Monthly Archives: August 2014

#18 – Heroes of BPD: Jeffrey Seinfeld

A few months ago I discussed Gerald Adler, a clinician who treated BPD using a psychodynamic method. Today I’ll write about Jeffrey Seinfeld, the New York-based social worker who pioneered a Fairbairnian approach to Borderline Personality Disorder.

On this blog, it has been discussed several times how psychodynamic therapists have already “cured” BPD. Here is an example of a borderline patient’s recovery from Jeffrey Seinfeld’s book, The Bad Object.

seinfeld1

I thought the reader might be interested to hear in detail about one of the “successes” in BDP recovery that are often referenced on this blog. Her story shows how complex, challenging, and interesting the journey may sometimes be. Some of this account is paraphrased, while the parts in quotations come straight from the text:

A Case Study: Kim (from The Bad Object, pages 101-123)

At the start of her therapy with Jeffrey Seinfeld, “Kim” was a 22-year-old Irish-American young woman. From ages 17-22, she been in regular treatment with another therapist, but had made little progress. After dropping out of high school at age 16, Kim lived at home with her mother. She did not work or attend school; rather, much of her time was spent abusing alcohol and illegal drugs.

With her first therapist, Kim showed no motivation to change, and indeed would boast about antisocial and destructive behavior, including tempting friends trying to quit drugs into again using them. She would regularly miss therapy appointments without calling to cancel. Her therapist as the time described her attitude as, “Who can blame me for messing up with all I’ve been through?”

Eventually, Kim’s first therapist referred her to Jeffrey Seinfeld. He had not lost hope for her, but felt that they had reached an impasse and that a change of approach might help her. Seinfeld scheduled Kim for twice-weekly appointments at a social-work center. For the first year or so of their work, she continued to regularly miss appointments without cancelling ahead, and to abuse drugs and alcohol regularly.

Kim’s Early Childhood

Seinfeld describes Kim’s childhood in this way: “Kim was an only child in an intact family. Kim’s mother alternately neglected and overindulged her. During Kim’s first year of life, her mother often ran out of the house to escape a psychotic husband… The mother would promise to return later in the evening, but often stayed away for days at a time. Kim therefore had repeated experiences of awakening to find herself abandoned by her mother. She grew to hate falling asleep if her mother was present, and she had frequent tantrums, insisting that her mother sleep with her…”

“Kim’s psychotic father had delusions that he was Jesus Christ and that demons possessed him. He underwent psychiatric hospitalization, and his condition was finally stabilized with psychotropic medication. Kim’s mother went to work when Kim was 3 years old, leaving her at home with her father, who was on disability. He would ignore her as he read the Bible or sat in a catatonic-like stupor. If she disturbed him with her romping and playing, sometimes designed to get his attention, he would beat her…”

“Throughout childhood, Kim was on a merry-go-round in her relationships with her family members. First she would side with her mother against her father. When her mother upset her, she would go to her father and side against her mother. When her father upset her, she’d go to her grandfather and side against everyone. As an adolescent, Kim took no interest in learning at school but instead “hung out” with peers and smoked marijuana daily. She dropped out of high school at the age of 16.”

Kim’s Early Therapy – The Out of Contact Phase

Seinfeld described how Kim’s life had little structure outside of her regular abuse of alcohol and drugs. She had trouble sleeping at night, and often slept during the day instead. Kim could not bear to be alone, and would often call her drug-abusing friends from high school to chat at all hours of the day. However, these friends were becoming less interested in her as they grew older and got jobs or moved away.

Kim felt that people were always too busy for her and would eventually abandon her. Thus, according to Seinfeld, her internalized bad object was a “busy object” who did not make time for her. Kim projected this image onto outside people based partly on experience with her real mother, who often did not take time to care for her.

(If the reader is not familiar with projection of internal object relations onto present day relationships, based on past bad experience with parents, the following article may be useful – https://bpdtransformation.wordpress.com/2014/02/02/the-fairbairnian-object-relations-approach-to-bpd/ )

Seinfeld notes that his main experience in relation to Kim early on was that she was oblivious to him psychologically. Seinfeld felt that Kim was unaware of his separate presence, but simply “told him stories” about her adventures with drugs, friends, alcohol, and other adventures. She did not expect any help, understanding, or admiration from her therapist. Referencing the out-of-contact phase, Seinfeld stated, “My position as an object was that of a witness as opposed to an admirer.”

After several months, Kim showed the first sign of becoming aware of Seinfeld’s intent to help when she wrote about him in her diary. She felt concern that her life was “going nowhere,” and wished that she could work or attend school. Shortly after this awareness, Kim cut her wrist with a razor. Seinfeld describes how “the self-mutilation is an antidependent attack against the vulnerable, libidinal self’s expressed need for an internal holding object. The antidependent self thereby reestablishes a closed, internal, invulnerable position.” In other words, the patient identified with how people rejected her need for help and support in the past, and repeated the same behavior toward herself in the present, acting as the bad parent and punishing herself (the bad child) inside her own mind.

This early phase of Kim’s treatment was an “Out of Contact” emotional phase, as described here:

https://bpdtransformation.wordpress.com/2014/02/08/four-phases-of-bpd-treatment-and-recovery/

Dwelling on the Rejecting Object

Seinfeld acknowledged noted how Kim’s life was in reality extremely difficult. Her “friends” were self-absorbed and did not truly care about her, she had little support from her parents, and she had no structure in terms of a work or academic program, in addition to addictions to drugs and alcohol.

However, despite these severe difficulties, Kim did not respond by looking for positive ways out of her predicament. Rather, as Seinfeld describes,

“Kim was constantly preoccupied with how her friends and family exploited, rejected, and did not care about her. She would dwell on the rejecting object and rejected, unimportant self-image through the day and so would remain in a depressive, victimized position… Even when the external person did not in reality reject her, Kim would interpret the situation as rejection…. All of this is not to say that the external objects did not often treat Kim badly; on the contrary, they often did. But Kim had her own need to perpetually activate the all-bad self-and-object unit.”

