#10 – Four Phases of BPD Treatment and Recovery

In their treatment of Borderline Personality Disorder, certain psychodynamic therapists developed a four-phase object-relations approach. The four phases included:

1)      The Out-of-Contact Phase

2)      Ambivalent Symbiosis

3)      Therapeutic Symbiosis

4)      Resolution of the Symbiosis (Individuation)

The Washington, DC-based psychoanalyst Harold Searles originated this approach in his work with hospitalized psychotic patients in the 1960s and ‘70s. He later adapted it to use with less disturbed borderline-spectrum patients. In the 1990s, New York social worker Jeffrey Seinfeld updated Searles’ four-phase model in his book The Bad Object.

Over the last 10 years, as I worked to transform my borderline illness in therapy, I passed through these four phases sequentially. They describe a severely troubled person’s emotional experience at different stages of treatment, while providing an object-relations model which delineates the relative strength of positive and negative self-and-object units. For me, they are the most accurate way of conceptualizing the progress of a borderline individual in recovery.

None of this is meant to minimize the great differences which exist among individual people diagnosed with BPD. These phases are not meant to be exact descriptions of what each borderline in recovery experiences. Rather, they are a rough map of the recovery journey.

This model’s four phases of therapy for BPD can be subjectively described as follows:

1)      Out-of-Contact Phase – In this earliest phase, the borderline individual is emotionally cut off from the outside world, existing in a “closed psychic system” where little to nothing from the outside world influences them in a positive way. Searles described the patient and therapist in this phase as being “isolated in their own psychic territories”. Out-of-contact patients experience themselves passing through life like automatons, with little to no subjective emotional experience. They experience profound depersonalization and derealization (not feeling real).

These people bring to mind tragic characters from Franz Kafka’s novels, individuals who experience life as meaningless and the outside world as full of capricious, heartless persecutors. They are symbolized in T.S. Eliot’s The Wasteland as “men who have lost their bones”. The wasteland represents the internal psychic world of people who, because of overwhelmingly severe neglect and/or abuse, have lost all hope of forgiveness, love or redemption. Instead of hope, there is the view of the outside world as cold, empty, unforgiving, and punishing.

The out-of-contact phase represents the most severely emotionally ill borderline individuals. These individuals usually have chaotic lives in which they are unable to commit themselves consistently to jobs, living places, or relationships. In therapy, they experience the therapist in his empathic helping role as being like “an alien creature from another psychic planet” (Seinfeld). They do not tend to develop a positive relationship to the therapist, or to understand what therapist is about.

2)      Ambivalent Symbiosis – This second phase represents those borderlines who have had enough positive emotional experience to hope that recovery is possible. They believe in the possibility of reclaiming a good relationship with the outside world. They form an ambivalent relationship in which they want to trust the therapist, but at the same time fear being retraumatized and thus maintain distance.

Searles described this phase as “the therapist and patient driving each other crazy.” There is a constant struggle between accepting versus rejecting the therapist’s help. The feeling tone between patient and therapist is primarily one of aggression, wariness, and provocation. In this phase, the patient will find complex, often subtle ways to maintain distance from the therapist and prevent the development of a therapeutic symbiosis.

The struggle of an ambivalent symbiotic patient to trust their therapist, and accept loving support from the world in general, brings to mind Joseph Campbell’s classic conception of the hero (from The Hero with a Thousand Faces). The archetypal hero must struggle against demons, ghosts, monsters, or human enemies to reunite with good people with whom they have lost contact.

A famous example is Homer’s Odyssey, in which Odysseus must prevail against monsters, sirens, and traitorous suitors to reunite with his beloved wife and son. Analogously, the ambivalent borderline patient must overcome the metaphorical demons of past neglect and abuse, fighting through their distrust and fear of closeness to become able to love other people again.

My favorite example of this transformation occurs in the Disney movie, Beauty and the Beast. The Beast must overcome his distrust and anger toward the outside world, and learn to love another, or be forever cursed to live in non-human form. His castle metaphorically represents the type of “closed emotional system” that many borderline individuals live in.

Compared to out-of-contact patients, ambivalent borderlines tend to commit themselves much more consistently to regular jobs, living places, and relationships. They have more real, positive emotional investment in the outside world, and thus more basis for hope that things can improve further. However, because they are afraid of intimacy and of really trusting others, their overall personality structure remains fragile, and they are vulnerable to separation stress.

3)      Therapeutic Symbiosis – If the borderline patient can come to deeply trust the therapist, the phase of therapeutic symbiosis gradually emerges.

Searles described the feeling tone of therapeutic symbiosis as characterized by “maternal care and love.” In this phase, the vulnerable, childlike aspect of the borderline reemerges and is nurtured by the therapist, who is idealized as a perfect parent.

