

The medication approach (anti-depressants and/or anti-psychotics) is useless in people with borderline, suicidal, and PTSD symptoms. In fact, anti-depressants are probably one of the major causes of iatrogenic (doctor induced) suicide in this country in the past 15 years, especially with individuals labeled borderline. Also, feeding a patient cocktails of neuroleptic (anti-psychotic) drugs acts simply as a temporary chemical restraint, often called a “chemical lobotomy.” In that sense, these drugs mimic ECT. I do not consider either real help for any individual and they make insight oriented therapy almost impossible.

Insight Oriented Psychotherapy:

According to Bertram Karon, Ph.D., one of the world’s most prolific researchers on effective psychotherapy with patients labeled schizophrenic, suicidal, and borderline, “The best suicide prevention is effective psychotherapy.” He goes on to say: “Of course the most effective way to prevent a suicide or a homicide is to understand the psychodynamics and deal appropriately in therapy with these issues.”

There are also a number of things that need to be confronted in any psychotherapeutic situation with a suicidal, borderline, or homicidal patient. Among them are his anger and rage, his and the therapist’s loss of control, and in a child, the significant parental issues, the patient’s developmental history, the ways in which the patient transfers his feelings (mostly bad and angry feelings) to the therapist, as well as other issues.

From the therapist’s perspective, he must be able to handle the transferential rage and aggression as well as his own feelings of lost control and counter-transferential issues. Finally, the therapist needs to deal with his own fears of the patient’s potential for suicide. Untrained,

fearful therapists, when they hear that a person has suicidal issues, get frightened and immediately refer to a psychiatrist, as though a psychiatrist has some magical powers to treat this problem. Unfortunately, when a therapist does this, the message to the suicidal person is “I am afraid of you and am not equipped to deal with your issues. The therapist is then immediately written off by the suicidal person.

Many therapists also do not want to work with people diagnosed as borderline for two reasons. The first is the rage that gets directed at the therapist. Borderline development results in a huge need to get rid of the aloneness they feel which results in rage that makes the therapist cease to exist. The counter-transference from an untrained therapist is a feeling of “I’m wasting my time here.” The second is that the amount of support needed is greater than with other kinds of development. You cannot resolve splitting until a strong positive relationship exists between the person and the therapist. In treatment, the unrealistic idealization of the therapist that the borderline person feels must be slowly worked through and discussed before it is relinquished and replaced by a more realistic view. The therapist’s goal is to slowly build up the earlier foundations of the ego structure through the relationship so that what is established is a not-so-harsh superego and thereby, less black and white pain in the face of imperfections and losses.

It should be understood that using this model, the therapist works toward a stronger continuum of emotional development so that a person can function in a more whole way. It is not a disease or medical issue and therefore, nobody is “cured.” People just learn to handle various issues in their lives in a smoother, more comfortable manner for them.

A Brief Word on Narcissism

Narcissism is often a component of borderline development. Narcissists are particularly hard to treat. They find it difficult to form the warm bond with a therapist that naturally evolves with most other patients. Instead, they often become cold or even enraged when a therapist fails to play along with their inflated sense of themselves. A narcissistic patient is likely at some point to attack or devalue the therapist, and it is hard to have to sit with such people in your office unless you are ready to accept that.

But narcissism is not limited to the most extreme cases who make their way to the therapists’ office. A healthy adjustment and successful life is based to some degree on narcissism. Healthy narcissists feel good about themselves without needing constant reassurance about their worth. They may be a bit exhibitionistic, but do not need to play down the accomplishments of others to put themselves in a good light. And although they may like adulation, they do not crave it.

Normal narcissism is vital for satisfaction and survival. It is the capacity to identify what you need and want. Pathological narcissists, on the other hand, need continual reassurance about their value. Without it they feel worthless. Though they have a grandiose sense of themselves, they crave adulation because they are so unsure of themselves that they do not know they have done well or are worthwhile without hearing it from someone else, over and over. The deeply narcissistic person feels incomplete, and uses other people to feel whole. Normally, people feel complete on their own.

”Narcissistic vulnerabilities,” as psychoanalysts refer to them, make people particularly sensitive to how other people regard them. You see it in marriage, in friendships, at work. If

your boss fails to smile when you greet him it may create a withdrawn, anxious feeling. If so, your self-esteem has been hurt. A sturdy self absorbs that so it’s not unbalanced. But if you’re vulnerable, then these seemingly small slights are like a large trauma. On the surface, extreme narcissists are often brash and self-assured, surrounded by an aura of success. Indeed, they are often successful in their careers and relationships. But beneath that success, feelings of inadequacy create the constant need to keep inflating their sense of themselves.

If they do not get the praise they need, narcissistic people can lapse into depression and rage. Thus, many workaholics put in their long hours out of the narcissist’s need to be applauded. And, of course, the same need makes many narcissists gravitate to careers such as acting, modeling, or politics, where the applause is explicit. Many difficulties in intimate relations are due to narcissism. Marriage brings to the fore all one’s childhood yearnings for unconditional acceptance. A successful marriage includes the freedom to regress, to enjoy a childlike dependency. But in marriage, a couple also tend to re-enact early relationships with parents who failed to give them enough love. This is particularly hard on those with the emotional vulnerabilities of the narcissist. All narcissists fall within the borderline spectrum of development, but not everyone in the borderline range of development is narcissistic.

In summary, a therapist who is not trained well will usually not want to work with a borderline person for all the reasons mentioned above. To avoid their own discomfort, they describe them as untreatable. Well trained therapists do not have that opinion. It is not a “mental illness,” (disease.) Rather, it is a breakdown of a developmental phase that we all go through and involves issues such as splitting, negative introjects, probably early abuse, suicidal issues, and narcissistic issues.

Well trained therapists have done well with these individuals, provided the therapist knows both what to expect and what he is doing. Because it is not a disease, no one is cured. However, with proper insight oriented therapy, people labeled as borderline do go out in the world and function quite well in relationships, employment, etc. Like the rest of us, the goal is not to be cured from some non-existent disease, but to simply resolve the issues in our development that stop us from functioning in a relatively comfortable manner.

Finally, the term “borderline,” when used as a medical or psychiatric diagnosis, is both useless and harmful in that it is suggestive of some evasive disease. To use the term from a developmental point of view is very different and can be helpful in understanding what in a person’s development, was not negotiated properly or fully successfully. Using the term “borderline developmental issues” enables us to go back in time and try to help the individual to undo, modify, and soften development that did not go smoothly the first time around. This is something that is being done all the time by private-practice therapists, but not by what I call “the mental health industry.” However, that is a topic for some other time.

Below, I have listed a few books that should be helpful in understanding the treatment issues with individuals who are dealing with borderline issues. I have also included several books that support my opposition to the medical model approach.


Adler, G. (1977). Borderline Psychopathology and Its Treatment. Northvale, N.J.:Jason Aronson.

Breggin, P.R. (1994). Toxic Psychiatry. New York: St. Martin’s Press.

Jackson, G. E. (2005). Rethinking Psychiatric Drugs. Bloomington, Indiana: Author House.

Jackson, G.E. (2009). Drug Induced Dementia: A Perfect Crime. Bloomington, Indiana: Author House.

Blanck, G., & Blanck, R. (1972). Ego Psychology: Theory & Practice. New York: Columbia U. Press.

Colbert, T.C. (1996). Broken Brains Or Wounded Hearts. Santa Ana, California: Kevco Publishing.

Ferenczi, S. (1950). “Introjection and Transference.” In Sex In Psychoanalysis: Selected Papers. 35-93. New York: Brunner/Mazel.

Freud, A. (1936). The Ego and The Mechanisms of Defense. London: Hogarth Press.

Freud, A. (1965). The Writings of Anna Freud, Vol. VI: Normality and Pathology in Childhood Assessments of Development. New York: International Universities Press.

(Hartmann, H., Kris, E., & Loewenstein, R. (1949). “Notes on the theory of aggression.” The Psychoanalytic Study of the Child, ¾, 9-36.

Jacobson, E. (1954). “The self and the object world: Vicissitudes of their infantile cathexes and their influence on ideational and affective development.” The Paychoanalytic Study of the Child, 9, 75-127.

Jacobson, E. (1964). The Self and the Object World. New York: International Universities Press.

Karon, B.P., & VanderBos, G. R. (1994). Psychotherapy of Schizophrenia: The Treatment of Choice. Northvale, New Jersey: Jason Aronson, Inc.

Kohut, H. (1972). “Thoughts on narcissism and narcissistic rage.” The Psychoanalytic Study of the Child, 27, 360-401.

Mahler, M. (1960) “Symposium on psychotic object-relationships: III. Perceptual differentiation and ‘psychotic object-relationship’.” International Journal of psychoanalysis, 41: 548-553.

(51) Mahler, , M. & LaPerriere, K. (1965). “Mother-child interactions during separation-individuation.” Psychoanalytic Quarterly, 34: 483-498.

(52) Mahler, M. Pine, F., & Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books.

(55) Masterson, J. (1973). “The mother’s contribution to the psychic structure of the borderline personality.” Paper read at The Margaret Mahler symposium on Child Development, Philadelphia, May, 1973. Unpublished.

#28 – An Interview with Lewis Madrona, M.D. about BPD and our Mental Health System

For this article I’ve interviewed Lewis Mehl-Madrona, a psychiatrist from Maine with 40 years’ experience in psychiatric hospital and outpatient psychotherapy settings. Lewis is a practicing psychiatrist and healer with his own website, his own personal blog, and his own online articles.

Lewis and I did a phone interview which I have transcribed below. Here are some highlights of Lewis’ thinking:

On BPD as an identity:  “What the label BPD is is a story or identity that people are encouraged to take on. And it’s not necessarily a story that’s conducive to feeling well or being well…”

On DBT and its founder:  “Marsha Linehan would say people get better, hope, you can feel better, you can do these things and you will feel better.”

On BPD as a lifelong illness:  “I think it’s really insane to say that the label (BPD) is lifelong… I mean how do you know that?… It’s not even logical. It’s a pretty cruel world we live in where we make people incurable – is it so we don’t have to work hard to understand them?”

On Recovery:  “(In response to my question about can people labeled BPD truly get well)… Oh absolutely, absolutely. And you know I think that it’s the same work whatever your label is.”

On the role of medication:  “I think the role for medication in our society has become a replacement for community… The medications don’t produce lasting change… no real solutions take place.”

On writing your own story:  “The science behind BPD is not good at all… I always remind people that the DSM is mostly created by white males over 50 years old sitting in hotel rooms around the beltway of Washington DC. These may not be the people you want to write your story… The story you create might be a lot more interesting.”

For more context, read on to the full transcript. Please note that Lewis’ views are his own, and his interview appearing on my site does not imply that he agrees with or endorses my positions. With that said, here’s the interview:

Edward: Lewis, thank you so much for making time to speak to me. I found you through the International Society for Psychological and Social Approaches to Psychosis (www.isps.org), and you know that I run a website dedicated to challenging the medical model of Borderline Personality Disorder and promoting a recovery model. I’m going to ask you some questions I’ve put together about the label BPD, and I’d like you to answer however you feel is best, which may or may not mean directly answering the question. First, so that readers can get a sense of where you are coming from, let me start with asking you to describe your professional background, your training, and what you do now:

Lewis: Ok well, I went to med school at Stanford, then did a couple of years of training at the University of Wisconcin, then went off and did a PHD in psychology and a postdoc in neuropsychology, and then I came back and finished my residency training in family medicine in psychiatry at the University of Vermont. Then I did some extra time to be certified in geriatric medicine as well.

Currently I’m teaching family medicine at the University of New England in Maine, so I’m one of their faculty, and I also do the psychiatry consulting service at Eastern Maine medical center [Lewis has worked on psychiatric wards]. And then I have my evening and weekend life as a person who dabbles in the healing arts. What that means is doing healing work with people – because I’m native American, it’s kind of a native American flavor, I try to help people using that background. I grew up with my grandparents who were part of the Indian culture.

lewis1                                                                 Lewis Mehl-Madrona

For many years I’ve also had a psychotherapy practice, more so earlier in my career; I don’t do much outside therapy at this point. I’ve always done a combination of different medicines, psychiatry, psychotherapy, other healing arts.

I’ve worked in medicine for 40 years, starting in 1975. Actually earlier, 1973. I started doing psychotherapy in training in 1973.

Edward: Ok thank you; I can see you’ve had a lot of experience in the psychiatric system. Do you have an idea of how many clients you’ve worked with who were considered “borderline” or who would approximate the DSM label for “Borderline Personality Disorder”?

Lewis: You have to clarify the term “borderline”. When it was first created, borderline was meant to refer to people who were not psychotic, but had severe emotional issues – I can’t remember if it was Otto Kernberg or someone else who coined the term – but it was supposed to mean people who under high stress crossed the border into psychosis but could then cross back. It was people who oscillated between those states.

I don’t remember when it happened, but somehow borderline came to mean people who are incredibly good at getting what they need from systems, like hospital systems. That’s how people are using it now, to refer to manipulative people that we don’t like in the system. I think that’s how the term is commonly used now.

Over the years I’ve seen a lot of people who fall into that category, as labeled by others. And yes I’ve certainly done psychotherapy with quite a few people who were given that label at one time or another.

Edward: Ok, interesting. I guess what I had in mind was more the first description; people who have serious emotional issues, can become psychotic under stress, are prone to splitting, can’t regulate their emotions, and so on. Can you say something more about how you understand the word borderline – how does it describe the functioning, feeling, defenses present in these people?

Lewis: My personal belief is that it’s a fairly useless label. I think people are more individual. Such a label really doesn’t say much about who the person is and what do they need help with. I think by and large all of the DSM labels are like that. For the most part they’re not really based on science of any kind. You can say in general terms things like depressed, anxious, psychotic, etc – maybe give general labels people fit into, with overlaps. But the craziness we have now is just something else.

Personally I don’t find BPD to be a very useful construct. What the label BPD is is a story or identity that people are encouraged to take on. And it’s not necessarily a story that’s conducive to feeling well and being well. So I think that’s the danger of the internet because people can get together and embrace their story about who they are as borderlines. And it makes it harder, if that becomes your identity, to not suffer in that way, or to see that it’s just one way to describe however it is you suffer, and there are other more helpful ways.

Edward: Ok thanks, that’s an interesting idea about how taking on the borderline label becomes a story, a kind of self-fufilling prophecy in a way. I do see that when I read online forums focusing on BPD at Reddit, Psychoforums, Psychcentral. Can you say something now about the causes of “borderline” states – are they mainly psychological, biological, etc? I realize now in asking this that the question may not make sense to you in these terms.

