#22 – Proof That Borderlines Are Motivated for Psychotherapy and Can Fully Recover

This post will answer critics who say: “Borderlines are not motivated to attend therapy. Borderline patients don’t stay in treatment. At best, therapy can manage but not cure BPD.”

These statements are absolutely false. Yet these myths continue to appear online, often being communicated to people recently diagnosed. As the studies below demonstrate, most people diagnosed with BPD do want help, most will stay in good treatment, and most do recover to different degrees.

Earlier posts have elaborated my dim view of the (non) validity of the BPD diagnosis. Since it cites studies using the BPD construct, this post might be viewed as hypocritical. That may be a valid criticism! Nevertheless, these studies provide evidence that people with “borderline symptoms”, however defined, can be motivated and recover both with and without therapy

Study 1:  88 Borderline Patients Treated Twice a Week for Three Years

Highlights: Led by Josephine Giesen at Maastricht University, Dutch researchers treated 88 borderline patients for three years with twice-weekly psychotherapy. Patients were randomly assigned to either Schema-Focused Therapy or Transference-Focused Psychotherapy, which are described in detail below.

After three years, a large majority of patients showed significant improvement, with many considered fully recovered and no longer diagnosable as borderline. In the group of 45 patients undergoing Schema-Focused therapy, more than half were no longer diagnosable as borderline after three years, and many more had improved significantly.

The researchers commented, “These treatments demonstrate that patients with BPD can be motivated for and continue prolonged outpatient treatment… Three years of treatment proved to bring about a significant change in patients’ personality, shown by reductions in all BPD symptoms, increases in quality of life, and changes in associated personality features.”

Here are details from the study:

Patient Population:  88 Dutch patients diagnosed with BPD. Average age around 30 years, with most patients in their 20s or 30s. Over 90% of patients were female. The group had average educational levels for Holland; about half had attended some college or completed a degree. As for functioning before treatment, around 50% were on state disability, 20% were working, and the remainder were students or stay-at-home wives/mothers.

Trauma in Patients’ Histories:  Over 85% of the patients reported childhood physical abuse. About 90% reported childhood emotional abuse or neglect. More than 60% also reported sexual abuse. Over half the patients had seriously contemplated or attempted suicide within three months before treatment. About three-quarters were taking some type of psychiatric medication.

Intervention: For a three-year period, patients attended two 50-minute sessions per week of either Schema-Focused Therapy (SFT) or Transference-Focused Psychotherapy (TFP). Treatment occurred at outpatient medical centers in four Dutch cities. The type of therapy given was randomized.

Definition of Schema-Focused Therapy: SFT is a psychodynamic treatment which assumes the existence of schemas (mental models of relationships) expressed in pervasive patterns of thinking, feeling, and behaving. The distinguished modes in BPD are detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. Change is achieved through a range of behavioral, cognitive, and experiential techniques that focus on (1) the therapeutic relationship, (2) daily life outside therapy and (3) past traumatic experiences. Recovery in SFT is achieved when dysfunctional schemas no longer control the patient’s life.

Definition of Transference-Focused Therapy: TFP is a psychoanalytically-derived therapy which focuses on the transference relationship between patient and therapist. Prominent techniques are exploration, confrontation, and interpretation. Recovery in TFP is reached when good and bad representations of self and others are integrated and when fixed primitive internalized object relations are resolved.

Therapist Composition: 44 different therapists treated the 88 patients. Over 90% of the therapists had doctoral or master’s level training. All therapists had previous treatment experience with BPD patients. Therapists averaged 10 years of experience working with borderline individuals.

Outcome Measures: Patient progress was assessed every 3 months for 3 years. The primary outcome measure was the BPDSI-IV, a 70-item scale measuring the severity and frequency of borderline symptoms. Patients also completed regular quality-of-life questionnaires. These included the World Health Organization quality of life assessment, a 100-item questionnaire covering level of satisfaction with interpersonal relationships, level of independent functioning, psychological wellbeing, and physical health.

Dropout Rate: Of 45 patients treated with Schema Therapy, only 11 dropped out during the entire 3-year period. So 75% of this group persevered in intensive therapy for at least three years.

Of 43 patients treated with Transference-Focused Therapy, 18 dropped out during the 3-year period. However, the study notes that 10 of these 18 drop outs disliked the therapy method or their therapist, and 5 of 18 had issues around TFP’s method of enforcing contracts. Many of these dropouts occurred in the first few months. In my opinion, TFP is a more rigid, less effective form of treatment, and so it’s unsurprising that more patients dropped out. There’s no reason these patients couldn’t do better in another treatment.