Seinfeld noted that if one person in her life disappointed her, she would flee to a different person, but then find them equally disappointing. For example, Kim would go from her too-busy mother, to her drug-abusing and neglectful boyfriend, to her psychotic father, to friends who were moving on with their lives and did not care. Frustrated by each of these people, Kim comforted herself by using drugs, alcohol, and by stealing her mother’ car and “joyriding” despite not having a license.

Seinfeld said that none of his interpretations of her self-destructiveness worked at first. He stated,

“Throughout the first of fourteen months of her treatment, she seemed relatively out of contact with mer. She would recount her adventures and seemed to expect nothing from me but my continued presence… There was no spontaneous, gradual shift in her relatedness. She continued to miss sessions at the same rate as characterized her previous (five year) therapy… She used my empathy to justify her “who can blame me” attitude.”

The Safety of the Bad Object

Seinfeld began to intervene with Kim by gradually making her more aware of how her feelings of rejection and worthlessness were caused not only by the actual behavior of other people, but by how she responded to and interpreted their actions. Seinfeld states, “When she described a bad experience in reality, I empathized with how she felt but then shifted the focus to what she was doing to herself in her mind with that experience. It was not difficult so show that all of the external people she discussed reflected one image – that of rejection in relation to her own image as rejected.”

Seinfeld notes how Kim eventually became aware that she continually maintained a negative pattern of thinking and expectation about others, even when nothing happened in the outside world to justify such thinking. Seinfeld commented to her that such dwelling on negativity might occur because it felt safer to Kim to feel rejected than to feel accepted.

Seinfeld also beautifully described how, “I listened to all that she said and commented from the vantage point of the activation of internal object relations units. I listened to this patient as one would follow the stream of consciousness in a novel by Joyce or Proust, in which reality is always brightened or shaded by the narrator’s internal vision and experience. Kohut (1984) has suggested that such novels reflect the fragmented sense of self in severe psychopathology. One does not ignore external reality from such a vantage point; rather, close attention is given to the subtle but constant interplay between internal and external worlds.” In other words, when listening to a borderline patient speak, the skilled therapist constantly tries to perceive how reality is distorted or “colored” in a positive or negative direction by the patient’s splitting defenses.

Ambivalent Symbiosis

Seinfeld notes that the foregoing work gradually move Kim toward an ambivalent symbiosis. She gradually became aware that Seinfeld cared about her and wanted her to get better. For the first time, Kim asked her therapist in subtle ways about whether he was interested in her viewpoint. She was no longer only telling stories or complaining about abuse. She would ask Seinfeld if he felt that her mother and boyfriend cared about her. She wanted to know if Seinfeld understood the desperation and uncertainty she felt. Seinfeld described how Kim displaced many of her wishes for closeness and support from him onto the mother and boyfriend, because it was initially too threatening to get close to Seinfeld and trust him directly.

The relationship now assumed a stormy, emotional, push-and-pull quality. Kim would want support from Seinfeld but then be angry that she only saw him occasionally for therapy. She wanted him to understand her feelings about her family, but then criticized him as overly intellectual and detached. She became jealous that Seinfeld’s own family own family got most of his time and love, while she only got the leftover scraps. Outside of sessions, she began to cut down on her drinking, but then would return to it when she felt that two hours a week with Seinfeld was inadequate. She would perceive Seinfeld, “sometimes as a saint and at other times as a psychotic with delusions of grandeur, like her father.”

Seinfeld therefore described how Kim tried to take in his support and acceptance, but would then reject it, both due to her familiarity and loyalty to the rejecting object and to her fear of vulnerability and openness toward the good object. For example, Kim asked Seinfeld for help with getting a referral to a doctor who worked in the same hospital as Seinfeld for a minor medical problem. When Seinfeld responded helpfully, she rejected the referral as inadequate by viewing the doctor negatively. This related to her being threatened by feeling that someone truly cared about her.

At this point, Kim began attending therapy regularly and never missed sessions, even becoming upset if she was forced to be late. Rather than being upset with her mother or friends as often, she became intensely upset with Seinfeld if he did not meet her demands for caring and empathy in a perfect way. Despite Seinfeld making extra time to talk to her on the phone outside of regular appointments, she would become angry when he eventually had to leave to go see his family. She viewed him as a “too busy” bad object just like her mother and friends had been the “busy bad objects” before. She again felt angry with Seinfeld for expecting her to depend on him for support, but having only a few hours a week to spend with her. She continued to alternately view him as a caring, supportive person whose help she desperately wanted, and then suddenly to transform him into a too-busy, uncaring, impersonal therapist.

Seinfeld comments on this ambivalent symbiosis in the following way:

“The patient activates the all-bad self-object unit to defend against internalization of the positive self and object unit. The insatiable need serves the antidependent defense. By making her need for contact with the external object insatiable, the patient can perceive of herself as rejected regardless of the external object’s behavior. Therefore, the patient is always able to think of her needs as being unmet, to think of herself as rejected and of the object as rejecting. The activation of the all-bad self and object unit results in depression and rage. Insatiable need, the oral self-exciting object relationships (e.g. use of alcohol while rejecting a truly supportive other), is then activated to counter the depression and rage. In this regard, the all-bad self-object relations unit becomes a vicious cycle constituting both the rejecting and exciting objects… Insatiable need serves to maintain the perception of the object as rejecting in antidependent defense. This patient succinctly stated the antidependent position, “If I don’t think you like me, why should I bother to like you?”

In other words, it’s necessary to understand how the patient is an active agent in perpetuating their view of the therapist and others as rejecting (creating an impossible-to-fulfill, or insatiable need) rather than potentially helpful and positive.