Lewis: I think trauma and isolation are the big things leading to mental health labels – if you’re surrounded by community, you can tolerate a lot more trauma than if you’re alone. And I think that’s been the process of the 20th century; the process was to eliminate community and get everybody alone in little boxes. It’s easier to manipulate people when they’re alone in little boxes; it makes a more malleable work force and prevents unionization and collective bargaining. It prevents people getting supported by each other.

So I think that a lot of what we see now [in terms of mental health and psychiatry] is so different from what we might have seen in the year 1900. People in general are so much more isolated now than in 1900 or 1800, and so it’s harder to build resiliency or regulate your moods when you’re always or mostly by yourself, and I think it’s crazy. For example the two parent child-rearing approach is insane; who ever thought that up was completely crazy. Healthy cultures have cross fostering, cross mothering, multiple mother figures at any given point, the idea of the whole village taking care of the children.

So I think some of this is political. And I relate these processes of isolation to more people getting these mental illness labels. I think more people are getting labeled everything, because there’s less social support and thus less resiliency. And some people of course have been severely traumatized in this isolation. When you’re isolated you don’t have anyone to go to to get nurturing, to help you feel better and regulate your mood…. almost everyone I see has trouble regulating mood, and are isolated, and the really amazing thing in the settings I work in [in psychiatric hospitals] is how little some of them are willing to do about it.

Often people come in and they want a drug to make them regulated and feeling happy, and that drug doesn’t exist; it’s not going to happen. I don’t know when we made that transition, I think it was probably in the 80s, when I was in training we used medication to make unbearable affects bearable so you can work with the feelings.

But as a a profession now we’ve trained people to think you should just take a pill and feel fine, and if it doesn’t work try another one and then everything will be great. And that embarks on the perpetual search for the right pill, which is a never ending story. I don’t meet many people who have found the right pill.

Edward: Ok, thank you and of course I agree with these ideas about medication. Now let me ask you about the way other therapists use the label borderline. Many therapists, including probably some you’ve heard, use the label borderline in a pejorative way to refer to people they consider difficult or unlikely to get better. Did you ever feel that way?

Lewis: Since I didn’t believe in the label borderline I wouldn’t have ever talked that way. It’s interesting because I’ve always given my cell phone to everyone I work with, which therapists who believe in the label BPD would say is insane, but I’ve never had anybody abuse that. The issues they have with clients; it seems it’s a side effect of a certain kind of power relation and not intrinsic to people, so I always give my phone to people and say if you’re in crisis I want to hear from you; it’s our goal to keep you out of hospital so I want to hear from you early. So my approach is probably a different approach than the people who roll their eyes and label people borderline.

Edward: Ok that makes sense. Let me jump in now and ask about therapists or psychiatrists who say that BPD is a lifelong mental illness and something that cannot be cured. Do you agree with that?

Lewis: I’ve definitely heard that more than I’d like to believe, and I think it’s really insane to say that some label is lifelong… I mean how do you know that, you’d have to be at the end of someone’s life to know that, it’s not even logical. It’s a pretty cruel world we live in where we make people incurable – is it so we don’t have to work hard to understand them? At least there’s people like Marsha Linehan who don’t believe that. I think she’s interesting since she began as a service user and did her own healing which is mostly Buddhism.

If you think about DBT it’s almost entirely basic Buddhism. She did her own healing and then she came up with a therapy that matched her own suffering. But really DBT works for everything because it’s basic Buddhism and Buddhism works for everything. But she would says people get better, that’s her whole message, hope, you can feel better, you can do these things and you will feel better. So there are people like her who don’t believe in the inevitability of perpetual life long suffering. Of course I certainly don’t believe that.

Edward: Ok yes I agree with your ideas against the idea of a lifelong BPD illness being bogus; this is a large part of what my website is about. Can you speak now a little bit about what sort of results you’ve had in working with these people – I guess now I’ll call them people who’ve been seriously traumatized and isolated, rather than “borderlines”, since it seems like you don’t think that way. Have you had good results with these people in terms of their feeling better, having satisfying relationships, working in jobs they like, and so on?

Lewis: Oh absolutely, absolutely. And you know I think that it’s the same work whatever your label is, I mean, What do we all need to learn how to do? – we all need to learn how to connect with other people because we all need others, we all need to learn how to regulate our moods and each other’s moods, we all need to learn to manage our suffering, and to a large extent most of us need to learn to eat better, to exercise, to do things that are good for us like yoga, tai chi and chi gong. We all need to live a healthier lifestyle, that involves meaning and purpose, having good relationships with others, and to the extent you can move in that direction, no matter what mental illness label you’ve managed to earn, you’re going to suffer less and feel better.

And so I think the work that I do is more experientially narrative. I’m trying to get at people’s stories about why they are the way they are, and then to look for ways in which that story could be altered so they can live differently. And I use a lot of what of what you could call DBT or a Buddhist approach or some of it is native American ideas. One of the profoundest things that Marsha Linehan pointed out is that life isn’t fair, and you have to live anyway, radical acceptance. Thomas Merton said things are sometimes not ok, and we may not be able to change them, but because it’s the right thing to do we need to try to change them whether it works or not. Part of recovery is also making an effort to be helpful to other people, and/or to change the political environment we’re embedded in.

Edward: Ok. So with the people you work with who get better, what are the most important things that help them to get better? I guess you’ve aleady talked about a lot of them – community, close connections to other people, living a healthy lifestyle, and so on?

Lewis: All the things I mentioned above; by and large that’s what we all have to do regardless of whether or not we’ve managed to achieve labelhood [i.e. been labeled BPD or some other DSM label]. We all need to cultivate community and find each other and build social networks that are nurturing and healing. We need to feel like what we’re doing is meaningful, that we’re creating value with the lives that we’re living. And we need to take good care of ourselves physically, exercise, diet, all those good things. Regardless of the label someone’s given you, it’s pretty much the same, what you need to do to get better.

Although we may have a different story to explain how we got to where we are. That’s the unique thing about doing therapy, no one’s story about how they got to where they are is the same. Each person has a wonderful story that needs to be cultivated and appreciated, and if it’s not satisfying hopefully changed to get to a more well story.

Edward: Ok, I like that description of changing one’s story. It’s so different than the DSM idea of managing symptoms of an illness. Can you discuss psychiatric drugs now – As a psychiatrist, how much do you use them with people, and are they more helpful or harmful, generally speaking?

Lewis: I use them as little as possible, and I think the role for medication in our society has become a replacement for community. If you have enough people around you, you have incredible support and you don’t need so much medication. If you’re isolated and by yourself, then medication stabilizes you whereas otherwise community would. So I tend to use the least possible medication to keep people out of hospital. Because I know if they get into hospital that they’re typically going to be given much more medication than they need. I think medication does allow some people to stay out of hospital; I don’t think it’s a good long-term solution.

The biology is clear that the brain receptors, over the course of a year or so on medication, tend to move back to where they were when they started the medication. The medications don’t produce lasting change, they just make it harder to get off the medication; you have to keep increasing or changing the medication to get an effect. The external world is a much more powerful shaper of the brain than any pill that you can take. If you haven’t changed your external world, and you come off medications, then you’re going to fall back to the same neurophysiological state you were in when you started the medication. This can become a vicious circle. The meds have to be increased, and switched, and so on; no real solutions take place.

Edward: Ok, thanks and I totally agree with this view on medication. I would add that taking medication strengthens the false narrative and identification that a person “has” a certain mental illness label that needs to be treated by taking that medication. Can you say something now about how working with more difficult people – people who might more often be labeled borderline – how is it different than working with less traumatized people? Does working with very traumatized people help you to work more effectively less difficult people?

Lewis: I think so… I don’t know that the level of trouble has much to do with the difficulty of the work. I think that sometimes people who are deeply suffering can be easier to work with than people who are suffering a little. Because if they [the deeply traumatized people] just do anything different they feel so much better and it can be incredibly motivating for them. I just personally enjoy getting to hear people’s stories. And figuring out how they might have a little less friction in their self-to-world interface. Some of the worlds that people visit are incredible, and to some degree we have to be grateful to people who are visibly suffering because they’re the canaries in the social mine shaft; they’re showing us we’re all unhealthy but for some reason they’ve visibly taken it on for us. Because of that I think we have an obligation, those of us who are feeling more well, whatever that means, to help people who are feeling less well, to suffer less.

To me the label BPD and other similar labels is sort of like a cultural story that’s been created for people to put on. It’s kind of like clothing that you wear and everybody’s encouraged to put on this same kind of clothing and behave in this kind of way. It’s almost like a prescription for the label BPD, like here, “Be this way, be a borderline”. I think it’s really unfortunate because people think BPD means something inevitable or they think that it’s true because some authorities say that it’s true.

But the science behind BPD is not good at all. Even the director of the NIMH Thomas Insel, who’s as hardcore a biological psychiatrist as they come, he said the DSM 5 is not acceptable as a diagnostic tool just because it’s so divorced from science. I always remind people that the DSM is mostly created by white males over 50 years old sitting in hotel rooms around the beltway of Washington DC. They may not be the people you want to write your story. You may want to find your own story about your suffering and your strengths. Their stories aren’t very strength based. The story you create might be a lot more interesting.

Edward: Ok, thank you. I like the last part there about the old psychiatrists and writing your own story. The idea of clothing people are encouraged to take on is interesting; I hadn’t thought about it in exactly that way. Ok, next questions, what are some books and experts you find useful in the mental health field? I was going to ask this question about BPD specifically, but given your earlier answers I’ll make it more general.

Lewis: Well of course everyone should read Mad In America [by Robert Whitaker], just because it’s so amazing. But in terms of books about therapy I like Marsha Linehan’s work, she comes across as amazingly compassionate and practical.

I also like Narrative CBT of Psychosis by Jakes and Rhodes; they’re very funny – they say “now that you opened the book, you can forget we put CBT on the cover, we only put it on there because the establishment requires us to put it on there.” And the the way they work with people is completely different.

I love everything RD Liang wrote, I suppose that dates me. I like the narrative work of Michael Wyatt. I like the guys in Finland, the Open Dialogue guys, Juuka Altonen, Jaako Seikkula, I can’t pronounce most of their names, but they’re pretty cool.

Those are the people that I try to have trainees read. I have trainees read Whitaker, John Weir Perry, RD Liang, Jakes and Rhodes. I like to share my own books of course.

Edward: Ok. I didn’t know you had written a lot. What have you written about?

I have a book called Coyote Medicine. It’s an autobiographical story of being an Indian in mainstrream medicine and how crazy it can feel at times. Kind of a cross cultural work .Then there’s Coyote Miracles, about people who have miracles, people who work with traditional healers. Then there’s Coyote Healing, also about working with healers. Then there’s Healing the Mind through the Power of Story – The Promise of Narrative Psychiatry which is a newer book.

And my latest book with Barbara Mainguy is Remapping the Mind, The Neuroscience of Self-Transformation. The word borderline is not in that book! We don’t like diagnoses. It’s better to get the experience, to get people to tell you what their experience is, than to use a label. It’s gotten harder to get people to tell you their experience. People come in to a therapy session and say, “I’ve been manic this week”, and I say, “Ok what does that mean? Tell me what happened?” There’s not a lot of use of the labels in any of my books.

Edward: Ok thanks, some good references there. I didn’t know you’d done all this writing. I’ll have to check it out. Now my last question, which you’ve kind of already answered: Is borderline or BPD a useful or accurate word to describe people? Would you replace it with something else?

Lewis: I would get rid of it. I think that it’s great to help people overthrow their label. If I ran the world, I would just say that some people are more well than others. And those who are more well should help those that are less well. And leave it at that.

Edward: Ok thanks again Lewis. I’m really glad you made time for this. Since you’re an ISPS member, I was pretty sure you wouldn’t answer the questions in the diagnosis-based way I asked them. And that’s great. Because I want to show people that many professionals out there don’t think BPD is a useful word and that there are other more hopeful ways of conceptualizing our suffering. And in the way you’ve answered my questions you’ve shown that approach. It’s particularly interesting because you’re a psychiatrist working across mental hospital and outpatient psychotherapy settings, and you still think the way you do. So thanks again for your time.

Lewis: My pleasure. Take care.


For more information about Lewis Mehl-Madrona, please see:

Lewis’ Personal Website

Lewis’ Personal Blog

Lewis’ Articles on Future Health

Lewis’ Books on Amazon

Lewis’ Professional Resume

[Note: Lewis knows me me under my real name, which is not Edward (see the “About” page). He consented to have the interview appear here, understanding that I disguise my identity because I prefer my employer not to know about my history in the mental health system.)

#27 – The Kleinian Approach to Understanding and Healing Borderline Mental States


A diagram showing some common psychodynamic approaches to understanding BPD. Read more to understand how this continuum works!

In earlier articles, I discussed the following ways of conceptualizing borderline mental states:

  1. Fairbairn’s Object Relations Approach, including the bad object, the internal saboteur and the moral defense.
  2. Harold Searles’ Four-Phase Model, including the out-of-contact phase, ambivalent symbiosis, therapeutic symbiosis, and individuation.
  3. Gerald Adler’s Deficit Model, which discusses the quantitative predominance of all-negative memories and the deficits of soothing-holding experience.
  4. Donald Rinsley’s Borderline-Narcissistic Continuum, which illustrates how BPD and NPD represent states of psychological developmental arrest that flow into one another.

If you are looking for explanations of why borderline mental states develop, what keeps people stuck in them, and how to become free from BPD, please check out the pages above. In my opinion these object-relational approaches explain BPD’s etiology and how to become non-borderline better than CBT or DBT approaches. The latter approaches typically focus on short-term symptom management rather than transformation and cure of BPD.

Today’s post will add another approach, the Kleinian Approach to Borderline States. Kleinian theory focuses on the Paranoid-Schizoid Position and the Depressive Position.

What do these words mean, and why are they useful in understanding borderline conditions?

Melanie Klein: An Early Psychoanalytic Pioneer

To start with, why is this approach called Kleinian?

The Kleinian Approach to BPD is based on theories developed by Melanie Klein, an early 20th century psychoanalytic theorist. Klein grew up in Austria and received psychotherapy as a young woman from Sandor Ferenczi, a Hungarian psychoanalyst who was himself an innovator in understanding schizophrenic and borderline individuals.

Klein studied psychoanalysis in Berlin and London, eventually becoming a renowned therapist of emotionally troubled children. Working with children enabled her to see processes of all-good and all-bad splitting occurring live in the therapy sessions. Having often been severely neglected or abused, the children misperceived Klein as all-good or bad based on their past experience with “bad” parents and their need for a “good” parent-substitute.