Understanding Improvement in these BPD Patients

So how was improvement in these patients measured?

To answer this, one has to understand the measures used in the study. The primary gauge was the BPDSI-IV scale, which was filled out by patients every three months for three years. The BPDSI consists of 70 items arranged in 9 subscales. For each of the 9 DSM symptoms, 7-8 questions are asked to determine how severe and frequent the behaviors/feelings have been over the past three months, from the patient’s perspective. Each question is rated on an 11-point scale, running from 0 (never, not at all, low) to 10 (daily, very intensely, high).

For example, several questions would ask about the intensity/frequency of a patient’s feelings of emptiness (DSM BPD criteria #7), several questions would ask about the intensity/frequency of a patient’s suicidal thinking/behavior (DSM criteria #5), several questions would ask about how unstable or intense the patient feels their relationships to be (criteria #2), and so on.

The scores relating to each symptom are then averaged, producing an overall rating for that symptom. (For example, the scores for all questions about emptiness would be averaged to produce one “emptiness score”, a number between 0 and 10.) These 9 average rating for the 9 symptoms (numbers between 0 and 10) are added up to give a “BPDSI-IV” score, which represents the severity of the patient’s borderline problems over the last three months. This number will be anywhere between 0 and 90, with 0 being perfect mental health and 90 being the severest borderline disorder.

Although I dislike the BPD diagnosis, I don’t mind the method used in this study, because it involves asking the “borderline” patients how they feel. In other words, the BPDSI scale is not a judgment by clinicians, it’s a report from patients.

Improvement in BPDSI and Quality of Life Scales during the first year:

With this understanding in mind, here is how the patients did over the first year:

borderlineimage1

In the top left graph, we see that in the schema therapy group (line with squares), the patients started out at an average BPDSI rating of around 35 (out of 90, with 90 being the most severe, representing the worst rating for each of the 9 BPD symptoms), but this had dropped to almost 15 by the end of the first year. The patients in the transference therapy group also improved, but a little less so.

The other measures are as follows:

The bottom left Euro-QOL scale is a measure of the patient’s subjective feeling of well-being on a scale from 0 to 100, with 100 being the best. We can see that it improved significantly for both patient groups over the first year.

The top right WHO-QOL scale is another quality of life scale, and the bottom right scale is a measure of psychopathology, neither of which I researched in depth. But the trend lines in each case are positive

Outcome In Terms of Symptom Reduction

Now let’s take a look at how the patients did in terms of each of the 9 BPD symptoms. Here is the graph of the treatment groups’ averages for symptom severity over time:

borderlineimage4

The left-hand numbers on each graph represent the average BPDSI rating for the group for that symptom. For example, for item C (top right), the “Identity Disturbance” rating (DSM symptom #3) started at an average of 5 out of a worst-possible rating of 10. This rating is an average for all the patients in the group. It then drops to an average of less than 2 out of 10 after the first year, an impressive reduction.

Average group ratings over time for all 9 BPD symptoms can be seen. From the top left, the items are: Abandonment score, Unstable Relationships sore, Identity Disturbance, Impulsivity, Suicidality, Emotional Instability, Emptiness, Anger, and Paranoid/Dissociative Tendencies. All of these ratings are from the patients’ perspective. The reader can see that in every case the trend is positive (symptoms getting less intense and frequent).

Detailed Outcomes Over Three Years

Lastly, here is data showing the patients’ progress over three years:

borderlineimage3

We can see that the patients improved a lot in the first two years, and tended to maintain that improvement between years two and three. I don’t interpret this pessimistically. After a significant period of early improvement, there is often a time where a person works to become more secure in their new level of functioning and relating. This may partly account for the “leveling off” of the scores between years two and three. If the patients continued in treatment (or on their own), they could improve further.

After three years, at least half of the Schema therapy group’s patients had recovered to the point where they felt well enough to no longer be considered “borderline”, and more than two-thirds were considered highly improved. “Recovery” was defined in this study as achieving a BPDSI score of lower than 15 out of 90, and maintaining that level through the end of the study. Other patients who improved a lot (e.g. going from a BPDSI rating of 50+ down to 25 or 20) would only barely be diagnosable as borderline, even if they weren’t considered “fully recovered”.

These studies tend to be very binary (e.g. people are either “recovered” or “not recovered”, but reality is not like that). It’s important to remember that improvement is a process; it’s never all or nothing!

Jeffrey Young’s Comments

Dr. Jeffrey Young of Columbia University is the developer of Schema Therapy for BPD. He commented on this study as follows: “With Schema Therapy, patients with BPD are now breaking free from lives of chaos and misery. Not only are they learning skills to stop self-harming behaviors, as they have with Dialectical Behavior Therapy, but a high percentage of BPD patients are finally making deeper personality changes that have not been possible until now.”