The Transition to Therapeutic Symbiosis

Seinfeld now constantly remarked upon the ways in which Kim focused on the ways in which he (Seinfeld) was not available because this felt safer and more familiar than focusing on the ways in which he was available. Kim came to recognize more and more how she herself played an active in viewing the external world negatively and keeping herself in a depressed state. She realized that if she were not provocative and looked for positive things in the outside world, they would appear there much more often than she expected. In this way, she could become an agent of positive change.

Gradually, Kim became aware of how unstructured and vulnerable her current life situation was. She realized how she was hurting herself by her continuing alcohol and drug use, and by ignoring opportunities to return to school or work.

Regarding the developing therapeutic symbiosis, Seinfeld stated,

“Kim’s vulnerable self became more connected to the internal holding object (the therapist as supporter of independent functioning and provider of love) through the transference, and she experienced severe separation anxiety. She faced the fact that her life was a mess and that she felt like a vulnerable child. She began to believe that I really was going to help her, that our relationship could affect the direction of the rest of her life.”

Seinfeld continued to explain that, at the same time as these positive feelings emerged, Kim feared that letting Seinfeld get too close to her would allow him to overpower and dominate her sense of self. She still feared trusting another person closely due to all the rejection from her past. So, she had to be very careful and gradual in the way she came to trust Seinfeld, lest he turn “bad”. Occasionally, she had dreams in which the “good” Seinfeld would turn into a psychotic madman like her father.

Gradually, Kim let herself get more and more attached to Seinfeld, and as this happened she began to feel self-empathy for the first time in her life. She remembered the alone, fearful child she had been and wanted to help herself.

Strengthening the Therapeutic Symbiosis

Kim bought a pet parrot that she would care for at home. She imagined herself as a good parent nurturing a good child most of the time. When the bird became difficult and squawky, she would briefly view herself as the bad mother and the bird as bad child. As her relationship with Seinfeld improved, she came to nurture her pet more and more and to be bothered less and less by its noisiness. As a projective container, it reinforced her positive internal self-and-object images via the fantasies of love she projected into it, supported by her relationship to Seinfeld.

Over the next year, Seinfeld described Kim’s progress as follows,

“As Kim became less depressed and angry , her vulnerability and strivings for autonomy emerged. Having decided that she must do something to change her life, she managed to earn a high school diploma. She then pursued college courses and part-time work… She brought to me her ambitions and interests for mirroring admiration. Her ambitions, which were originally grandiose, gradually became realistic. She informed her drug-addicted boyfriend that he had to stop using cocaine if he wanted to continue to see her. She saw him less as a rejecting object and more as a person with problems that interefered with his capacity for intimac. His family eventually arranged to have him go for detoxification. Kim remained in contact with him but also started to see other men.”

Seinfeld then described how Kim gradually focused more and more on her own goals and independence, and became less dependent and close to Seinfeld as she had been at the height of the therapeutic symbiotic phase. Thus she transferred into a more “resolution of symbiosis”-like phase, as described in Article #10.

———————-

Comments on Seinfeld’s Case of Kim

In this case study, one can see how in the early phases of treatment, Kim was at first oblivious to Seinfeld as a potential helper, due to the extreme neglect and abuse she experienced as a child which left her with a structural deficit of positive internal self and object images. She literally could not recognize help and love when she saw them.

As she gradually became aware of Seinfeld as a potentially helpful therapist, her fear that he might reject her like her parents had done, as well as her general unfamiliarity with and distrust of genuinely kind people, caused her to distance herself from him as a potential good object. It required painstaking work to become aware of how she herself continually viewed others (and later Seinfeld) as “all-bad” while rejecting the good aspects of the outside world in order to overcome this phase.

Eventually, the therapeutic symbiosis took over, and Kim was able to trust Seinfeld and take in his love and support. At this point, she was no longer “borderline”, and began to feel well and stable much of the time. She resumed school and work, developed new positive relationships with other men, and gained a healthy capacity to view people like her mother and abusive boyfriend as troubled people rather than persecutory rejectors.

In reading this article, I learned how important it is to identify the subtle ways in which we distort others into “all-bad” and “all-good”, when we are borderline. We can apply these case examples our own lives, since we all distort external reality to a greater or lesser degree. Since they are often based unrealistic projections from past negative relationships, learning to “distrust” or question our initial negative perceptions can be a positive, corrective process. It allows us to realize how the world outside is much more positive than it sometimes appears when we are viewing things through the lenses of “bad objects.”

Seinfeld As An Author

Seinfeld is one of those authors I read about a certain topic and say, “Wow, this guy is brilliant! That really is how things are!” I remember being struck right away by his penetrating descriptions of borderline problems and what was necessary to transform them. The reader is again recommended to his book, “The Bad Object”, which is available used on Amazon. Its case studies of successfully treated borderlines are some of the best of any book I’ve read, especially the cases of “Kim” described here, along with similar-length successful cases of “Justine”, “Diane”, “William”, and “Peggy.”

To understand Seinfeld’s concepts, it may again be useful for the reader who is unfamiliar with the psychodynamic explanation of BPD to skim through the following articles:

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

https://bpdtransformation.wordpress.com/2014/02/08/four-phases-of-bpd-treatment-and-recovery/

Seinfeld adapted an object relations theory of trauma, building on theories developed by Ronald Fairbairn working with abused children in the early 20th century. Seinfeld understood how parental neglect and abuse became internalized by the (future borderline) child, and then was constantly replayed in their adult life, causing the borderline symptoms. He adapted the four phases that Harold Searles pioneered with schizophrenic patients, and modified them for use with less-disturbed borderlines. These phases – Out-of-Contact, Ambivalent Symbiosis, Therapeutic Symbiosis, and Individuation – involved “reparenting” the borderline individual so that they learned to love themselves and eventually became able to love other people.