Melanie Klein noticed that the more abuse and neglect the child had experienced, and the worse the relationship between child and parents, the more severe the splits in the child’s perception of the therapist tended to become. This meant that, despite the fact Klein tried to treat them well, children with worse parents tended to more unrealistically perceive Klein as an “all bad” mother figure. This transference (transfer of feelings from past people onto present people) is related to how borderline adults tend to misperceive potential friends or lovers as uninterested and rejecting.

Klein also noticed that as they improved in therapy, children who had initially utilized all-bad splitting became attached to her as a good parent figure, growing emotionally to the point where they could trust her and feel concern for her wellbeing (reparation). Children from healthier families often started therapy at this more advanced position, allowing Klein to observe a more positive mode of relating from the beginning.

From these two different ways in which the children related, Klein posited two primary orientations toward perceiving the world as seen from the child’s perspective. She called the first, developmentally earlier, more dangerous and isolated way of experiencing the world the Paranoid-Schizoid Position. She called the second, later, more secure and dependent orientation the Depressive Position.

These two positions can be understood as regions along a continuum of increasingly healthy and integrated personality development, the early, paranoid-schizoid part of which anyone can get stuck in given enough trauma and deprivation, and the later, depressive part of which anyone can reach given sufficient positive resources.

The Paranoid-Schizoid Position

The paranoid-schizoid position is the way of experiencing one’s emotional life that corresponds with what are commonly labeled “borderline” mental states or “schizophrenic” mental states. In my understanding, borderline and schizophrenic states of mind are not different in kind, but only in degree; schizophrenia represents a more severe version of the splitting, self-fragmentation, and primitive defenses seen in borderline states. As discussed in the many psychodynamic books linked to in earlier posts, both borderline and schizophrenic states are fully reversible and curable with sufficient help over a long period.

Back to the topic at hand. Why is the “paranoid-schizoid” position called that and what does it mean? The “paranoid” part refers to misperceiving external others who are neutral or mainly good as “all-bad”, as paranoid people tend to do, and the “schizoid” part refers to the tendency to withdraw and isolate oneself from meaningful emotional interaction with others, as people who feel threatened and unsafe tend to do. When a person’s entire personality is centered around misperceptions of others as “bad”, and when a person isolates themselves interpersonally in a way that tends to perpetuate these misperceptions by not allowing in good corrective influences, they are operating in a “paranoid-schizoid” mode.

The term paranoid-schizoid is not meant to be pejorative, only descriptive. I think a better, more empathic term for the paranoid-schizoid position in adulthood would be something like, “The Adult Worldview of the Traumatized Child”, so please keep that in mind when reading these labels.

To Klein, the paranoid-schizoid position represented the earliest way of experiencing the world for a young child who is trying to test whether or not the external environment is safe and supportive. If parents and other important relationships mainly nurture and protect the child, then the child’s mind will develop a feeling of basic trust in others and of basic security in the world. This security will help them gradually move from the paranoid-schizoid to the depressive position. If neglect, abuse, trauma, and excessive stress predominate during childhood and early adulthood, if bad experiences tend to outweigh good experiences, then the person will get stuck in or regress back to the paranoid-schizoid position. In experiential terms, such a person will continue to feel unsafe and to distrust others relatively indefinitely, and may not even know what they are missing.

Core Features of the Paranoid-Schizoid Position

The paranoid-schizoid position features:

  • Lack of basic trust in others’ good intentions (“the basic fault” as discussed by Michael Balint).
  • Predominance of all-bad splitting, i.e. viewing others as rejecting and oneself as unworthy.
  • Predominance of feelings of aggression and envy over love and gratitude.
  • High levels of anxiety, a constant feeling of insecurity at the core of one’s being (“ontological insecurity” as discussed by R.D. Laing).
  • Frequent acting out – drinking, drugs, sex, food, etc – to defend against overwhelming negative emotions and lack of self-soothing ability.
  • Tendency to isolate oneself and withdraw emotionally and physically. Related lack of awareness of others as psychologically separate from oneself.
  • Lack of subjective sense of self.
  • Use of primitive defenses to block awareness of what a precarious emotional state one is really in, including denial, avoidance, splitting, projection, and projective identification.

My Emotional Experience of the Paranoid-Schizoid Position

These descriptions are highly technical and removed from real experience. So here is how I experienced the paranoid- position, i.e. the out-of-contact and ambivalent symbiotic phases, emotionally:

  • As my being a tragic, pointless character from Dante’s Inferno, The Myth of Sisyphus, or Kafka’s Metamorphosis, doomed to endlessly repeat the same self-defeating behaviors.
  • As being alive and dead at the same time – alive physically, but dead emotionally and dead because no one knew the real me.
  • As being unable to trust or confide in anyone, because nobody cared and nobody had time.
  • As waging a constant battle to keep my terror and rage controlled enough to survive.
  • As having no idea how normal people handled relationships and problems so easily, resulting in intense envy.
  • As continuing to live emotionally in “the house in horrors” (my name for my childhood home with its physical abuse).
  • As being a cork on a stormy ocean on which you could never tell where the next rogue wave was coming from.
  • As being very aware of negative inner thoughts and very unaware of what was going on around me. These bad thoughts felt to me like persecutory demons.
  • As having to preserve as much energy as possible to defend against potential threats and dangers. I often thought of myself as an emotional warrior, spy, antihero, or survivor.
  • As being willing to do almost anything addictive or distracting rather than feel the bad feelings and the lack of love.
  • As a vengeful, hateful, evil person who wanted to take revenge on those who hurt me and strike back at the world to feel some power and self-control (It is, I think, this type of paranoid-schizoid experience in young men that leads to many mass shootings).

These experiences are correlates of periods when the all-bad self and object images were mostly or fully dominant over the all-good self and object images. For many years this paranoid-schizoid nightmare was my predominant way of experiencing myself and the world.

Kleinian Theory Compared to Other BPD Models

The paranoid-schizoid position correlates with the following elements of other psychodynamic approaches to borderline states:

The Four Phases, the Structural Deficit, the Borderline-Narcissistic Continuum, and the Paranoid-Schizoid and Depressive Positions are all analogous ways of describing a continuum of early emotional development. They can be diagrammed as follows:


These “primitive” (meaning developmentally early) mental states are consequences of the quantitative predominance of bad self/object images along with a structural deficit or quantitative lack of positive, loving memories. In other words, they result when someone has many more bad than good experiences with other people, and/or when the absolute quantity of good experiences is severely lacking.

The lack of love in the past, combined with present fears that keep a person from getting help, can keep an adult frozen in the paranoid-schizoid position for long periods. In this situation, partly out of a fear of being totally alone or objectless, the person will maintain a closed psychic system of all-bad internal relationships which feel like tormenting inner demons, monsters, and ghosts. The paranoid-schizoid state can feel like an inner hell or prison.

How All-Bad Splitting Perpetuates the Past in the Present

The psychoanalytic writer James Grotstein discussed the persecutory inner representations of the paranoid-schizoid individual as acting like a “band of merciless thieves” or “gang of brutal thugs”. These internalized relationships attack the vulnerable part of the person that wants help by “warning” or convincing them that other people are untrustworthy, uninterested, dangerous, and rejecting, even though this may no longer be true in the present.

These all-bad identifications are seen when borderline people tell themselves, “I am worthless”, “Nobody wants to help me”, “Other people are always too busy”, “Things never work out for me,” and so on. There is sometimes a large grain of truth to the negative perceptions about others, but the individual also colors what they perceive and how they “self-talk” to make things seem worse than they are. In other words, they only perceive the all-bad aspects and spit out the all-good aspects of external reality. In this way they treat themselves as did people in the past who rejected or neglected them. This is what I call “perpetuating the past in the present.”

These paranoid-schizoid inner objects or memories can be understood as schemas, i.e. models of representing past experience in relational terms. These models actively (and often negatively) influence the ability to perceive reality accurately and to take action in the present.

Examples of Paranoid-Schizoid Experiences in the movies Psycho, Memento, and Beauty and the Beast

Several dramatic films illustrate how past attachments to “bad people” (and more importantly the internal memories and self-images based on them) block potential relationships to new good people and serve to keep a person in the paranoid-schizoid position.

1 – Psycho: Norman Bates, the main character in Alfred Hitchcock’s horror movie Psycho, exemplifies the paranoid-schizoid position. Because he fears his mother will be jealous, Norman is unable to tolerate the presence of Marion, the lovely young woman who comes to visit his motel. In reality Norman’s mother is long dead, her rotting body sitting in a rocking chair in the manor house. But her remembered voice is alive and well in Norman’s mind, guiding his actions and ordering him to kill off the threatening “good” Marion. Norman constantly experiences the paranoid-schizoid position, always feeling in danger and unable to trust outsiders.

While Norman is actively psychotic, a parallel process plays out in less disturbed borderline mental states. Norman’s acting out of the way he imagines his mother would reject his wish for a positive relationships is disturbingly similar to how some older borderline adults keep sabotaging potentially good relationships even after their abusive parents are gone.

Memories of disappointing interactions with parents and peers therefore “warn”, discourage, and forbid the borderline person not to trust and enjoy relationships with friends and lovers in the present, because if they do they would be betraying their past bonds to “bad” parents (for which they often blame themselves) along with risking rejection by the potentially good new person. These unconscious identifications with all-bad memories of others explain the repeated frustrations that many people labeled BPD have with keeping friends and sustaining romantic relationships.

Check out the Psycho Trailer.

2 – Memento: In the Christopher Nolan movie Memento, Guy Pearce plays a man, Leonard, suffering from an unusual problem:  He cannot form any new memories. This disability occurs after he is beaten by thugs who killed his wife. Therefore, Leonard is unable to remember or trust anyone new he meets. He becomes at the mercy of others who take advantage of his limited memory. The constant sense of paranoia that Leonard exhibits, along with his great difficulty in discerning what is real and what is a deception, brings to mind the paranoid-schizoid mental experience.

People in severe borderline states experience similar difficulty in trusting others, usually not because they are amnesiac, but because they are terrified that being dependent and close will result in rejection or abandonment. In other words, they believe that the present will repeat the past, i.e. that new potentially good people will turn bad, just as parents and peers rejected them before. These inner identifications with bad objects (objects meaning memories of past experiences with others), combined with a lack of past good object experience to rely on, results in the extreme sensitivity to imagined rejections that borderline people experience.

I remember watching the Alien movies starring Sigourney Weaver as a boy and being terrified by the scenes where a human suddenly turned into a monstrous alien and devoured a fellow colonist. I think these scenes unconsciously reminded me of my father’s sudden transformations into a violent “monster” who physically beat me, which fed my expectation that other adults would turn on me if I trusted them.

Check out the Memento Trailer.

3 – Beauty and the Beast – This classic Disney children’s movie features another example of the paranoid-schizoid position. Due to his selfish and unkind nature, the Beast has been condemned to live alone in his castle. He can only be redeemed if he learns to love, and earn another’s love in return, by the time the last petal falls from a magic rose. Rather than seeking someone to love him, the Beast becomes hopeless, withdrawing and isolating himself inside his castle. When beautiful Belle tries to penetrate his “closed psychic system” of all-bad expectations, the Beast is at first aggressive and untrusting, not believing that anyone could love his true self.

Gradually, the Beast is able to permit himself to be vulnerable and experience closeness with Belle. This move toward dependence, attachment, reparation of past harms done to Belle, and realization of the love he has been missing out on, represent the Beast’s movement from the paranoid-schizoid to the depressive position. Gaston and his henchman represent the all-bad objects that serve to impede reunion with the hoped-for good object, and the Beast must courageously fight them off to defend his loving relationship with Belle (i.e. to securely reach the depressive position).

Check out the Beauty and the Beast Trailer.

The Reunion Adventure – The Transition from Paranoid-Schizoid to Depressive Positions

The timeless theme of reuniting with a lost good person by fighting past inner demons and their external representatives repeats in many classic stories, including Homer’s Odyssey, the Star Wars movies, the epic films Gladiator and Braveheart, Disney’s Aladdin and the Lion King, The Crow starring Brandon Lee, and the novel Ulysses by James Joyce.

To see the repeating narrative, the reader need only think of how the heroes in these stories are separated from those they love by evil forces (“bad objects”) before having to fight for reunion with the lost beloved person. Joseph Campbell provides many additional examples in his book The Hero with a Thousand Faces. This epic battle comes alive in long-term psychotherapy of borderline states, when the battle is to overcome all-bad projections onto the therapist in order to trust and depend on the therapist as a new good person who can help the client move from the paranoid-schizoid to the depressive position.

The Paranoid-Schizoid Position and DSM Diagnoses

Different degrees and permutations of the paranoid-schizoid way of relating are commonly (mis)labeled as: Borderline Personality Disorder, Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder, Bipolar Disorder, Schizoaffective Disorder, Schizophrenia.

I don’t believe in the validity of these labels as distinct illnesses; rather, people should be viewed as individuals with strengths and deficits along a continuum of ego functioning. If they are used at all, labels like “borderline” should be viewed as a cross-sectional working hypothesis which loosely describes the problems a person has at a given time. Labels like borderline emphatically do not represent a life-long incurable illness. In my view, DSM labels should be abolished since psychiatrists are unable to use them as descriptions of pathological ways of relating with which people can work creatively and from which healing is possible.

Instead of something descriptive and hopeful, the labels become perversely distorted into “lifelong mental illnesses” which may have a genetic or biological cause. This is ridiculous since no evidence exists that these diagnostic labels are reliably discrete from each other, nor that biology or genes cause the behavioral, thinking, and feeling problems to which they refer. It’s offensive, harmful, and arrogant for psychiatrists to misrepresent problems of thinking, feeling, and behaving to vulnerable people in this reductionistic, pessimistic way.

Therefore I again encourage readers to consider dismissing labels like Borderline Personality Disorder from your mind. Instead, consider thinking of individuals as experiencing different degrees of borderline mental states at different points in time and of borderline states as being reversible and curable.

The Depressive Position and Healthy Personality Organization

Since much of psychology is focused on what is wrong, pathological, symptomatic, or immature, I now want to focus on maturity, wellbeing, and psychological health, using these questions:

How do many people become emotionally healthy, i.e. able to regulate their feelings and self-esteem, to work productively, to form families, become loving parents, have intimate friendships, etc.?

Are emotionally healthy people just born that way, or does childhood experience matter, and if so how much?

Why are healthy people not borderline?

How can borderline people become healthy?