For the borderline patient, who has struggled his whole life to achieve psychological wholeness, it is difficult to overstate the benefit of a prolonged therapeutic symbiosis. A genuine therapeutic symbiosis is a psychic rebirth or redemption, a transformation in which the person comes to feel truly alive for the first time. It marks the beginning of the subjective sense of self, and the first true awareness of psychological separateness from other people.

During this phase, the borderline’s independent functioning is enhanced. They become more assertive in achieving goals in work, study, or other interests. They begin to be able to tolerate separation from other people better, without always feeling lonely or abandoned. And their self-esteem improves dramatically.

Because of the awareness of separation and the gain in self-esteem, the (former) borderline in therapeutic symbiosis usually develops healthier, rewarding relationships with new people in the outside world. They become increasingly aware of how many positive experiences they have missed out on during their earlier years as a borderline personality.

4)      Resolution of the Symbiosis / Individuation – In this final phase, the (now former) borderline comes to function increasingly independently, and to need the therapist less and less. Gradually, the patient becomes disillusioned with the therapist, realizing that the therapist is not their parent, cannot solve all their problems, and will not be there forever.

In this phase, the patient increasingly develops an individuated sense of themselves as a unique and valuable person. In a parallel fashion, they become more and more aware of other people’s separateness and of the individuality of others. In a successful treatment, the patient gradually tapers down the frequency of meetings with the therapist, coming increasingly to manage life’s challenges using their own inner resources.

Comments on the Separability of The Four Phases

In reality, these four phases are not strictly separate. For example, a given patient could have periods of being out-of-contact, alongside periods of being ambivalent toward the therapist. Often, one phase at a time will predominate. But sometimes, the patient will show aspects of multiple phases at once.

Searles described how patients may oscillate between phases, progressing in a two-steps forward, one-step back fashion. This is particularly the case when a patient is transitioning from one phase (e.g. from being mainly ambivalent and doubtful toward the therapist) into another phase (e.g. to trusting and accepting the therapist’s support).

Like the diagnosis of Borderline Personality Disorder itself, these phases are not scientifically validated or based. They are based purely on the observation of therapists working with borderline patients. For that reason, they should be viewed with caution, since they may not be useful or a fit for everyone diagnosed with BPD. However, in my experience, these phases and the underlying object-relations they are based on (to be discussed below) form a remarkably accurate and useful way to conceptualize BPD recovery.

 An Object-Relations Analysis of the Four Phases

To better understand them, it is helpful to describe the four phases using object-relations terminology. For an overview of object-relations, please see my last article below, on the theories of Ronald Fairbairn, one of the founders of object-relations theory.

https://bpdtransformation.wordpress.com/2014/02/02/the-fairbairnian-object-relations-approach-to-bpd/

Writers like Searles and Seinfeld thought about early psychological development in terms of the “good” and “bad” object relations units theorized by Fairbairn. They then integrated these units into the sequential four-phase theory of treatment for borderlines which I am outlining here.

Here are the four phases again, this time considered in terms of the relative strength of positive and emotional self and object images within the mind of the borderline patient:

Out-of-contact Phase’s Object Relations – This phase features a strong dominance of all-negative mental images of self and other. These self-and-object units actively reject internalization of anything positive from the outside world. The patient continuously maintains a “closed system” in which he is “attached to the bad object” (Fairbairn). There is no symbiotic interaction with the therapist, no recognition that a positive relationship is even possible, and no projection of a hoped-for good object into the transference relationship.

Ambivalent Symbiotic Phase’s Object Relations – The all-negative images of self and other are still stronger, but there is a larger (minority) proportion of positive images compared to the out-of-contact phase. This relatively greater quantity of positive images result in the patient becoming aware that a positive, nurturing relationship with the therapist is possible. In other words, the patient possesses an internal “hoped-for good object.”

However, the dominance of the all-negative images during ambivalent symbiosis result in the patient distrusting the therapist and using projective identification to reject them. The patient distorts the therapist, turning him “all bad” in their mind in order to block the development of a positive relationship. In other words, the patient sabotages himself by actively attacking his potential positive relationship to the therapist.

The patient turns the therapist into someone disappointing and rejecting, even when the therapist’s actions in reality do not warrant this view. As long as it continues, this projective activity maintains the dominance of the negative self-and-object units by rejecting the internalization of the therapist as a good object.

As an ambivalently symbiotic relationship evolves, the patient will gradually reveal more of themselves to the therapist, coming to feel more trust and support. This process happens gradually, in a two steps forward, one step back fashion. Like a slow drip, like grains of sand in an hourglass, each positive experience makes the patient’s positive self-and-object images slightly stronger. This gradually tips the internal balance away from the negative images toward the positive self-and-object images.