It’s hard to summarize everything else from Seinfeld’s book on how to treat Borderline Personality Disorder (The Bad Object). So, as with the post on Gerald Adler, I will focus on a few key points.

#1: The Concepts of Structural Deficit and Bad-Object Conflict

One of Seinfeld’s foundations for understanding BPD was seeing a borderline individual as having both “a structural deficit of positive self-and-object images” and “bad object conflict.”

What the structural deficit means is that, compared to a healthier or “normal” individual, a borderline has not taken in sufficient positive experiences with the outside world to feel secure psychologically. This results in an inner emptiness or psychic void that makes it harder for the borderline to take in new positive experiences in the present, since they have trouble recognizing them as positive. This is the same concept as Adler’s notion of introjective insufficiency:

https://bpdtransformation.wordpress.com/2014/04/30/15-heroes-of-bpd-gerald-adler/

In healthier people, who have had much nurturing, love and security in childhood, the high number of past positive memories serve as “receptors” that help them recognize, seek out, and take in new positive experiences. By contrast, the borderline-to-be child usually receives very poor responses to their need for nurturance. Instead of internalizing a sense of love, security, and blessing, the future borderline child is left with an emptiness or longing for love which then becomes repressed. That is the structural deficit as described by Seinfeld and Adler – the quantitative insufficiency of internal positive memories based on a lack of past external positive experiences.

It is the structural deficit that results in the borderline’s being relatively unreceptive to new positive experience. For the adult borderline, positive experience – for example, being offered friendship, acceptance, and interest by other people – will seem unfamiliar, strange, alien, and even threatening when they are encountered. This is why, early on in the therapeutic process, Seinfeld found that severely borderline patients often didn’t know how to relate to him in a positive way. Rather, they experienced him in his helping role as, “an alien creature from another psychic planet.”

#2: Bad Object Conflict

As for “bad object conflict”, Seinfeld understood this to mean that not only is there a lack of positive memories, but there is a predominance of powerful negative memories (or images of oneself and other people) in the borderline’s mind. These scary, traumatic negative memories don’t just sit there – they act to reject the internalization of new positive memories. They are like metaphorical demons or monsters that scare the patient away from trusting others.

The child who becomes borderline internalizes many memories of being unloved, rejected, and even hated by inadequate parents. These memories collectively form the unconscious “internal bad object” or “rejecting object.” Despite its painful nature, relating to a rejecting other as an adult often feels safer and more familiar than trusting someone new who might prove disappointing. Also, the borderline tends to feel a perverse loyalty toward the people who abused him in the past, and to feel he is “bad” and therefore unworthy of help from good people.

For both these reasons – fear of being vulnerable toward good people, and loyalty toward the bad people from the past – the borderline individual tends to reject potential help and remains attached to the image of themselves as a worthless, undeserving, bad person. This can be acted out in many ways – via remaining alone and isolated, via abusive or neglectful relationships with present-day partners, via staying attached to the original abusive parents in the present day, via self-injurious acting-out behaviors, and so on.

Therefore, Seinfeld described how the borderline acts in subtle and overt ways to actively maintain an internal negative view of themselves and others. I would call this, “Perpetuating the past in the present.” The bad-object conflict thereby works in a vicious cycle to maintain the “structural deficit” because as long as the activities focused around bad perceptions of oneself and others predominate, quantitatively speaking, then new positive experiences are not being taken in in sufficient amounts to “tip the balance” and effect lasting psychic change.

Seinfeld likened the negative and positive relationships of a borderline patient (as long as they remain borderline) to a mathematical equation. In his formula, negative relationships to external others are activated more frequently than positive relationships, maintaining the attachment to the internal bad object and preventing the internalization of a good set of self-and-object images strong enough to displace the bad object.

According to Seinfeld, unawareness of the good object (“object” meaning person or people) tends to occur more in the out-of-contact phase, and active rejection tends to occur more in the ambivalently symbiotic phase, as described in post #10 on the Four Phases. Active rejection is necessary in the ambivalent symbiotic phase, because the good-object images are strong enough in that phase to pose a threat to the internalized bad object, which the patient unconsciously fears losing (since it is what he is familiar with).

#3: The Exciting Object

Another key concept from Seinfeld’s writing is the nonhuman exciting object. The exciting object is any addictive, stimulating, non-human object that serves to fill the void created by the lack of the good object. Food, drugs, sex, alcohol, medications, excessive use of TV or internet, and other nonhuman “things” can provide an addictive fix to compensate for the lack of love that a borderline feels.

The exciting object is part of Seinfeld’s mathematical equation of how BPD works. Because of the structural deficit and the bad object conflict, the all-negative split self and object units are mostly dominant in the borderline’s mind. These all-negative images reject the taking in of new positive experience which could be soothing, and therefore the borderline feels mostly empty, unhappy, and unstable emotionally.

To try to assuage these bad feelings, the borderline turns to nonhuman exciting objects as described above. These exciting objects plug the “hole” or emptiness created by the lack of truly satisfying positive relationships to good people in the outside world. However, exciting objects can only do so temporarily, since they are not truly satisfying long-term. Once their effect wears off, frustration will set in, and the borderline will usually return to involvement with the bad self and object images. This will then lead to more psychic pain around bad objects, resulting in the need for more exciting objects to assuage it, and so on.

#4: Interrupting the Rejecting-Exciting Object Cycle – Therapeutic Symbiosis

The main focus of Seinfeld’s book was not on the negative aspects of how a borderline functions, but on how to heal them. Seinfeld believed this could be done by interrupting the constant oscillation between rejecting and exciting objects via the internalization of a new good object relationship.