These are complicated, contentious issues. In most cases the answer to the first three questions is that emotionally healthy people have had many more good than bad interpersonal experiences during childhood and early adulthood. Compared to people who are labeled “borderline”, healthy people usually had more opportunities for trusting, secure, long-term relationships with family, mentors, and/or friends.

These good relationships helped them to overcome the paranoid-schizoid position and the splitting defense – which when not prolonged are normal parts of every child’s development – and to develop the capacities for ambivalence, self-soothing, and intimacy. In one sense, emotionally healthy people were simply lucky – lucky as helpless children to be born into families where love and security were readily available.

I believe that that healthy adults usually had parents who, while they were not perfect, were good enough most of the time. They were “good parents” in the sense of empathically responding to the child’s needs, comforting the child when vulnerable, and supporting the child’s independent activities. These parents themselves usually had a considerable degree of healthy personality development; i.e. the parents themselves did not make heavy use of splitting, and were able to accurately perceive their children as mostly good and only slightly “bad”.

In other words, non-borderline parents tend to raise non-borderline children, and borderline parents are more likely to raise future borderline children. NAMI won’t like to hear that parents can cause BPD, but sometimes the truth hurts! As suggested by the ACE Study below, poor  parents do more frequently raise “borderline” and “schizophrenic” children. That doesn’t mean poor parents are “bad people” or that they should be blamed for their children’s problems. Of course they shouldn’t.

Rather, the passing of abuse and neglect from generation to generation is a tragedy for which no one should be blamed, and the maximum amount of support should be given to such parents to help understand and change destructive patterns.

The ACE Study – How Adverse Childhood Events Increase Risk of Psychiatric Diagnoses

What evidence is there that childhood neglect and abuse correlate with increased mental illness diagnoses? The recent Adverse Childhood Events (ACE) Study of 17,000 people has explored the connection between childhood trauma and psychological disorder diagnoses. This study polled a large sample of people seen in hospital and medical settings to examine how frequently different childhood experiences co-occurred with physical illnesses and mental health diagnoses. The ACE study shows that childhood emotional, physical, and sexual abuse are directly linked to likelihood of both physical illnesses and psychiatric disorder diagnoses in a dose-response fashion.

In other words, the more abuse and neglect a person reports in childhood (a higher “dose amount”), the more likely a person is to be labeled depressed or schizophrenic in adulthood. In my way of thinking, more childhood abuse and neglect increases the chances that a child will become developmentally frozen in the paranoid-schizoid position and experience borderline or psychotic mental states as an adult.

Here are details on The ACE Study.

Drawing from the ACE Study, one can deduce that the less frequent and severe are a person’s experience of childhood abuse or neglect, then the less likely the person is to experience “borderline” or “psychotic” mental states as an adult. Although the survey didn’t cover it, I’d bet that a strong group-level relationship exists between having had reliable, loving parents (as the child experienced and perceived them) and an absence of adulthood mental health diagnoses. It makes sense because families with less abuse and neglect also tend to have more love, safety, closeness, and support (I could be wrong about this, but I doubt it. Let me know what you think in the comments).

Further Sources on Healthy Childhood Emotional Development

I’ve now digressed again from the topic of healthy personality development. The point I’m trying to make is the obvious one that loving, secure human relationships are crucial to healthy personality development. Rather than discuss this in further detail, I wish to refer the reader to sources with more knowledge than I.

Some good writers on healthy emotional development, i.e. on what helps young people become navigate past the paranoid-schizoid position (avoiding borderline mental states) and enter the depressive position (and reach psychological maturity) are:

1) Donald Winnicott (e.g. Maturational Processes and the Facilitating Environment). Drawing on his experience as a English pediatrician-therapist, Winnicott wrote beautifully about the healthy emotional development of children. Winnicott viewed psychotic states, including severe borderline conditions, as the “negative” or mirror image of healthy emotional development. They illustrated for him what happens when healthy parenting and secure childhood emotional development break down or never become firmly established.

Winnicott’s book is available for free as a PDF on this page.

2) James Masterson (e.g. The Seach for the Real Self). The American psychiatrist Masterson wrote mainly about borderline and narcissistic personality problems but always discussed what happens in healthy development contrasted with borderline/narcsisistic development. Masterson explained how the borderline/narcissistic personality could become healthy via internalizing self-parenting functions that they had missed out on in childhood.

Check out Masterson’s book on the search for the real self.

View a Youtube interview with Masterson.

3. Heinz Kohut (e.g. How Does Analysis Cure?). German psychoanalytic pioneer Kohut developed the field of self-psychology, which emphasizes how crucial empathic parental responses are to the young child’s healthy emotional development. He developed the ideas of idealizing relationships (referring to how children need a strong, safe figure to protect them) and mirroring relationships (how children need a supporter for their independent functioning).

It is instructive to understand how these relationships fail to occur between parents and future-borderline children, and why such relationships do not immediately develop when borderline adults go to psychotherapy. From Kohut’s work one can see that if most borderline adults had received adequate mirroring and idealizing responses earlier in life, they would likely be normal, healthy people today.

Here is an Overview of Self-Psychology.

4. Lawrence Hedges (e.g. Working the Organizing Experience; Interpreting the Countertransference). Hedges is a California-based psychogist who recasts schizophrenic and borderline disorders as “organizing” and “symbiotic” ways of relating. He has a beautiful way of writing about how certain “potentials” for relateness never get activated and become frozen in borderline and psychotic mental states.

In the link below, which is a free e-book download, the sections “Borderline Personality Organization” (pg. 98) and “A Brief History of Psychiatric Diagnoses” (pg. 175) may be of interest. Hedges’ writing is not about healthy personality development per se, but he constantly discusses what positive elements are missing in the relational development of psychotic and borderline individuals.

Access a free e-book copy of Hedges’ Relational Interventions.

5. Allan Schore (e.g. Affect Regulation and the Repair of the Self, The Science of the Art of Psychotherapy). Schore is an American neuroscientist who writes about how reliable, secure attachments to caregivers are crucial to the developing child’s brain, and how attachments to parents directly modify how genes express or do not express themselves. Schore does fascinating brain scans showing how the child’s brain reacts to good and bad relational influences. He also shows why nature and nurture cannot be separated and quantified in such myths as, “BPD is 50% genetic.”

Here is an Interview with Allan Schore on Youtube summarizing Attachment Theory.

6. Ed Diener (e.g. Happiness: Unlocking the Mysteries of Psychological Wealth). Diener is a sociologist who researches how social conditions on a national level promote psychological wellbeing. Good parents and mentors are extremely important for psychological wellbeing, but factors beyond family relationships a lot too, like poverty, educational opportunities, diet and exercise, safety at a national level, freedom of speech, economic inequality, etc. Diener shows how these factors correlate with psychological wellbeing for national populations.

As you might guess, people in Iraq, North Korea, and Zimbabwe really are far less happy than people in Sweden, Australia, and South Korea. While advanced nations have their own problems, Diener shows how some poor countries suffer such severe instability that they are almost “paranoid-schizoid” worlds, in which people constantly feel threatened and are unable to actualize their potential for wellbeing.

Here is Diener’s Book on Wellbeing.

Compared to the simplistic, symptom-focused descriptions of Borderline Personality Disorder in the DSM , I believe so much more can be understood from these etiological depth approaches to borderline conditions and healthy emotional development.

Returning to the Kleinian theory, how does the Depressive Position fit into healthy emotional development?

Key Characteristics of the Depressive Position

The Depressive Position, although it might sound negative (like “depression”) actually refers to increasing psychological attachment, closeness, and maturation. It was called “Depressive” because Melanie Klein focused on how the young child experienced guilt, depression, loss, and increased concern for their parents’ wellbeing as they emerged from the paranoid-schizoid position. These “depressive” feelings emerged as the child became more aware of the mother as a separate person and realized how their actions could negatively affect her.

But the real thrust of the depressive position lies in these characteristics:

  • Increasing security in positive emotional attachments to other people (development of basic trust).
  • Predominance of all-good splitting followed by capacity for ambivalence.
  • A richer, nuanced, three-dimensional view of oneself and others.
  • Predominance of love, gratitude, reparative urges, and guilt over aggression, envy, hatred, and vindictiveness.
  • Increasing ability to self-soothe, tolerate frustration, and maintain self-esteem.
  • Repression replaces splitting, denial, and projection as primary defense.
  • Increasing awareness of others as psychologically separate from oneself.

This link from the Melanie Klein Trust explains the depressive position in more detail.

My Experience of the Depressive Position and Therapeutic Symbiosis

As stated before, a lot of these descriptions are technical and removed from real experience. So here is how I experienced the early part of depressive position, i.e. therapeutic symbiosis, emotionally:

  • As the end of a war in which I was a survivor emerging from the ruins, realizing that the whole battle had been going on in my mind, not the outside world.
  • As an incredible realization that I was not in danger, people could be trusted, the world was safe.
  • As emerging into real life after years in emotional hibernation.
  • As seeing the world and other people in color for the first time.
  • As “the halcyon (blessed) days”, my term for this period in my diaries.
  • As the sense that everything was right between me and my therapist, that I was like a blessed child and she was like a loving mother.
  • As a regression to being the playful, carefree child that I had never been able to be in my actual childhood.
  • As an overpowering sense of loss about how many years had been lost to misery and fear because of my parents’ abuse.
  • As feeling like a savior because I had saved myself by finding good people, just like the Beast found Belle to free himself from the curse.
  • As a feeling that I had become a self, a real spontaneous person for the first time.
  • As being able to enjoy other people and experiences, finally.

These feelings are correlates of the period when all-good self and object images begin to outweigh all-bad self and object images, i.e. the phase of therapeutic symbiosis as described by Harold Searles. In this stage the formerly borderline person achieves a healthy narcissistic level of object relations and reaches the depressive position.

Why Don’t Some People Reach the Depressive Position?

In severe borderline mental states, a person remains fixated psychologically in the paranoid-schizoid position as described above. Viewed from various vantage points, the borderline person tries to become healthy, functional, securely attached, and able to regulate their feelings but may fail because:

  • They have a quantitative deficit of internal positive memories that healthy people use to soothe themselves (Adler’s structural deficit), but don’t yet have the resources in their daily life (friends, family, therapist, etc) needed to repair this deficit.
  • They are simply unaware of the positive relationships they are missing (Searles’ out-of-contact state).
  • They are scared of trusting and depending on others due to past trauma which they fear new people may repeat, and thus choose to remain attached to their internal all-bad relatoinships (Fairbairn’s object-relations model of the attachment to the bad object, Searles’ phase of ambivalent symbiosis).
  • Their use of primitive defenses like denial, avoidance, acting out, projection, projective identification, leads them to unconsciously repeat self-destructive patterns.

This is only a brief attempt to answer the question about why some borderline individuals remain in the paranoid-schizoid position. I am still optimistic that healing and progress out of the paranoid-schizoid position is possible with appropriate insight and help.

Final Thoughts On Recovery From Borderline States and Progress to the Depressive Position

My own experience and research suggests that the single most crucial thing for recovering from borderline states in a long-term, dependent, loving relationship with somebody. It could be a therapist, a friend, a family member, or some combination of these. Feeling safe and loved by others for years is what enables children to become healthy adults, and it is also what enables once-borderline adults to become healthy adults. There is no substitute for internalizing the self-soothing and self-organizing functions of a loving, mature outside person. As I described in an earlier article, I experienced these healthy relationships for the first time with my therapist and a few key friends.

In normal childhood development, there is a “healthy” or normative paranoid-schizoid experience called the practicing phase, in which the child jubilantly explores the world and is relatively unaware of mother’s separateness. For most children, the parents and environment are supportive enough that the children don’t get stuck in a pathological paranoid-schizoid position that later becomes a borderline adult mental state.

Rather, most healthy children progress out of the normative paranoid-schizoid position into the depressive position at a relatively young age. These children are unlikely to regress and become borderline unless they encounter some overwhelming prolonged stress in later life. For children who are constantly neglected and abused, the risk is much greater that they will psychologically retreat and stay in the pathological paranoid-schizoid position, which leads to experiencing a chronic borderline or psychotic mental state in adulthood.

Again, it should be remembered that “normal”, healthy people would often have become borderline adults if they had experienced sufficiently severe abuse and neglect in earlier life. In Kleinian terminology, anyone can get stuck in the paranoid-schizoid mode of functioning when subjected to enough prolonged stress. People opearting in borderline mental states are not fundamentally different than the rest of us – they are just as human, but more unlucky in some ways.

With sufficient insight and resources, borderline people can become weller than well, i.e. become free from borderline symptoms, study and work productively, have intimate friendships and relationships, and experience joy and meaning. After they have become psychologically mature, life challenges still present themselves, but former borderlines can handle them with confidence as the capacities for ambivalence, regulating feelings, and maintaining self-esteem are developed in the depressive position.


I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

– Edward Dantes

#26 – Why BPD Should Be Abolished, and What Should Replace It

Do we want people to believe that BPD is a real psychiatric illness that they must manage for the rest of their lives, or do we want to promote a message of hope which says, “You can become free of your emotional distress and live the life that you want”?

By presenting BPD as a severe mental illness which can be managed but not cured, the medical model of the BPD label utterly fails to promote hope. Additionally, the medicalized concept of BPD is scientifically broken: It does not describe a valid illness which is consistent across a population.

Why do we keep using BPD if there is so much wrong with it? Is it possible that we would be better off without BPD?

And if BPD is should be abolished, what should replace it?

This article addresses how to replace BPD.

To this question, my first answer is “Nothing” – that we should simply abolish BPD – and my second answer is “Emotional Dysregulation Susceptibility Syndrome”, which I will explore as a hopeful alternative. Let’s discuss these options.

Background: The Medical Model and My Opposition to NEA and “Make BPD Stigma Free”

My central conceptual argument is that Borderline Personality Disorder as defined in the DSM is an unreliable, invalid concept. Given its current popularity, it’s not easy to fight against the prevailing notion of BPD as a valid mental illness. But after speaking to many people who also experience BPD as a flawed, discouraging concept, I am more resolute in this view than ever. If you are unfamiliar with the argument against BPD, please see here, especially Myth #5:


While I prefer to understand people without labels, due to practical considerations I contend that BPD should be replaced by a more hopeful label. This new label should refute the myth of BPD as a life-long mental illness and emphasize vulnerability to stress along a continuum.

My position against BPD directly opposes the thinking of many in the psychiatric establishment, including large organizations like TARA BPD, the Treatment and Research Advancements Association for BPD, and NEA BPD, the National Education Alliance for BPD.

TARA and NEA assert that BPD is a “serious psychiatric illness”, one which they can reliably investigate and for which they will create improved treatments. In my opinion, these medicalized viewpoints represent poor research and outright misinformation.