Therapeutic Symbiotic Phase’s Object Relations – This phase begins to predominate when the all-positive images of self and other become stronger than the all-negative images. Once this internal balance shifts, the patient comes to fully trust the therapist and to strongly internalize the therapist’s positive attitudes. Of course, the therapist must be a truly “good” person in reality for this to happen.

Therapeutic symbiosis is still based on splitting, in that the patient unrealistically sees the therapist as all-good, disavowing and splitting off any less-than-perfect aspects of the relationship. Emotionally, the patient feels the therapist to be an all-good parent figure relating to the patient as a perfect child.

This stance is maintained via extensive projective identification by the patient, who now maneuvers the therapist into the role of good parent, expecting to be treated well (a contrast to the earlier phase of ambivalent symbiosis, in which the patient unrealistically rejects the therapist as untrustworthy, projecting past bad objects into the present transference relationship).

As therapeutic symbiosis proceeds, the dominance of the positive images of self and other grows. The patient feels gradually less vulnerable to the now-unconscious, persecutory, all-bad self-and-object images. Over time, the patient internalizes the psychological functions that can only come from an extended good-object relationship. These include the ability to comfort themselves, regulate negative emotions, maintain self-esteem, and delay gratification.

Resolution of Symbiosis / Individuation Phase’s Object Relations – In this phase, the patient begins to integrate the all-good and all-bad sets of images (resolving splitting). They will gradually realize that the therapist is not a perfect parent. Like in the ambivalently symbiotic phase, but in a less distorted way, the patient will again perceive the therapist’s imperfections. However, this time, with a stronger positive set of self-and-object images as a foundation, he will arrive at a “whole object” integrated view of the therapist as a mostly good, but slightly “bad” person.

In a parallel way, the patient will “update” their view of themselves. They will see themselves as mostly good and worthy, but possessing some shortcomings and weaknesses. They will finally see themselves as a whole person.

The therapist now becomes a repository for the patient’s remaining all-bad object images. By practicing his independent functioning while objectifying the therapist as an imperfect, disillusioning, sometimes needy parent, the patient feels increasingly separate intrapsychically from the “bad objects” of his past. Over time, he individuates, coming to develop his own unique interests, preferences, identity, and sense of self.

Advertisements

19 thoughts on “#10 – Four Phases of BPD Treatment and Recovery

  1. Pingback: Take Risks To Recover from BPD | BPD Transformation

  2. Pingback: #15 – Heroes of BPD : Gerald Adler | BPD Transformation

  3. Pingback: The new therapy: from house to home? | Life in a Bind - BPD and me

  4. Pingback: #18 – Heroes of BPD: Jeffrey Seinfeld | BPD Transformation

  5. Pingback: #20 – Splitting Explained and Thoughts on DBT | BPD Transformation

  6. Pingback: #22 – Proof That Borderlines Are Motivated for Psychotherapy and Can Fully Recover | BPD Transformation

  7. Pingback: #23 – The Borderline-Narcissistic Continuum: A Hopeful Approach to Diagnosis | BPD Transformation

  8. Alaina

    Very interesting.

    So when I told my therapist about when I was four and I threw mud balls at the clean white sheets my mother had just washed in the old wringer washer and hung on the line, and my therapist jokingly said “No wonder she tried to kill you” — — — then after several weeks of trying to decide if he was an evil therapist or a good therapist, I finally decided he was simply a human therapist who sometimes says stupid things when his blood sugar is low (he is a diabetic), I must have been in that final fourth phase, huh?

    Liked by 1 person

    Reply
    1. bpdtransformation Post author

      Right that makes sense… thinking that way about someone is ambivalent and reflects seeing their good aspects and bad aspects at the same time in one picture. These phases are not exactly sequential but often one tends to predominate over the others and it sounds like at this time you were getting to a more integrated state!

      Liked by 1 person

      Reply
  9. Pingback: #26 – Why BPD Should Be Abolished, and What Should Replace It | BPD Transformation

  10. Pingback: #27 – The Kleinian Approach to Understanding and Healing Borderline Mental States | BPD Transformation

  11. Pingback: Article on BPD recovery – cw thinks

  12. Anonymous

    Wow. Very enlightening article. Almost makes me feel like there’s hope. The only thing beyond me is how there can be any if all 4 stages are happening in a myriad.. it’s a lot to keep up with, energy consuming, and consistency — while these stages are occuring in and out?

    Like

    Reply
  13. Pingback: Paranoid-Schizoid and Depressive Positions And Recovery from BPD | Therapy Diaries

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s