In normal language, the borderline needs to overcome their fear of trust and dependence, allowing themselves to develop a satisfying, loving relationship with the therapist. Seinfeld emphasized that successful therapy must move beyond a detached, professional relationship, and should explicitly involve love and closeness between patient and therapist. This does not mean that the pair are friends outside the sessions; rather, it means that a parental-like relationship of vulnerability, tenderness, and support is nurtured within the frame of the sessions.

This is the phase of therapeutic symbiosis. Seinfeld described how, “In this phase, there is a full reemergence of the vulnerable, regressive true self, in the care and protection of the idealized holding-therapist… At first, the patient’s vulnerable self is increasingly related to the therapist as holding object. The Internal positive self and object representation unit is increasingly dominant over the negative self and object representation unit, as long as the external therapist is highly available to reinforce the strengthening of the positive unit… As one patient said, “So long as everything is all right between you and me, I feel that all is well with the world. The good internal object serves to neutralize the bad, persecutory, rejecting object….

“In the later part of therapeutic symbiosis, the patient internalizes and identifies with the therapist to the point at which he is no longer so dependent upon the external therapist… The patient can now increasingly comfort, soothe, and mirror himself, regulating his own affect, mood, and self-esteem. In unconscious fantasy, he is now the comforter, sympathizer, and holder, as well as the comforted, empathized with, and held… All goodness is taken into the self; all badness is projected into the external object world…. In this way, the patient can establish a psychic foundation (of primarily positive self and object images) to eventually integrate the good and bad self and object units into whole, or ambivalently experienced, self and object images.” (pages 73-74)

Seinfeld’s Model of BPD – The Inversion of the Normative Developmental Psychic Process

Seinfeld continues, “The healthy child tries to take in or internalize the good object and reject or externalize the bad object. In the model I’m developing, the borderline patient manifests an inversion of the normative developmental process. Instead of taking in the positive object relations unit and rejecting the negative object relations unit, he takes in the negative object relations unit and rejects the positive object relations unit. In Fairbairn’s terms, he is attached to the internal bad object. The out-of-contact phase and ambivalent symbiosis are manifestations of the pathological inverted symbiosis in terms of the attachment to the bad object and rejection of the good object. Symbiosis becomes therapeutic when the patient adopts the normative but primitive developmental position of taking in all that is good and rejecting all that is bad. In this way, the patient can establish a psychic foundation to eventually integrate the good and bad object relations unit.” (page 75)

To me, this is a beautifully clear model of what causes BPD – bad relationships are taken in during development and reenacted continuously during adulthood, whereas good relationships are not taken in and are rejected later on. Successful recovery from BPD involves an reversal of this process.

Through the phase of therapeutic symbiosis, the patient can gradually gain confidence and make progress in three main areas in their outside life: 1) Leaving behind negative relationships (for example, to abusive partners, friends, or parents), 2) Developing new positive friendships and relationships to replace the bad ones, and 3) Developing enhanced autonomous functioning, work and interests.

In this way, the formerly borderline patient reverses the mathematical equation that had predominated when they were “borderline.” Instead of remaining attached to the all-negative images of themselves and others, the patient engages in new relationships and activities that are good, encouraging and self-supporting. In this way they take in a quantitative predominance of positive self-and-object images, and “spit out” the bad self and object images.

How To Interrupt the Rejecting-Exciting Object Cycle – Insight

The reader is probably interested as to how a borderline may start to break out of the negative-exciting object attachments. What Seinfeld worked on in therapy (and what one can work on with oneself) is developing the insight into how one sabotages oneself, which allows one to start making more constructive and adaptive choices instead.

Attachments to bad objects from the past are like schemas or relationship-templates that one replays over and over in the present “perpetuating the past in the present”), even though one doesn’t have to keep doing so. A person needs to identify how they are replaying bad relationships in the present, and treating themselves in the way that their parents did, to begin realizing how their behavior could change. As they become aware of the structural deficit (of positive self and other representations, resulting in unreceptivity toward good experience), and of the bad object conflict (which actively rejects and causes a person to fear good relationships), the borderline can start to actively seek out better experiences.

A great way to illustrate how this process works is via a case example. Hopefully, in the case of Kim above, the reader should be able to identify the structural deficit, bad object-conflict, use of exciting objects, and the ways in which Seinfeld interrupted these activities and nurtured insight in the patient, to encourage internalization of the therapist as a good object.

Recovery as a Mythic Journey

Lastly, I loved Seinfeld’s view of the therapy process as a mythic or epic journey. Seinfeld states (page ix), “This volume shows how to help the patient overcome what has been decribed as the most serious obstacle to psychotherapy: the negative therapeutic reaction. It is the bad object that is predominantly responsible for this reaction. The patient and therapist enduring the travails of the therapeutic journey often resemble Odysseus and his crew forced to outwit the demons, sirens, witches, and Cyclops threatening to thwart the long voyage. In fact, those mythological demons personify the manifold masks of the bad object often described as exciting (but not satisfying), enticing, bewitching, addicting, engulfing, rejecting , punishing, and persecuting…

“The bad object is comprised of the actual negative attributes of the parental figures – often a composite of both mother and father along with later figures resembling them – and the child’s fantasies and distortions about these figures. In this regard, the unsatisfactory experiences with the parental figures give rise to frustration and anger, which color the child’s perception of the object… The designation “bad” regarding the other person does not refer to a moral valuation but rather to the child’s subjective unsatisfactory experience with it… Therapeutic progress threatens the patient and therapist with the terrible wrath of the bad object. The patient is conflicted between his loyalty and fear of the bad object and the longing to enter into a good object relationship that will promote separation from the bad object… Fairbairn believed that the term “salvation” was a more apt designation than that of “cure” for the patient’s subjective experience of his need to be rescued from the bad object.” (preface page x)

This article is getting long enough already! I hope the reader, whether having borderline traits themselves, or wanting to help or understand someone with BPD, has found some interesting insights in Seinfeld’s approach to treating Borderline Personality Disorder.