Let me list and critique some of National Education Alliance BPD’s main positions. I hope the reader will sense how badly NEA’s claims on BPD, which often border on outright lies, fail to meet the criteria for good science and basic common sense.

My Response to NEA’s Misinformation about BPD

(Source – http://www.borderlinepersonalitydisorder.com/what-is-bpd/bpd-overview/)

1) BPD is an “illness”.
NEA’s position: BPD is a single illness which causes unstable mood and behavior.
Edward’s response: BPD is not one unitary entity that causes anything. BPD is not a single illness because the symptom-cluster that supposedly represents BPD cannot be reliably identified by any biomarkers (genes, brain scans, etc.) nor reliably identified by different psychiatrists across a population, as the NIMH recently admitted.
The way a person understands their world based on past experience leads to unstable mood and behavior.

2) Genes are involved in causing BPD.
NEA’s Position: Scientists generally agree that genetic and environmental influences are likely to be involved in causing BPD.
Edward’s response: This is misleading on so many levels it’s hard to know where to start. Again, BPD is not one reliable entity. And there is no evidence that genes “cause” any of the distress-experiences denoted by the BPD misnomer – such thinking involves the mistaken assumptions that genetic and environmental factors work as separable influences in a quantifiable manner. I have written about these distortions extensively in my article on twin studies (#4).

3) Brain scans provide evidence that biological factors cause BPD.
NEA’s position: There is evidence that biology is a factor in causing BPD, due to imaging studies in people with BPD showing abnormalities in brain structure and function.
Edward’s response: Does NEA think the public cannot understand basic cause and effect? Of course seriously distressed people have observably different brains than “normals”. That doesn’t mean biology or genes cause these differences; neglect, abuse, and lack of love, which are much more prevalent in those labeled “borderline”, inevitably lead to different brain functioning. But that doesn’t even mean those things cause BPD or that BPD is real. Never take a difference for an illness.

4) Biological factors make people more likely to develop BPD.
NEA’s position: The current theory is that some people are more likely to develop BPD due to their biology or genetics and harmful childhood experiences can further increase the risk.
Edward’s response: The current theory is a demonstrably false hypothesis. Constitutional vulnerability to stress may make it easier for some people to become overwhelmed by environmental stress, but that doesn’t mean that BPD is in any way a valid illness, nor that such people cannot become well. Plus biology and genetics do not act alone in the way implied in this reductionist model (see – http://www.madinamerica.com/2015/06/are-dsm-psychiatric-disorders-heritable/ )

5) The prevalance of BPD can be quantified.
NEA’s position: BPD affects 5.9% of adults at some time in their life
Edward’s response: Does anyone really believe that a subjective, descriptive label with no biomarkers can have its prevalence reliably identified to a tenth of a percentile?

6) BPD is a life-long mental illness.
NEA’s position: People with BPD have BPD for life. (NEA stops short of saying this outright, but they imply it. Their website talks over and over about managing and reducing symptoms in “borderlines” of different ages, never once mentioning the possibility of becoming free of “the illness” or discussing the possibility of full recovery)
Edward’s response: This is one of the most damaging myths being promoted about BPD. Problems that are mislabeled BPD can be fully recovered from; people who once approximated borderline criteria can eventually live a satisfying, emotionally normal life. Many thousands of people have already done so. Getting better is hard work, but people do not have to cope with and manage BPD for life. People need real hope, not the discouraging prospect of a life-long illness.

My Manifesto Against National Education Alliance for BPD

As can be seen, NEA BPD set themselves up as the experts on how to define and treat the BPD “illness”, an illness label they obviously intend to keep. But they may not have considered that former “borderlines” can see through their propaganda.

My position on NEA’s “BPD as a serious psychiatric illness” notion is this:

  • Severely distressed people do not have accept the label BPD as an identity nor as an explanation for their problems.
  • Emotional problems are not reducible to “psychiatric illnesses”, nor are they the exclusive province of psychiatry.
  • Effective help which often leads to full recovery from problems mislabeled BPD already exists. Recovering does not require the assistance of “experts on BPD”, nor does it require DBT and medications, although these can help. Also, people can have their own definition of recovery and a meaningful life.
  • Emotional problems mislabeled BPD can be completely healed and do not have to be managed for life.

It’s time to say goodbye to National Education Alliance’s harmful theories about BPD as a life-long psychiatric illness, to end the borrowed time these theories have been living on.

Why Reducing BPD’s Stigma is Doomed to Failure

I also oppose the message of blogs that attempt to put a positive spin on BPD, like “Make BPD Stigma Free”. In my opinion, reducing BPD’s stigma and building “BPD Pride” is doomed to failure. To me, these efforts resemble shifting deck chairs around on the Titanic. Similar attempts to reduce depression’s and schizophrenia’s stigma have foundered miserably; the problem is that reducing complex emotional issues to medical labels explains nothing and fails to empower people.

Two examples of such programs are instructive:

  • “Defeat Depression”, a large scale British campaign to reduce the stigma of Major Depressive Disorder, failed to reduce stigma and did not improve outcomes according multiple follow-up studies.
  • “Beyond Blue”, an Australian attempt to reduce the stigma of so-called mental illnesses, also backfired. Studies investigating its effect found that those who knew less about mental illness diagnoses, or who were given a diagnosis but rejected it, had better outcomes than similar people who believed they “had a mental illness.” This unsettling finding has been confirmed in John Read’s research (e.g. Models of Madness).

The disturbing conclusion of this research is that accepting that you have a “mental illness” – as opposed to rejecting the medical model of emotional distress – actually decreases the chances of recovery. This shocking Youtube presentation by critical psychiatrist Sami Timimi covers this and other eye-opening facts about “mental illness”:

If Defeat Depression and Beyond Blue failed to destigmatize depression, why should a destigmatization program for BPD succeed? Alongside “schizophrenia”, BPD is the most unreliable, invalid, confusing, harmful, stigmatized, and useless label. Even if BPD were to lose its stigma, it would remain an unreliable term that explains nothing about an individual’s problems.

Abolishing BPD – The Ultimate Goal

Borderline Personality Disorder can and should be entirely abolished. BPD should be consigned to history as a tragically misguided way of
concretizing emotional distress.

Here is how a world without BPD would look:

1) No More BPD Diagnoses: Distressed people would no longer receive the BPD label during hospitalizations or psychiatric consultations. They would be understood as individuals using the Formulation approach to distress (see article #19 here – https://bpdtransformation.wordpress.com/2014/12/04/19-hope-meaning-and-the-elimination-of-borderline-personality-disorder/).

2) Label-Free Treatment: Psychotherapists and treatment programs would help distressed people without viewing them as borderline, no matter how much the client “fit” that outdated term.

3) Label-Free Family Understanding: Families would be helped to support their distressed members without being fed the fiction that their loved one “has BPD.” Parents, siblings, partners, and children would find that their loved ones’s problems can be understood without calling them borderline.

4) A New Research Paradigm: into severe emotional problems would cease to be focused around BPD. It would instead use the emotional dysregulation spectrum concept that I’m going to discuss. There would be more qualitative, experience-focused research, and less quantitative label-focused research.

5) Abolition of BPD and the DSM: BPD would be abolished from the DSM, as it has already been removed from ICD (Europe’s version of the DSM, from which BPD was recently voted to be dropped). Furthermore, as an unscientific fraud full of fictional illnesses, the entire DSM would be eviscerated.

In time, BPD would be viewed as an outdated relic, a sad symbol of an age where psychiatrists constructed bizarrely misguided labels for emotional distress. People in the year 2200 would look back on “BPD” in disbelief, much as people today look back at centuries-old conceptions of physical illnesses. BPD would be mocked alongside notions of evil spirits released by bloodletting and plagues caused by divine curses.

A BPD-free world is possible. People often underestimate what can be done over long periods of time with sustained, gradual effort. Perhaps BPD’s life is already growing short.

How Would We Understand People Without BPD?

What a scary idea! How could we ever understand people showing “borderline” symptoms without labeling them with BPD?!

How do we understand the problems of anyone we care about?

1) Listen to their story. Learn about what past and present experiences are causing their distress. Develop a shared understanding of their problems based on their history.
2) Learn about what they want to change in the future. Develop a shared understanding of their needs and dreame.
3) Understand fundamental human needs for security, dependence, respect, and independence.

These are the fundamental steps in the Formulation approach to emotional distress, as described here in the story of Emma:


People labeled “borderline” can be effectively helped without labeling them as BPD. But because of the reductionist ideology that has crippled the minds of too many mental health “professionals”, abolishing BPD without a replacement label may be a bridge too far. The Big Pharma profit incentives which maintain the need for medicalization of emotional distress present another obstacle.

The First Step Toward Abolishing BPD – A New Name

Supported by the public’s ignorance about what a precariously perched house of cards “BPD” really is, the profit motives of psychiatrists and Big Pharma will likely block a total abolition of BPD, even though BPD paradoxically never existed and does not exist today. Therefore, I suggest the intermediate step of renaming BPD, something which has already begun to happen for other pseudo-illnesses such as “schizophrenia”.

If done well, renaming BPD would accomplish multiple goals:

1) Undermine the false conceptualization of emotional distress as an illness that is consistent from person to person.
2) Emphasize that emotional distress varies along a continuum and that people labeled “X” are not always “X” (i.e. are not always distressed, but are vulnerable to stress).
3) Reduce stigma by introducing a fresh name without negative connotations.

Despite these hopeful goals, one might argue that replacing BPD with another name would lead to just as much stigma and misunderstanding.

But could a new name truly aspire to be as miserably uninformative as Borderline Personality Disorder?

Would BPD by any other name smell just as bad?

I doubt it.

Japan, Jim Van Os and the Abolition of Schizophrenia

I’ve gone through some brainstorms about what BPD could be renamed, drawing on the campaign against “schizophrenia” for ideas. Many people are calling for schizophrenia to be abolished, and Japan legally abolished schizophrenia about 10 years ago

(Yes, there really are no more “schizophrenics” in Japan. They have a new, less-stigmatizing name for psychotic distress, meaning “integration syndrome” in Japanese, and people undergoing psychotic episodes are no longer called schizophrenic. The entire Japanese government-recording and psychiatric-labeling system for psychosis has been changed. See here – http://www.schres-journal.com/article/S0920-9964(09)00140-6/abstract ).

Jim Van Os, a Dutch psychiatrist, created a website labeled “Schizophrenia Does Not Exist” here: https://www.schizofreniebestaatniet.nl/english/

Van Os renames schizophrenia, “Psychosis Susceptibility Syndrome” , or PSS. The name implies that psychotic experience occurs along a spectrum of severity, involves vulnerability to environmental stress, and that people who have been psychotic in the past are not always psychotic today. In this model, “schizophrenia” as a discrete illness is meaningless and false.

Taking Van Os’s lead, I suggest replacing Borderline Personality Disorder with “Emotional Dysregulation Susceptibility Syndrome”, or EDSS.

The Emotional Dysregulation Susceptibility Syndrome

If BPD were renamed Emotional Dysregulation Susceptibility Syndrome, what would that mean? The EDSS concept would contrast with BPD as follows:

1) Spectrum, Not Illness: EDSS represents a spectrum or continuum of increasing vulnerability to emotional distress. Despite similar appearances, people vary along this spectrum both in degree and kind of distress experienced. People would have more or less “EDSS” in relation to others and themselves at different times. EDSS is therefore not one illness, but a spectrum of related conditions – it refutes the misrepresentation of BPD as an internally reliable illness.

2) Vulnerability, Not Illness: EDSS represents a heightened susceptibility or proneness to emotional distress, usually correlated with neglect and abuse in childhood. EDSS itself does not cause distressing symptoms; rather, it represents the heightened likelihood of environmental stress causing these distress experiences. Compared to BPD, EDSS gives more weight to what happens around a person, rather than to isolated non-contextual internal experiences. EDSS is a syndrome – again meaning it represents similar-appearing experiences which do not necessarily reflect a consistent underlying illness.

3) Recovery and Freedom, Not Management: EDSS represents a psychological state that someone can be in at a certain time of their life, but can grow out of and be free from at a later time. It is in no way a lifelong condition. With effective help, people have a good chance of moving out of the EDSS spectrum for good. This refutes one of the most damaging lies about BPD: That BPD is a life-long illness.

(If you could rename BPD, what would you call it and why? Or would you keep BPD? Let me know in the comments.)

A Psychodynamic Model of the EDSS Continuum

Drawing on my psychodynamic background, I conceptualize Emotional Dysregulation Susceptibility Syndrome as a continuum marked by a relative deficit of positive self/object images, combined with a predominance of all-bad images of self/other within a person’s mind. The deficit of good internalized experience and the predominance of all-bad self/other images would usually correlate with neglect, lack of love, abuse, or trauma caused by parents and peers in childhood and young adulthood. I developed this model fully here, drawing on the “master theorist” of borderline-spectrum conditions, Ronald Fairbairn:


The deficit of all-good images leads to the inability to comfort oneself when under stress (i.e. emotional dysregulation), and to the increased susceptibility to stress relative to most emotionally-healthy people who had more consistent past and present support. All the other distress experiences commonly labeled “borderline” – e.g. destructive acting out, lack of identity, rapidly shifting moods, extreme rage, splitting, etc. – would be understandable results of having to cope with the missing self-comforting functions that can only be provided by a predominance of good self/other images over bad self/other images, i.e. enough good experiences in one’s past to reassure oneself when under present-day stress.

These distress experiences would also be understood as present-day replayings of past trauma; i.e. as the projection of the all-bad self-object images internalized in childhood onto others in the present, which make the person experiencing EDSS feel that they are “bad” and others are rejecting or unavailable.

EDSS might also be conceptualized as the spectrum encompassing the “Out of Contact” through “Ambivalent Symbiotic” Phases in this 4-phase model:


These descriptions do not represent an illness, but rather a dynamic state of relating to oneself and others at a certain time. One can function at any point along the spectrum from almost Non-EDSS to very severe EDSS – i.e. from approaching a normal range of being able to comfort oneself and function well, with only occasional regressions into serious distress – down all the way to very severe EDSS, in which the distress experiences are constant and severe to the point that normal functioning is not possible. Hopefully that the paradigmatic differences between BPD and EDSS are clear.

You Don’t Have to Accept the BPD Label

I hope these ideas will be encouraging and provoke thought about whether BPD really is valid and useful. Replacing BPD might seem unthinkable now, but there were times when women voting seemed impossible, when black people being free seemed impossible, and when tobacco causing health problems seemed impossible. Radical change can happen. Often, the process leading to a dramatic change is gradual and unseen, like when decades-long pressure building under the Earth’s crust goes unnoticed before an earthquake.

