Monthly Archives: October 2015

#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.)

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

ParallelPsychModels1

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:

PSPvsSearlesPhases3

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.

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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