Lastly, here is an interview and memoriam for Jeffrey Seinfeld, who sadly passed away a few years ago.

http://www.orinyc.org/JeffSeinfeld_InMemoriam.htm

Please share any comments you have below!

——————————–

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

#17 – Five Myths About BPD Debunked

Thus far on this blog, I have described my recovery from borderline symptoms and outlined a psychodynamic understanding of Borderline Personality Disorder.

Today I would like to take on some of the highly prevalent myths about BPD. These ideas circulate across the internet on forums, blogs, and webpages about BPD. To me, they are unreasonably pessimistic, scientifically baseless, and unhelpful.

Here are five myths that people newly diagnosed with BPD are often told:

Myth #1: Borderlines cannot become lastingly free from borderline symptoms (i.e. BPD can only be ameliorated, not removed).
Myth #2: Effective treatments that “cure” BPD have not yet been developed.
Myth #3: BPD is caused by genes and biology.
Myth #4: Medication and therapy are equally effective treatments for BPD.
Myth #5: BPD is a valid diagnosis and a real medical condition.

If you are upset by any of these ideas, you don’t have to continue reading – after all, I can’t force people to give up their view of BPD as incurable, genetically-based, and a valid scientific diagnosis. But if you are open to the possibility that rejecting these notions can be encouraging and useful, read on.

    Myth #1: Borderlines cannot become lastingly free from borderline symptoms (i.e. BPD can only be ameliorated, not removed).

On some BPD blogs, one reads that BPD is a “life sentence”, that “there is no cure for BPD”, that “BPD symptoms can only be managed”, and so on. My reaction to these statements is pity. It is tragic that people who are already facing severe life challenges have their problems compounded by such unwarranted pessimism. It creates a vicious cycle, where people who are already struggling with real emotional problems are further discouraged by hearing – falsely – that they are unlikely to recover. This then exacerbates their real problems, leading to further discouragement, and so on.

Can I prove on this blog that BPD can be fully recovered from, as one can prove that water boils at 212 Farenheit? No. But what I do have is my own experience, plus a large amount of research on BPD gleaned from former BPD sufferers and therapists.

For the six year period from about 2003-2008, I suffered with all of the nine borderline symptoms in the DSM. It was absolutely hellish – most days were a psychological war, filled with constant anxiety, bleak depression, hopelessness about the future, suicidal thinking, feeling horribly alone, being unable to relate positively to anybody, and so on. Because I’ve been there, I understand where other blogs about BPD being so difficult are coming from. I describe my difficult experience more in post #3, “The Tragic Borderline Experience.”

But as of 2014, I have been developing increasingly good relationships and functioning better and better for the last 5-6 years. I don’t have any of my former borderline symptoms, nor do I fear they will recur. Most of the time, I’ve felt vigorous, alive, capable, motivated, and real. A small minority of the time, I feel worried and down, but not more than most people and not without real cause. In light of my past history, I feel that I have triumphed. I describe how this progress occurred in post #2, “How Did I Recover from BPD?”

This personal experience convinces me that BPD can be recovered from in a deep, lasting way. We only truly know what we directly experience, and that is my “proof”. My experience indicates that BPD can not only be ameliorated and managed – it can be fully dissolved, removed, and triumphed over.

Perhaps somebody reading this is saying, “Edward, how do we know you’re telling the truth? This whole blog could be a fantasy.” While that is untrue, let’s indulge that fantasy for a moment. 🙂 Taking my experience out of the equation, what other evidence says that borderlines have recovered to live good lives as non-borderlines?

Firstly, there are many other blogs reporting full recovery or great improvement from BPD symptoms. For example, Scottish Clare’s blog (http://www.tacklingbpd.com), Debbie Corso’s blog (http://www.my-borderline-personality-disorder.com), A.J. Mahari’s blog (http://www.borderlinepersonality.ca), Rachel Reiland’s book and website (http://www.getmeoutofherebook.com), are examples of former borderlines who write about their recovery.

Secondly, there are dozens of books with hundreds of case studies of borderlines who recovered. For example:

James Masterson – Psychotherapy of the Borderline Adult
Jeffrey Seinfeld – The Bad Object
Helen Albanese – The Difficult Borderline Patient: Not So Difficult To Treat
Peter Giovacchini – Borderline Patients, the Psychosomatic Focus and the Therapeutic Process
Bryce Boyer – Psychoanalytic Treatment of Schizophrenic and Characterological Disorders
Vamik Volkan – Six Steps in the Treatment of Borderline Personality Organization
William Meissner – Treatment of Patients in the Borderline Spectrum
Gerald Adler – Borderline Psychopathology and Its Treatment
Donald Roberts – Another Chance to Be Real: The Treatment of Borderline Personality Disorder
Harold Searles – My Work with Borderline Patients

These are some of the psychodynamic books that are my area of interest (if one added in CBT and DBT, you could come up with a much bigger list of books that are optimistic about BPD). These ten books alone contain about 40-50 case studies of borderline patients who recovered fully and/or made great improvements to become diagnostically non-borderline. I don’t recommend reading these books, because it is more useful to connect with real people. However, they show that many therapists have worked successfully long-term to cure patients with Borderline Personality Disorder. I doubt that all of these authors are colluding to lie about borderlines getting better 🙂

So, an increasing number of direct-experience accounts and professional-therapist accounts of BPD recovery are now available to provide hope. The question should no longer be whether borderlines can become non-borderline, but how better to provide them the resources to enable deep and lasting recovery.