If a small but growing number of people reject the BPD label, this process can build momentum toward renaming and/or abolishing BPD. I encourage everyone reading this who has ever been labeled “borderline” to consider that you no longer have to identify with or accept BPD, period.

If a psychiatrist labels or has labeled you as BPD, or if the voice of people calling you borderline is stuck in your mind, I encourage you to tell them something like this:

“The BPD label you’ve called me is a simplistic checklist of distress factors, factors which anyone under stress for long enough can experience to different degrees. There are no reliable genes, brain-scans, or other biomarkers which can identify so-called BPD. In fact, BPD is in no way a reliable classification; it is an “illness” fabricated out of thin air without a basis in real science.
There is therefore no proof that I have an illness like you say, or that there is anything innately wrong with my brain; most likely, I am reacting in a perfectly logical way to the stresses I’ve gone through. There are other, better ways to understand my problems, and I do not accept the false label of BPD that you are putting onto me. If I get enough help, I can fully recover and live the life that I want.”

Psychiatrists and therapists need to hear this from more of the people they call “borderline”!

#25 – Who Was The First Borderline? – From Cavemen and Dinosaurs to Creationism and the FSM

Where did BPD come from, and how was it passed down to modern humans? This is one of the more vexing questions of our age. For an answer, we must turn to the all-knowing wisdom of American psychiatry, which proclaims:


“BPD is strongly inherited.” This seems like an answer to where BPD comes from. But is it? According to psychiatry, BPD is mostly in the genes. But how could this dreaded disease have originally developed? It didn’t magically appear out of thin air. This begs the question:  From whom was BPD first inherited? Who – or what – was the real “first borderline”?

In this essay, I will take psychiatry’s thinking to its logical conclusion. If BPD is “inherited”, we should be able to track down the ultimate source of this nefarious malady. Prepare to embark on a fascinating journey of discovery. My theories are based on exciting new research by paleo-psychiatrists – scientists who study mental illness in prehistoric creatures.

Early Speculations on BPD’s Origin

Early paleo-psychiatrists raised questions like the following in their search for the first borderline:

Was the first borderline an Egyptian slave who began to have mood swings under the stress of building the pyramids, 4,000 years ago?


Was the first borderline a Bronze Age Mesopotamian mother who, traumatized by hard farm work, began to view her fellow Sumerians as saints or devils, 8,000 years back?


Or was the first borderline an Aboriginal hunter-gatherer who, after too many attacks by dingo dogs, developed identity diffusion in the Australian outback 12,000 years ago?


Did one of these ancient people first become borderline, and then transmit the invisible plague to their prehistoric children and on to us?

(Aside: Recent genetic studies by paleo-geneti-psychiatrists have suggested that, in addition to the normal gene-coding letters A, C, G, T, the nucleobases B, P, and D are present in the genomes of people with BPD. So genes in a healthy person, which originally read GATCGGCAGGAACAT, would come to read GATBPDCAGBPDGAABPD. This is why I’ve been terrified to get my genes mapped, for fear those cursed combinations will appear in my DNA strands, to be inevitably passed on to my children.)

BPD and Early Man

Returning to the main story, the answer is no. BPD extends back far past early Egyptians, Mesopotamians, and Aborigines. Paleo-psychiatrists recently found that cavemen exhibited Borderline Personality Disorder. Witness the following image, found on prehistoric cave walls at Laschaux, France, but concealed from the public until now:


With this life-like painting revealed, it is scientifically proven that BPD extends at least to our caveman ancestors. This is so easy to figure out, even a caveman can do it.

So perhaps BPD originated with these forward-thinking cavemen, who would have been traumatized by living in rotten, damp caves.  But couldn’t cavemen have inherited BPD from earlier humanoids?

Through the theory of evolution, we know that humans evolved from early apes (or at least, people who think the earth is more than 6,000 years old know this). So maybe the situation looks more like this:


These monkeys are not going to tell us anything definitive, but that bonobo looks suspicious.

Prehistoric Megafauna and BPD

Early apes are an interesting potential source of BPD. But other evidence suggests that the vile pathology worms its way back further. Each of these early humans and apes evolved from other life-forms, any of which could have been the first carrier of the abominable affliction. The plot thickens, and if we want to know where BPD truly came from, we must gaze deeper into the past.

Paleo-psychiatrists recently found this fossilized face-off between the last saber-toothed tiger and the first prehistoric mountain lion. From their facial expressions, it was deduced that they were snarling the following at each other:


But of course, if prehistoric big cats had borderline symptoms, it begs the question of where they inherited them from. Peering further over the horizon, here is cave art drawn by a Paraceratherium, revealing fantasies it was having about the cause of its family’s BPD symptoms:


So in this image, we have evidence that BPD existed at least 15 millions years ago, in the age of the megafauna or giant mammals. But there’s more.

Psychiatry’s Return to the Days of the Dinosaurs

Excited by their study of the megafauna, paleo-psychiatrists dug ever deeper into forgotten times. The two creatures below were recently unearthed from a prehistoric swamp after being buried by a 65-million-year old mudslide. Paleo-psychiatrists determined that they were saying the following:


Well, this picture is not exactly about BPD. But given the high comorbidity between Avoidant PD, Narcissistic PD, and Borderline PD, it can be said with confidence that BPD dates back at least 65 million years. If avoidant and narcissistic dinosaurs roamed early Earth, then giant reptilian borderlines would have been lumbering around too.

Indeed, all sorts of personality-disordered dinosaurs must have existed in the Cretaceous, Jurassic, and Triassic eras. This makes it much more difficult to trace who the first borderline was. But it does enable us to watch The Land Before Time and Ice Age: Dawn of the Dinosaurs with a new understanding of these monsters.

The search begins to seem endless. Who was the real first borderline? This situation brings to mind the Where’s Waldo? books, when you can never find the little guy in red and white stripes. Or perhaps it should be Where’s the Borderline?:


Sorry. Back to the topic at hand.

Early Avian and Mammalian Ancestors

As I was saying, paleo-psychiatry keeps making new discoveries. To trace the passage of the fearsome plague that is BPD into humans, we should also investigate the earliest birds and mammals, who shared common ancestors and lived alongside dinosaurs. Early mammals lived in a traumatic environment, which we know is a risk factor for BPD. Perhaps the trauma of living with big, scary dinosaurs was transmitted into their genes, creating a vulnerability that led to BPD in humans.

One can imagine the following scenario:


As well as this one:


It makes sense that borderline traits might develop and be genetically transmitted in such an environment. But couldn’t BPD have developed in pre-dinosaur times, and been transmitted from an even earlier starting point?

A Never-Ending Goose Chase

We must commend paleo-psychiatrists for their efforts to trace the early animal origins of BPD, efforts which are as scientific and respectable as those of modern-day psychiatrists to study BPD in humans.

But despite heroic efforts, paleo-psychiatrists have not traced BPD’s ultimate origin, which remains shrouded in mystery. It seems straightforward to follow the evolution of BPD from modern day humans, past cavemen, through early mammals and dinosaurs, all the way to the earliest forms of life. But this process never reaches a satisfying conclusion. With evolution working as it does, there would always be another creature from which to inherit BPD.

We can even imagine unicellular cells, flitting around the primordial fires of early Earth, transmitting their borderline traits to the first multicellular organisms:


But let’s not go there.

Creationism – A Solution to the Conundrum?

There is another possibility. What if evolution is wrong, and another theory explains BPD’s origin and heritability? What if Earth is only 6,000 years old, as creationists solemnly preach, and as some of our finest public schools teach as an alternative to evolution?

Creationism would elegantly explain how BPD developed. Under creationist teaching, BPD would be a result of the trauma that early humans experienced living alongside dinosaurs and other “prehistoric” creatures. If God created the Earth 6,000 years ago, he would have put all the creatures in history together, even if it resulted in strange alterations to traditional Biblical stories, like this:


And this:


And this:


No wonder the authors of the Bible wanted to cover up this sordid state of affairs. Living alongside dinosaurs would have made things scary and unpredictable for early humans. And as we know, such traumatic environments are a prime cause of BPD. Therefore, 6,000 year-old dinosaurs may have been the primary reason that BPD developed and was genetically passed down from early to modern humans.

Thus, the trauma of living alongside these monstrosities would have affected mankind’s genes such that BPD would quickly develop as a distinct disease.  As Jonathan Swift might have said, this is “a modest proposal”, but a convincing one.

Just imagine the following scene, which would have been a daily occurrence 6,000 years ago:


And this:


Who would not develop borderline symptoms in such conditions?

And imagine having to live alongside abominations never preserved in the fossil record (the fossil record having been planted to trick creationists into believing in evolution, of course), like this:


How horrifying! Thank goodness the dinosaurs and swamp-monster abominations were finally wiped out in an almighty Ragnarok-like battle against invading aliens:


If dinosaurs and aliens had not annihilated each other a few thousand years ago, then modern civilization would never have developed. If dinosaurs did not die out, we poor humans would have been stuck with dinosaur-induced BPD symptoms, but without the gentle ministrations of modern psychiatry to help us manage them. So let us give thanks that aliens and dinosaurs wiped each other out, because DBT wouldn’t be possible with Tyrannosaurs constantly chasing us.

For me then, creationism provides the best explanation of BPD’s origin. It seems that we must renounce evolution, and accept the fact that the Earth is only 6,000 years old, since no other theory explains BPD’s origins so simply and elegantly. Remember Occam’s Razor – the simplest explanation is usually the correct one.

Alternate Explanations: Pastafarianism

However, there are other explanations. I was recently contacted by a Pastafarian paleo-psychiatrist, who suggested that the Flying Spaghetti Monster might be the cause of BPD. (For those of you who don’t know, Pastafarianism is the religion which teaches that a Flying Spaghetti Monster created the universe. Visit the Church of his Noodly Appendage at http://www.venganza.org )

So, instead of this scenario leading to BPD:


The following scenario would have accounted for the illness:


However, try as I might, I cannot think of a real reason why the Spaghetti Monster would want to create BPD. His job is to create the universe and feed people pasta, not generate mental illnesses. So this doesn’t fly with me, even if the Spaghetti Monster “flies” in another way.

The Scientific Integrity of My Research

For those of you who think this is a joke, it is not. Do not hurt my feelings by commenting that these theories are unscientific. I am earnestly supporting the efforts of our nation’s finest  psychiatrists in tracing the source of BPD, a pathology which even they admit “the causes and origins of are unclear”. What could be more noble than shedding light on the origins of such a misunderstood affliction?

The Learning Doesn’t Stop Here

Despite their confusion around the inheritance issue, there is much more to be learned from psychiatry’s penetrating insights into BPD.

Psychiatry wisely teaches us that BPD is a “severe illness”, that BPD has a “course” and an “outcome”, that a certain percentage of the population “has it”, how psychotherapy and medications can “manage it”, and so on.

We must give thanks to psychiatry for creating such a wonderful and sympathetic way of understanding human emotional problems. Hearing the pontifications of psychiatrists on BPD is like listening to beautiful classical music.

If you want to learn more about these encouraging, scientifically-sound ideas via our government’s finest websites, as well as from many forums about BPD, make sure you are prepared. Before you research BPD’s cause and origins on Google, you will need:

  • A good sturdy chair.
  • A thick pillow to keep your ass from getting sore.
  • Eyedrops
  • Pain relief ointment for your mouse-clicking finger.
  • Tissues
  • Headache medications.

And take heart: Everything you learn about BPD from traditional psychiatry will be just as scientifically valid as my research above. Good luck!

The Scientific Process by which BPD Sprang Into Being

Now, if BPD first developed in early humans living alongside dinosaurs – who wouldn’t have referred to their symptoms as “Borderline Personality Disorder” – it is interesting to consider when the term BPD first emerged in modern psychiatric usage. Below is an imagining of the scientific process by which BPD may have developed.

A Conversation Between Two Medical Doctors of the Mind (i.e. Psychiatrists)

Date:  March 1st, 1939
Setting: Psychiatry Conference, somewhere in WW2-era America…
The players: Dr. Chillingworth and Dr. Hadley

(Setting – Drs. Chillingworth and Hadley are smoking it up outside a beautiful hotel, discussing the current state of the psychiatric art..)

Dr. Chillingworth: “I’m so thrilled to be back at our nation’s premier psychiatry conference. Our catalogue of mental afflictions is crying out for new names. You know, my dear Hadley, I don’t think we’re upsetting people enough by calling them neurotics and hysterics. The masses need to know when there’s something wrong with them, and those labels just don’t do it for me anymore. We need something to really get the blood boiling.”

Dr. Hadley: “I agree, dear Chillingworth. I call the crazy ones schizophrenic, but they don’t even react! It’s most disturbing. I wonder where we’ve gone wrong.”

C: “Ok, let’s put our minds to it. What name will really upset people?”

H: “How about “Weirdo Syndrome”? You know, for the bizarre folks who aren’t totally crazy, but we don’t know what else to call them?”

C: “Oh humbug! Is that the best idea you have?!”

H: “Forget that. What about “Queer Disorder”. It could be a brand new affliction. We know there’s something wrong with the homos; everyone suspects there’s a malignant germ plasm in their blood!

C: “No dice! Our friend Dr. Beavis beat you to the punch – he’s presenting this idea tomorrow. Don’t worry, homosexuality will be an official disorder. Come on, we need something original!”
(Historical note: Homosexuality was an official DSM disorder until the mid 1970’s).

H: “How about….. “borderline”? We can use it on the ones who aren’t neurotics, but aren’t raving psychotics? You know, the people who are always pissing me off.”

C: “Yes!! Yes. That’s it. … “Borderline!” Wow…. It’s a bunch of bullshit – it doesn’t mean anything. But that’s why it’s brilliant. People won’t know what it means, so it will work perfectly. Let’s use it!”

H: “But how can we be sure that people will buy it, Chillingworth?”

C: “That’s easy. We list things about people who aren’t raving psychos, but are “messed up”. We say if you fit enough of the criteria, you’re a borderline! We make it all sound very scientific and official. The criteria could be things like being irritable, having mood swings, having relationship problems, being impulsive, etc. etc. Things anyone can have, taken to an extreme. Anything we can make up about people we don’t like.

H: “But do you really think people will believe that? I don’t know…”

C: “Of course they will! Give yourself some credit, Hadley; stop overestimating your fellow human beings. Most members of our species are uneducated idiots. If psychiatrists repeat a made-up label loudly and often enough, people will believe it. Remember, the public think we’re experts.”