    Myth #2 : Effective Treatments that “Cure” BPD Have Not Yet Been Developed

As a medical word, “cure” is probably not the right word for an emotional condition like BPD. Perhaps one would do better to say “deep recovery”, “living the life you want”, “finding fulfillment and meaning”, “being free from constant emotional suffering”, etc. Whatever terms are used, there are treatments and support systems that make these things a real possibility for sufferers of BPD.

Since it is very similar to the first myth, I will not write about this idea at length. However, there are several effective treatments that can lead a person to no longer meet the criteria for BPD. My favorite approach is psychodynamic-psychoanalytic psychotherapy, of which all the books listed above under Myth #1 are examples. Reading the case studies in these books leaves little doubt that borderlines can become free from their symptoms. That’s not to say it’s easy or immediate; it takes years of work. But it’s possible for anyone.

Other effective approaches include DBT (Marsha Linehan’s approach), Mentalization Based Therapy (Peter Fonagy), and Transference Focused Psychotherapy (Otto Kernberg). I am not as familiar with these approaches, so cannot comment at length. However, many people with borderline issues have reported that they are very helpful, as can be seen at forums like http://www.PsychCentral.com . Debbie Corso’s blog gives a lot of information about DBT and how she used it to recover. I recommend the reader to check out her story, linked above.

Interestingly, empirical longitudinal studies show that many patients diagnosed with “BPD” recover to become diagnostically non-borderline. Here is an example – http://www.borderlinepersonalitydisorder.com/wp-content/uploads/2012/07/Zanarini10-yearCourseofBPD-10-23-12.pdf

Although some aspects of this report are suspect (since it is based on the medical-model version of BPD, and implies that it is partly a biologically-caused disorder, which I disagree with), it is encouraging in that it reports statistics such as:
– Over a 10-year period, over 90% of patients eventually experience a remission of BPD as defined by not meeting enough of the DSM criteria for the disorder.
– 78% of (formerly) borderline patients attain broadly-defined good psychosocial functioning over a 10-year period (defined as at least one meaningfully close relationship with a partner or friend, and good work/vocational functioning).

These numbers are based on about 300 borderline patients who were followed for 10 years after initial intake into a hospital in the Northeastern US. It’s not possible to generalize to any one person based on group statistics, but they show that improvement and remission from BPD is very possible. Many people diagnosed with BPD are still being indoctrinated with the idea that it is an incurable, life-long illness. It’s time to begin changing that attitude.

    Myth #3: “BPD Is Primarily Caused by Genes and Biology”

This is a statement that I read now and start laughing. Often promoted by drug companies, hospitals and universities (funded by Big Pharma), or establishments psychiatrists, websites touting this viewpoint say, “We now know that BPD is caused by both genetic and environmental factors!” or, “A person with BPD has a broken brain!” or, “BPD has now been found to be 68.72% hereditary!”

To go back to one of my earlier articles, I’d ask the reader to consider the following:

BPD is based on 9 subjectively assessed symptoms. Jack could have symptoms 1 through 5 only. Jane could have symptoms 5 through 9 only. Both would be “borderline”, even though they shared only one symptom in common and have four unique symptoms each. For example, they could both have self-injurious acting out (e.g. being promiscuous or abusing a substance), but be completely different in their other symptoms.

The extreme biological determinists would say that Jack and Jane have the same “disease,” and that is it is genetic and biological, caused by misfiring neurons. This makes no sense. Patterns of complex human emotional problems that (in some cases) barely overlap cannot be reduced to a biologically-caused disease.

In my view, the motivation behind labelling BPD as a biologically-caused disorder is profit. Pharmaceutical companies want to sell more drugs, and to do so, they need to promote the myth that emotional problems originate in brain biochemistry. This is discussed further here:

https://bpdtransformation.wordpress.com/2014/03/16/the-science-of-lies-psychiatry-medication-and-bpd/

As for BPD being hereditary, that is equally ridiculous. Firstly, the notion that a genetic percentage-contributor for the condition can be quantified is simply not true, given the complex way in which genes and environment interact. I recommend the reader to Evelyn Fox Keller’s outstanding book, “The Mirage of a Space Between Nature and Nurture”, for an explanation of this concept.

While constitutional vulnerability to stress may be a factor in who develops so-called “borderline” symptoms, that does not mean BPD runs in families due to genetic factors (although, it may certainly run in families due to generationally-transmitted abuse and neglect). In an earlier article, the way in which gene studies misrepresent BPD and other mental health conditions as biological diseases was discussed:

https://bpdtransformation.wordpress.com/2013/12/09/is-borderline-personality-disorder-caused-by-faulty-genes/

These two linked articles extensively undermine the genetic and biological arguments. I will leave it to the reader to peruse them further if desired.

    Myth #4: Medication and therapy are equally effective treatments for BPD.

One of the best current forums attacking the myth that medications really “work” to treat most mental illnesses long-term is Mad In America (http://www.madinamerica.com/).

I recommend the reader to peruse some of its intriguing articles on medication, such as:

http://www.madinamerica.com/2014/07/continuing-antidepressant-debate-clinical-relevance-drug-placebo-differences/

http://www.ncmhr.org/downloads/Anatomy-Of-An-Epidemic-Summary-Of-Findings-Whitaker.pdf

Given that medications only treat the anxiety and depression associated with BPD, rather than BPD itself, my position is that medications can at best be palliative. Palliative means they reduce symptoms to a limited degree, without treating the root cause of someone’s problems. At worst, medications can cause horrible side effects, waste money, and promote the fantasy that pills will solve long-standing personality problems.

I have never heard of a borderline who was cured by medication alone. But as discussed above, there is convincing evidence, both from first-person accounts of recovered borderlines, and from third-person accounts of therapists working with borderlines, that full lasting recovery from BPD can be achieved via psychotherapy, self-help, and human support in general. Therefore, psychotherapy and human support are the treatments of choice for BPD.