H: “This is great! But you know, I just realized something, Chillingworth. You’re pretty messed up yourself.”

C: “Tell me something I don’t know!”

H: “Indeed. Moving on… do you think that, many decades years from now, people might think this “borderline” label we dreamed up is real, and a whole industry will be based around labeling and managing these “borderlines”? I don’t know if I would feel good about that.

C: “Oh stop whining! The Borderline affliction will become real, because we say it is. We became psychiatrists so we can be exalted as experts and given bundles of money. Who cares if we have no idea why people act like they do? And who gives a damn about people in the future? Our genius is that we have no idea what we’re talking about, but people pay us anyway. Have faith, my friend.”

And thus was born “Borderline Personality Disorder.”

(Historical note: BPD was in fact “born” after psychiatrists in the late 1930s invented the term out of thin air. Perhaps not exactly like this. But close enough…)


My thanks go to Sameer Prehistorica (http://sameerprehistorica.deviantart.com) and Harry Wilson (http://harry-the-fox.deviantart.com) for allowing the use of their beautiful art. Also, credit to http://www.speechable.com, a great, free resource for attaching captions to pictures).

I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or would like to more effectively help someone who is borderline, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment


– Edward Dantes

#24 – How I Triumphed Over Borderline Personality Disorder

I recently rewrote my story of struggling with and overcoming the borderline diagnosis. The account below describes the beatings I endured as a child, periods of extreme hopelessness, encounters with stigmatizing psychiatrists, an argument that conceptualizing BPD as a life-long disorder can be harmful, analysis of how I deconstructed the borderline label, a very brief account of my therapy, and some of my proudest achievements in work and love.

Although it’s brief for a life story, I hope you find this account encouraging. I’m not better or fundamentally different than anyone else who gets labeled BPD, and given sufficient support anyone with “borderline” symptoms can do very well.

How I Triumphed Over Borderline Personality Disorder

Welcome to my story of recovery from Borderline Personality Disorder (BPD). This story will illustrate how I went from fearing this dreaded diagnosis, to being hopeful about it, to finally no longer believing in its validity.

Here are two early encounters with “mental illness” that show how I grew to fear psychiatric labels:

Vignette #1 – When I was eighteen, my mother and I sought professional help after years of emotional abuse at the hands of my father.

In our first session, the therapist said, “It sounds to me like your father has a personality disorder…You know, there are normal people, there are those who are a little bit outside our societal norms, and then there are people who are really beyond the pale. In this last group are the ones we call ‘personality disordered’. These people are very difficult to help, and many therapists consider them ‘untreatable’.”

Being unfamiliar with “personality disorders”, my mom and I didn’t know what to make of this. But despite my father’s abuse, I disliked this therapist’s cavalier labeling of someone he had never met.

Vignette #2 – At age twenty, I became suicidal and had to be involuntarily committed to a psychiatric hospital. The following example comes from a group therapy session inside the hospital:

“Mood disorders are biologically-based mental illnesses,” the psychiatrist announced authoritatively, surveying the fifteen young adults in front of him. “But while these disorders might be biological, it doesn’t mean you can’t manage them effectively.”

My mind reacted explosively: How the hell could you possibly know this? What evidence do you have? I desperately wanted to shout at him. But I remained silent, slouching backward in my chair.

These snapshots encapsulate the hopeless viewpoint with which psychiatry assaulted me. It would take everything I had to break free from the resulting fear and despair.

How I Became “Borderline” – A Very Brief History

As of this writing, I’m twenty-nine years old. I grew up in a family of four on the east coast of the United States. My father worked a demanding financial-sector job, and my mother taught school part-time while caring for my younger sister and me. Our childhood was marked by isolation, emotional deprivation, and physical abuse. Starting when I was six, my father regularly beat me for small infractions such as arguing with my sister, outside of which he remained emotionally distant. He often sat on our living room couch staring into space for hours at a time.

Two memories of the abuse stand out. On one occasion, when I was around ten, my father, who was about 6’3 and 225 pounds, chased me to my room, broke my locked bedroom door off its hinges, and attacked me with fists to my face. On another, he picked me up and threw me ten feet across a room onto the sharp edge of a table. He would usually follow these incidents by telling me that he loved me, but would then return to his catatonic-like state on the couch. My mother tried to protect me, but was too afraid and insecure to be of much help. Child services were never contacted.

By my late teens, I felt depressed, scared, and helpless. Despite doing well in school – I was a good student who enjoyed playing tennis and violin with school groups – I had no close friends, and didn’t know how to talk to girls. The growing pressure to leave home and function as an adult felt incredibly threatening. At the same time, my father’s mental health was deteriorating further – he had to be hospitalized multiple times for manic episodes and suicidal depression.

As our family life broke down, things felt increasingly hopeless. I felt furious at my parents, and suffered intense mood swings of rage, emptiness, depression, and terror. I wanted to get help, but couldn’t trust anyone enough to open up about what I was feeling.

Eventually I became suicidal, and after concocting a plan to kill myself, which almost succeeded, I was involuntarily hospitalized. This episode led to the diagnosis of Borderline Personality Disorder, given to me by a psychiatrist at the hospital. I spent two weeks at the hospital in a shocked, barely coherent state, getting little help from superficial group therapy and heavy medications. The only good thing was that I stopped being actively suicidal.

The First Phase – BPD: A Life Sentence?

In the year after my hospitalization, I extensively researched my “illness”. Most readers will be familiar with the core “borderline” traits:  they include black and white thinking (“splitting”), self-damaging behaviors, impulsivity, fear of abandonment, and unstable interpersonal relationships.

Through interactions with psychiatrists, internet forums, and pop psychology books, I found out the following “facts” about Borderline Personality Disorder:

  • BPD is a life-long mental illness; it can be managed but not cured.
  • Due to their reputation for being manipulative and demanding, most “borderlines” are avoided by therapists.
  • Twin studies show that 50% or more of vulnerability for BPD is transmitted through genes.
  • Brain imaging reveals that the brains of borderlines differ significantly from the brains of “normals.”
  • Borderlines suffer from a constitutional deficit that prevents them from regulating their emotions normally.

As a young person, I didn’t know how to evaluate these data. If a person had “Ph.D” or “M.D.” by their name, I tended to believe what they said. When I was already vulnerable, these ideas heightened the terror. I became possessed by the fear of being a “hopeless borderline”, of having a life-long mental illness that was impossible to cure. I was not only facing formidable challenges in reality – like my father’s abuse and a lack of social skills – but was further impeded by the intense anxiety and hopelessness surrounding the label “BPD”.

Questioning The Pessimism

By the time I was twenty-one, my parents had divorced and I’d chosen to live with my mother. For two years after my hospitalization, I was unable to work or attend college. Much of my time was spent at home, severely depressed, isolated, and brooding about being a “hopeless borderline.”

At this time, I was seeing a psychiatrist once a week for fifty minutes a session. Over a two-year period, he prescribed me twelve different antidepressant and antianxiety medications. We kept trying different pills, with nothing helping much. If I had known then what I know now – that many psychiatric medications are little more effective than placebos – I would never have taken so many.

To his credit, this psychiatrist tried to “do therapy” with me. Unfortunately, I was in such a traumatized state that I could not take in his empathy nor understand my family history. However, I gradually became aware that someone wanted to help. I noticed that although my psychiatrist knew I had been labeled borderline at the hospital, he never used this label on me.

This experience with the kind psychiatrist built up a sliver of hope. I realized that I felt a little better after talking to him, and wondered if that feeling could become stronger. Sometimes I would have the thought, “Maybe there is really nothing wrong with me.” Part of me wanted to fight, to become alive, to feel like a real person. When I had the daily thoughts about borderlines being doomed, a voice inside my mind started saying, “They are lying to you!” I wanted to find out what this meant.

Over time, I felt increasingly angry about the way borderlines were stigmatized. How could borderlines be so bad? Had none of them ever been “cured”? What if the things I’d read about borderlines were untrue, or the result of therapists who didn’t know how to treat them?

The Second Phase – “Borderlines Can Do Well”

With these doubts surfacing, I began to research BPD in greater depth. Up to that point, I had received most of my information from the hospital staff and internet forums where people spoke negatively about “their borderlines.”

I decided to go on Amazon and look for new information. The books that influenced me the most were older psychoanalytic texts. Their authors included Gerald Adler (Borderline Psychopathology and Its Treatment), Jeffrey Seinfeld (The Bad Object), James Masterson (e.g. The Search for the Real Self), and Harold Searles (My Work With Borderline Patients).

As I read about borderlines in long-term therapy, I was shocked to realize that many borderlines had fully recovered. The case studies showed people starting out hopeless and nonfunctional, but becoming able to work productively and enjoy relationships. It was crystal clear from the narratives that these “borderlines” were coming to trust others, working through their pain, and coming alive. I finally had some hope. Given enough time and support, former borderlines could improve greatly and even be “cured”.

I remember thinking, “Wow, a lot of what I’ve been told about BPD is completely wrong; this is not a hopeless condition! If other borderlines can recover, why can’t I do it?”

This burst of hope inspired me to seek help. I pursued psychodynamic therapy, interviewing several therapists and finding a kind psychologist who had worked with many trauma survivors. I went to see her twice a week for several years.

Gradually, painstakingly, I made progress. Through reading accounts of borderlines recovering and discussing the fears around diagnosis with my therapist, my anxiety and hopelessness lessened. I formed a really good bond with this therapist, coming to trust someone deeply for the first time. Being “reparented” and taking in her love was the most important step in my becoming well for the first time (I would call it “recovery”, but I had never been well before).

For the first time ever I had periods of feeling calm. I felt like Michael Valentine Smith, the Martian man from Stranger in a Strange Land who learns what it is to be human. Becoming able to trust other people, feeling safe in my own skin, appreciating the sun and the flowers and the trees, feeling that I was going to survive, it was all strange, incredible, and bittersweet.

Using online groups like Meetup, I tentatively started to seek out people my age. Feeling more capable, I earned a professional qualification and began teaching sports to young children. The more time I spent around energetic kids, the harder it was to remain pessimistic. Being still a child at heart, I found a talent for relating to children on their level.

The Third Phase: “My Way of Thinking about BPD Doesn’t Make Sense”

In difficult times, I continued to worry about the pessimists who said full recovery from BPD was impossible. I was still thinking of things in terms of “borderlines act like this, borderlines don’t act like that, borderlines can do well, borderlines can’t do well, etc.” The label still felt real.

But with life experience, I began to doubt BPD. I wondered if BPD – the disorder, not the symptoms – really existed at all. The following questions became increasingly problematic:

  • How can therapists reliably determine the degree of a given symptom that warrants its inclusion in a BPD diagnosis? For example, who can say when someone’s relationships are unstable enough, or when a person feels empty enough, to cross the threshold and suddenly become a “borderline” symptom? The subjective, descriptive nature of BPD symptoms seemed like a major weakness.
  • Person A could have only symptoms 1 through 5 from the DSM IV, and Person B could have only symptoms 5 through 9. The people might even be very different in how they express the one common symptom. Do persons A and B really have the same “disorder”?
  • Did researchers have strong evidence that BPD was genetically transmitted, or that brain differences between borderlines and “normal” were caused by biology?
  • Why does BPD have 9 symptoms? Why not 4, or 23, or 87? How was BPD’s existence as a 9-symptom “illness” first inferred?
    (I realize that BPD has magically “changed” in the new DSM V. But in slightly varied forms, all of these criticisms would apply just as much to the “new BPD”; these examples represent the time when the DSM-IV was current).

As far as I was concerned, there were no satisfying answers to these questions.

The Fourth Phase: “I Don’t Need BPD Anymore”

Something felt fishy about the whole psychiatric labeling system. I suspected that BPD, along with the other labels, represented a house of cards that would collapse under close examination. More research was in order.

This time, I discovered a group of writers including Stuark Kirk (e.g. Making Us Crazy), Paula Caplan (They Say You’re Crazy), Jay Joseph (The Gene Illusion), John Read (Models of Madness), Barry Duncan (The Heroic Client), Mary Boyle (Schizophrenia: A Scientific Delusion?), and Richard Bentall (Madness Explained). From their writing and through observing myself, I came to the following conclusions:

  • While all the borderline symptoms are real in different degrees and varieties, BPD itself is not a reliable or valid syndrome. In other words, there is no evidence that the symptoms labeled “BPD” occur together in people more frequently than would be expected based on chance alone;
  • No one can reliably draw a line for any of the borderline symptoms beyond which one is “borderline” and before which one is “normal.” In other words, the subjective, descriptive nature of borderline symptoms fatally undermines their reliability;
  • Twin studies do nothing to prove that “BPD” is transmitted through the genes, this is partly related to the non-validity of BPD and partly to methodological problems with twin studies;
  • There is no evidence that a constitutional deficit in regulating emotions exists in “borderlines”;
  • Because BPD is invalid and unreliable, biological researchers studying “it” are doomed to roam a circular labyrinth. They will continue to generate false hypotheses and misleading conclusions based on the illusory imposition of a “borderline” cluster of symptoms onto random mixes of severely distressed people.
  • Psychiatrists will continue clinging to the existence of “BPD” and other personality disorders. If they were to admit that BPD et al. are unscientific fabrications, their status as “experts” would be undermined.

It will be recalled that my young self had feared BPD as an incurable, genetically-based “illness”. By the time I was twenty-five, my thinking had evolved radically. If the placeholder “BPD” was a nonexistent ghost, then many of these ideas ceased to have meaning. It didn’t make sense anymore to worry about getting better from “BPD.” One cannot become free from a condition that is not diagnostically valid; one cannot be cured of something that cannot be reliably identified; genes cannot cause a fictitious disorder; medication and therapy cannot be compared for the treatment of a speculative phenomenon, and so on.

This is how I think about “Borderline Personality Disorder” now – as a ghost, a fiction, a figment of psychiatrists’ imaginations. In asserting this, I am never saying people’s painful experiences are not real. They absolutely are. But affirming people’s pain is very different from arguing that Borderline Personality Disorder exists as a distinct “illness”.

Further Emotional Growth

As I increasingly separated from the label “borderline”, further emotional growth took place. Based on my work teaching children, I started my own business, which involved advertising, accounting, hiring staff, and communications. I moved into my own house, living independently for the first time, while continuing to socialize more. I was happy a lot of the time.

In my late twenties, I had my first real relationship with a woman. She was an attractive college girl; we had several interests in common and got along well. After the hopelessness stemming from my abuse and the BPD label, loving another person had seemed like an impossible dream. I was glad to be proved wrong – loving her was better than I had ever imagined! This relationship was a first in many ways, teaching me a lot about emotional and physical intimacy.

I realized how, during the long years dominated by fear, despair, and anger, I had missed out on the best things in life. I realized that believing in “Borderline Personality Disorder” had only held me back.

A New Way of Thinking

If BPD didn’t exist, how could I understand my past “borderline” symptoms? The black and white thinking, emptiness, despair, fear, and rage had been very real. To understand them without the BPD label, I needed a new model of reality. I started by picturing distressing thoughts and feelings existing along a continuum of severity.

In my new thinking, each symptom was no longer “borderline” or “not borderline”; rather, my feelings and thoughts were the result of my family experience and everything that came from it. In particular, I needed to understand how my father’s physical abuse and my mother’s lack of emotional availability had contributed to my problems. In this way my past started to hold meaning (whereas, calling myself “borderline” didn’t really explain anything).

I modeled some of my thinking after Lawrence Hedges, a California-based psychologist. He rejects the DSM labels in favor of a system called “Listening Perspectives”. In this model, a person uses different ways of relating to other people at different points in time. Hedges describes these levels as “organizing (a term to replace ‘psychotic’)”, “symbiotic (to replace borderline)”, “self-other (for narcissistic)”, and “independence (for neurotic-healthy)”.

These terms do not denote distinct “disorders”, but rather fluid ways of relating which fade into one another along a continuum, which evolve based on environmental input, and which always involve others. A person will operate in different parts of this continuum at different times and with different people. In this model, one would never “have” a borderline or psychotic “disorder”; the words “organizing” and “symbiotic” would have no meaning outside of a specific relational context. The focus is on understanding and changing restrictive ways of relating, not on labeling or managing “illness”.

I probably lost some people here! This way of thinking is not proven science, but it works for me, and it’s far better than believing in the static, hopeless “Borderline Personality Disorder.” I mostly don’t even think about BPD now, because it’s not worth my time. I’m more interested in real things!

Helping Others Break Free

Two years ago, I revisited some internet forums about BPD that I had first seen as a teenager. To my surprise, these forums were alive and well; more people than ever were discussing such weighty topics as:

  • What’s the best way to manage “your borderline”?
  • You know you’re a borderline when…. (fill in the blank)
  • Can I have borderline, schizoid, and antisocial PDs at once?
  • Are borderlines more sexual than the average person?
  • Why won’t my family take my BPD seriously?
  • Do borderlines have a conscience?
  • Are borderlines more sensitive than the average person?
  • If BPD is biologically based, why do people blame us for our behavior?
  • How do you fill your spare time when you have BPD?

If these weren’t so sad, they would be funny (well, some of them are darkly humorous, but let’s not go there…). Anyway, hundreds of people were discussing how to “live with BPD”, “manage this illness”, “learn to accept my diagnosis”, and other twisted medical-model jargon. The level of distortion inherent in these questions is so massive that I will not even begin to discuss them; the reader can infer my opinion from the preceding paragraphs. It’s tragic that already-traumatized people are fed these lies about BPD being an “illness” they’ll have for life; for many it will only make the path to wellness harder in the long run.

After seeing these forums, I started a website telling my story of hope and critiquing the medical model of BPD. This project has allowed me to learn from other people so diagnosed. Talking with them has only reinforced my conviction that people labeled “borderline” don’t have the same “illness”. Rather, they are unique individuals, most of whom have had very difficult lives. Almost all of them want to understand their problems and get better; they are basically good people with good hearts. I would never want to label any of them “borderline.” My messages to them are,

1) Full recovery and healing from so-called “borderline” symptoms is absolutely possible, and
2) You don’t have to understand yourself through the invalid label “BPD”.

For some reason, people like these ideas a lot better than the prospect of managing a life-long “personality disorder”.



I will finish this article with a scene the movie Inception:

“You mustn’t be afraid to dream a little bigger, darling.” My goal is for more people to be able to say that to the idea that they can’t overcome the borderline label. The “enemies” in this movie could symbolize my fears of having BPD for life and never becoming truly well.  To be able to dream bigger, I had to explode these distortions with more positive experiences and with better data, as symbolized by Tom Hardy’s big gun!

#23 – The Borderline-Narcissistic Continuum: A Different Way of Understanding “Diagnosis”

For the purpose of understanding psychiatric problems in a more nuanced and optimistic way, here is a diagram from Donald Rinsley’s book Treatment of the Severely Disturbed Adolescent:


Please click on the picture to see it larger. Each row corresponds vertically to the rows above and below in describing degrees of emotional development, and each row describes emotional growth over time from left to right. The majority of the text in brown is Rinsley’s own diagram; the bottom additions in white are mine.

Donald Rinsley was among the most respected authorities on borderline and narcissistic conditions in the second half of the 20th century. He was a psychodynamic therapist who ran a psychiatric hospital for severely troubled adolescents in Topeka, Kansas in the 1960s, 70s, and 80s. He later worked extensively with personality-disordered and psychotic adults in an outpatient psychotherapy practice.

I believe that much can be learned from studying Rinsley’s diagram. It explains how psychiatric diagnoses were originally understood in psychodynamic theory – as problems in relating and functioning that occur along a continuum of severity and merge into one another. In other words, psychiatric conditions are not distinct disease entities; there are no clear lines that separate one from another.

At the upper and lower ends of each “disorder”, one cannot confidently say that a person is, for example, a higher level borderline versus a lower-level narcissist, since the conditions fade into one another. Note how the arrows denoting each region don’t stop before running into each other; they overlap.

Here are explanations of the diagram’s different rows.

Row 1: Mahler’s Phases of Child Development: Autism-Symbiosis-Differentiation-Practicing-Rapprochement-Object Constancy.

In this row, Rinsley lists phases of healthy child development that, when interrupted, can cause arrests in emotional development – i.e. psychiatric problems. Roughly, autism (which does not refer to autism as understood today) refers to the earliest period when a baby is unaware of the external world and feels fused with its mother at a body-level. Symbiosis is when the child starts to relate in a back-and-forth need-fulfilling way with its mother.

During differentiation, the baby realizes that it is separate from its mother psychologically as well as physically. In practicing, the child discovers and explores the external world via its newfound ability to walk. And in rapprochement, the child develops a good relationship to the mother as a separate person and faces conflicts around dependency/attachment and independence/autonomous functioning.

In these descriptions, “mother” is synonymous with “caretaker”, “parental figures”, and “the external world of people”. In the object constancy phase, the mother is finally perceived as a mixture of good and bad qualities, meaning that splitting is overcome,, and the child is increasingly able to regulate their emotions. It is this achievement that is lacking in borderline conditiions. For progression through these phases to occur, it is crucial that good-enough mothering be consistently available; otherwise the child can get “stuck” in a certain phase.

There is one area where I disagree with Rinsley. I don’t think it’s possible to put the phases of infantile development into a neat timeframe (as Rinsley attempts to do by saying that object constancy takes over in healthy toddlers at around 24 months, for example). I think children’s development is highly individual and that aspects of these phases continue to be worked on long after the first few years of life, even in emotionally healthy children.

Row 2: States of Self-Object Fusion or Differentiation

In this row, Rinsley indicates whether a person sees themselves and others as fused (indistinguishable from each other; this is a psychotic state), split (self images experienced as separate from images of other people, but viewed as all-good or all-bad, a borderline state), or integrated (seeing a mix of good and bad qualities within both self images and images of other people, a neurotic/healthy state). Roughly, fused self/object images relate to “psychotic” states, split images to “borderline” or “narcissistic” states, and integrated images to “neurotic” or healthy states of minds.

Row 3: Specific Diagnostic Categories

Here Rinsley lists diagnostic labels that correspond vertically with the phases of child development and self-object differentiation from the higher rows: Autistic-presymbiotic schizophrenia, symbiotic schizophrenia, bipolar disorders, borderline personality, narcissistic personality, neuroses, etc. I will not describe specifically what these diagnoses mean; the reader who is familiar with DSM categories will recognize them.

The crucial thing is that the diagnoses overlap along a spectrum and thus are not distinct illnesses. Rinsley conceptualized diagnoses as morphing into one another as treatment progressed; for example, one could start treatment at an upper-level schizophrenic, become a “borderline” a year or two later, then become narcissistic, and finally end up functioning at a neurotic, essentially healthy level after several years.

As conceived by Rinsley, diagnoses never represented fixed “illnesses” that one had to have for life. Treatment could change diagnosis; there was the prospect of transformation. American psychiatry has fallen far from this viewpoint with its current pessimistic views of rigidly separate “mental illnesses” that one can only “manage.”

This reminds me of how many years ago, I attended a National Alliance of Mental Illness meeting. At this session people talked about how mental illnesses were “brain diseases” that one could “learn to live with”. Even back then I thought that was a pathetic, limiting idea. Who wants to just “manage their illness” when they could become truly well? Having realistic hope that one can transform oneself  is so much more motivating! In my opinion NAMI is not to be trusted, due to their reliance on drug company funding. This funding implies a tie to the hopelessness of the disease categories of modern-day psychiatry.

Row 4: Major Diagnostic Categories

Here Rinsley lists the broad diagnostic regions: firstly, psychoses, which include schizophrenias, bipolar disorders, and some lower-level borderline conditions. These conditions represent emotional arrests in the earliest developmental periods. They include people who have fused images of themselves and other people; i.e. the person cannot distinguish between themselves and other people at an emotional level (and they see themselves and others as all-good and all-bad).

The second group is characterological (personality) disorders. These include the borderline, narcissistic, and also schizoid disorders. These also exist on a continuum and flow into one another. They feature splitting as their primary defenses Such people can emotionally perceive differences between themselves and other people, but they still see themselves and others as all-good or all-bad. The shorthand “G (S O)” with the space behind S and O mean that good self and object images are perceived as separate from each other, but are not integrated with bad self and object images. By contrast, in the psychotic conditions, with S-O, the dash between S and O means that the person experiences a lack of separation or differentiation between images of themselves and other people; they cannot emotionally tell where they end and other people begin. This “fusion” phenomenon occurs in some people who gets labeled with severe borderline conditions, which are partly psychotic, but it is a chronic condition in schizophrenic states.

Finally, in the last major diagnostic group, the psychoneuroses, the psychic structure gets reorganized so that splitting is eliminated and the person can see good and bad qualities coexisting in both their self-image and in their images of others. The shorthand S (G B) means that good and bad qualities are perceived together in oneself and others without splitting.

Row 5: Quality of Internalized Self-Object Images

This row describes how supportive or comforting the person’s internalized images of other people are. The more positive experiences a person has had, the further to the right hand of this continuum they are likely to be. Unstable archaic images refer to states where a person feels psychologically unstable because they are not comforted by sufficient positive memories / internalized good experiences. This corresponds to psychotic conditions and to lower level borderline states. This deficit is the reason for the commonly cited inability to regulate emotions in Borderline Personality Disorder. I wrote about this in my article on Gerald Adler’s insufficiency model:


The “stable archaic introjects” refers to when a person uses splitting, but the positive images are predominant most of the time over the negative, so the person can regulate their feelings better. This corresponds to higher level borderline and narcissistic conditions.

Lastly, differentiated self and object states refer to the ability to see good and bad in the same self or other-image. In this way people can consistently be perceived as mixtures of good and bad. This makes truly mature relationships possible based on genuine caring and interest in the other person, as opposed to mainly using people for what they can do for you (as with narcissistic conditions), or being so deficient in supportive introjects that one has trouble comforting oneself or trusting others at all (as in borderline and psychotic states).

Row 6: Seinfeld’s Phases – Out-of-Contact, Ambivalent Symbiosis, Therapeutic Symbiosis, Individuation

In this row, I listed Jeffrey Seinfeld’s four phases in a way that corresponds vertically to the horizontal continuums in the rows above. Borderline states are associated either with the upper part of the out-of-contact phase, or more frequently, with the ambivalent symbiotic phase. As one progresses into the therapeutic symbiotic phase – corresponding to being able to trust and feel supported emotionally by other people consistently – one stops being “borderline” and progresses toward healthier narcissistic and neurotic levels of functioning. It occurs to me that it’s too bad these words still sound pathological and negative. Again, we need better words to describe challenges in relating and functioning, words to give people hope of becoming fulfilled and well, not just managing an “illness”.

Please see the article below for a detailed description of Seinfeld’s four phases. Understanding the relative strengths of positive and negative self/object images explains how schizophrenic states can evolve into BPD, which can evolve into NPD, which can evolve into neurosis/healthy personalities, etc. Really, all of these conditions represents problems with adapting and managing life problems; rather than “brain diseases” Given sufficient support, all of these conditions can evolve or morph into one another along the left-to-right continuum of emotional growth. Here are Seinfeld’s phases:


And here is an example of how a young woman progressed through the four phases, starting in the lower-level out-of-contact “borderline” phase”, progressing through the narcissistic phase, and finishing in the neurotic-healthy part of the spectrum:


Row 7: Common DSM levels and Hedges’ phases

In this row, I put common DSM labels – schizophrenia, BPD, NPD, neurosis, etc. These are not truly valid illness categories, but they have some meaning if understood as part of a developmental continuum.

Below these labels, I put Lawrence Hedges’ descriptions of the four developmental levels which Seinfeld described in his phases. I haven’t written about Hedges yet, but he is my favorite psychodynamic writer along with Jeffrey Seinfeld. His descriptions of people’s problems are much more empathic, human, and hopeful than the DSM labels. More on Hedges in a later post.


The equivalencies for the bottom row would be roughly as follows:

Schizophrenia/lower borderline (DSM) = Out-of-contact (Seinfeld) = Organizing Experience (Hedges)
Lower-to-mid level Borderline PD (DSM) = Ambivalent symbiosis (Seinfeld) = Symbiotic Experience (Hedges)
Higher-level Borderline through Narcissistic PD (DSM) = Therapeutic symbiosis (Seinfeld) = Self-Other Experience (Hedges)
Neurosis-Healthy = Individuation (Seinfeld) = Independence Experience (Hedges)


My goal in this article was to give the reader a taste of how psychodynamic theorists think about schizophrenia, borderline, narcissistic, and neurotic-healthy mental states as existing along a continuum of emotional development. This viewpoint is different than the rigid DSM categories which dominate American psychiatry today.

In my opinion, this spectrum or continuum based approach, while not perfect, is more informative and realistic than rigid DSM categories. Since it is developmental, it implies the hope that one can grow beyond frozen emotional development to become emotionally mature. That’s why it’s my rough guide for thinking about “borderline” and “narcissistic” states, although I try not to use those words too much!


I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

– Edward Dantes