It should be noted that medications are not all bad. In my early years of coping with extreme rage and hopelessness, I used psychiatric medication for a limited time. It stopped me from being overwhelmed by anxiety. However, after entering therapy and stabilizing, I gradually titrated off the medication. In the big picture, medication was a very limited tool.

    Myth #5: BPD is a valid diagnosis and a real medical condition.

It is time to reveal my true colors. I do not believe that BPD is a real disorder, although I believe all its symptoms are real and painful. Let me explain.

Saying that BPD exists is like saying that a certain group of stars in the sky are the “Big Dipper” constellation. There is nothing in nature that makes a constellation exist, only humans’ illusory projection of order into the stars’ positioning. In other words, a constellation itself is not a real external entity – it’s just an idea in people’s minds projected onto that external entity. It is a reification or simulacrum.

Likewise, BPD is an artificial construct. Like a constellation based on stars, BPD is based upon an artificial grouping of human behaviors, although there is nothing innately in those behaviors that makes it valid. Unlike constellations, BPD is even less reliable, because at least constellations are based on artificial groupings of clear physical entities. BPD, on the other hand, is based on subjectively assessed psychological-emotional symptoms which must reach a certain threshold intensity for inclusion. Why those nine symptoms were chosen for BPD (and not dozens of other possible symptoms), why it should be nine symptoms and not more or less, and when exactly each symptom is intense or different enough from “normality” for inclusion, are all mysterious, hard-to-answer questions.

More insidiously, these questions lay bare the fact that BPD is a nonscientific figment of psychiatrists’ imagination. I have no hesitation in saying this, despite having had all nine “borderline” symptoms myself. BPD as a medical condition is a fraud. It is richly ironic that the term “borderline” appears so often on this site, when I do not even believe in its validity.

However, as I noted in article #8 on the BPD diagnosis, BPD does have its uses. It does have some generally understood, if imprecise, connotations. One must admit that BPD means something to some people, although exactly what is not always clear. Because people insist on speaking about BPD as a valid medical diagnosis, I have found a way to think about it usefully. I usually translate “borderline” to mean that a person is struggling with some uncertain degree of severe emotional problems, often based on early neglect and/or abuse, and usually involving splitting in which negative perceptions of self and other are stronger than the positive self-and-other units. For me, this is more meaningful than the trite and superficial DSM diagnosis. This self-and-object theory is described here:

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

When I read on a blog that someone “has” BPD; my first thought is that this doesn’t tell me much about them. I am more interested in hearing about their personal history, what they are anxious about, their hopes for the future, what resources they are using to improve, etc. Those things are real. The main positive aspect of the BPD label is that it allows people to find effective help for the range of problems that are imperfectly described by that label.

I would like to share here the viewpoint of the British Psychological Society (Great Britain’s counterpart to the American Psychological Association) on the validity of personality disorders and other mental health diagnostic categories:

“One way of examining the validity of mental health diagnostic categories involves using statistical techniques to investigate whether people’s experiences actually do cluster together in the way predicted by the diagnostic approach. The results of this research have not generally supported the validity of distinct diagnostic categories. For example, the correlation amongst symptoms for specific mental disorders has been found to be no greater than if the symptoms had been put together randomly. Similarly, cluster analysis – a statistical technique for assigning people to groups according to particular characteristics – has shown that the majority of psychiatric patients would not be assigned to any recognizable group. Statistical techniques have also highlighted the extensive overlap between those diagnosed with one disorder and those diagnosed with another.”

(from the newsletter of the British Psychological Society (BPS), 2000, pg. 17. I have altered a few words to make the meaning clearer as applied to personality disorders, rather than psychoses, which the original paragraph also discussed. However, the essential meaning of the passage is unchanged.)

The BPS viewpoint implies that there are no clear boundaries between, and thus little validity or reliability within, each of the mental disorders of the DSM, including Borderline Personality Disorder.

Interestingly, if ones accepts that Myth #5 is indeed a myth (in other words, that BPD is not a valid medical condition), then it becomes necessary to reevaluate myths # 1 through 4. Here they are again:

Myth #1: Borderlines cannot become lastingly free from borderline symptoms.
Myth #2: Effective treatments that “cure” BPD have not yet been developed.
Myth #3: BPD is primarily caused by genes and biology.
Myth #4: Medication and therapy are equally effective treatments for BPD.

If the placeholder “BPD” is actually an unreliable, fictional diagnosis, then many of these ideas cease to have meaning. 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, and medication and therapy cannot be compared for the treatment of a speculative phenomenon.

This is how I now think about BPD. Such an approach might seem invalidating. However, I empathize with people’s experience of being borderline as an identity, as I thought of myself that way for many years. What I am saying doesn’t mean that people’s suffering or experience is not real, only that the medicalization of emotional suffering, crystallized in BPD as a diagnosis, is suspect.

Paradoxically, I find rejecting the notion of BPD as a valid diagnosis to be encouraging and human. All nine symptoms listed under the BPD diagnosis are real and occur to different degrees in different people. But, I don’t believe someone suddenly “has” BPD when they have five out of nine of them.

Rather, I try to see human problems, including the nine so-called BPD symptoms, as existing on a complex continuum. On this spectrum, everyone’s problems are unique and cannot be compartmentalized into “diagnoses”. Such an approach is more human and respectful of individual differences. It’s not easy to think that way, since we are accustomed to think in categories and divisions. But I never liked how psychiatry labels many severely troubled people as “borderlines” when really, everyone’s problems are their own.

Some of these ideas might be controversial, especially this last myth. I don’t expect everyone to agree. If you have your own opinion, feel free to share it in the comments below. There’s a need for increasing dialogue, both about what can help people who are diagnosed with BPD improve, and also about the worth of the BPD diagnosis. Although it may be controversial, such dialogue may be interesting and useful, and can only have a positive effect for those diagnosed with BPD in the long-term.

 ——————

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