For Young, this study demonstrates that therapy for BPD can lead to full recovery, and that longer-term psychodynamic therapy can be very effective. However, his comment might be a little grandiose, as people with borderline symptoms made “deeper personality changes” long before he invented Schema Therapy.

Young’s group added that this intensive schema therapy may have advantages over Dialectical Behavioral Therapy. According to Young, “DBT relieves many of the self-destructive behavioral symptoms of the disorder, but may not reduce other core symptoms, especially those related to deeper personality change.”

Interestingly, Young noted that part of schema therapy’s success may involve its emphasis on “limited reparenting”, i.e. on the creation of a loving relationship between patient and therapist. This is closely related to what I discussed in article #10, in the phase of Therapeutic Symbiosis:

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

More information is available at www.schematherapy.com, and I adapted the statements above from this webpage – http://www.schematherapy.com/id316.htm

My View on Schema Therapy

I am by no means an expert on Schema Therapy, and I have no affiliation with Dr. Young. My understanding is that SFT involves a mix of cognitive-behavioral and psychodynamic techniques. It focuses on building a positive therapeutic relationship, on better managing daily life, and on working through past traumatic experiences. These elements are common to most therapies.

Schema therapy also contains an object-relations (psychoanalytic) foundation, in that it conceptualizes the borderline patient as using “schemas” in their mind to represent and relate to themselves and others. Examples of these are punishing parent and angry child, uncaring parent and abandoned child, etc.

Schema therapy helps the borderline patient understand how these faulty models developed – often due to trauma and poor parenting – and to stop the replaying of negative past interactions from destroying the potential for new, better relationships in the present. In this sense, it is based on Fairbairn’s object relations model, discussed below.

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

As Fairbairn said, “The psychotherapist is the true successor to the exorcist. His business is not to pronounce the forgiveness of sins, but to cast out devils.” 🙂

How Individuals Get Lost in Group Studies

My biggest criticism of this type of study is that it obscures individuals’ experiences behind numbers and averages. Of course, its intent is not to provide individual detail. But,I would like to hear from individual patients what their life experience was like at the end of treatment compared to the beginning. I’m sure many would speak very positively about their progress. Since we don’t have that, I recommend the reader to case studies referenced in these posts:

https://bpdtransformation.wordpress.com/2013/12/15/what-to-do-if-you-are-diagnosed-with-bpd/

https://bpdtransformation.wordpress.com/2014/08/17/18-heroes-of-bpd-jeffrey-seinfeld/

The Mystery of Why People Are Still Pessimistic About BPD Treatment

In the bigger picture, this study’s results are obvious. Intensive help helps people, just like the sky is blue and the sun rises in the east. “Borderlines” are no exception to this. If they can access effective support – and are given a reasonable sense of hope – people diagnosed with BPD will do very well. What we need to be doing is getting more people access to effective treatment, and leaving behind the outdated myths that BPD is untreatable or incurable.

It’s amazing how such common sense escapes people who say, “borderlines don’t seek help, borderlines won’t stay in treatment, borderlines can’t be cured etc.” In my opinion, they are about as well-informed as people who think the Earth is flat.

Here is the original study of the 88 Dutch patients: http://archpsyc.jamanetwork.com/article.aspx?articleid=209673

Other Studies on Psychotherapy’s Effectiveness for BPD

This study is one of many investigating psychotherapy’s effect on BPD. Below are additional examples, one from a hospital outpatient program, one from DBT, and one comparing different psychotherapies:

Treatment of Borderline Personality Disorder with Psychoanalytically-Oriented Partial Hospitalization, An 18 Month Follow-up: http://psychiatryonline.org/doi/abs/10.1176/appi.ajp.158.1.36

Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug Dependence: http://www.ncbi.nlm.nih.gov/pubmed/10598211

Evaluating Three Treatments for BPD: A Multi-wave Study: http://www.borderlinedisorders.com/images/AJPRCT.pdf

All of these studies show positive results. Again, this is not rocket science – good treatment helps people diagnosed with BPD!

What If Borderlines Don’t Get Good Therapy?

But what is people diagnosed with BPD don’t get good long-term psychotherapy? Do they inevitably do badly?

No.

Several studies address this question, including the one summarized below:

http://www.borderlinedisorders.com/images/AJPRCT.pdf

Here are the highlights of this study:

Study 2:  290 Borderline Patients In Massachusetts

Patient Population: 290 patients diagnosed with BPD, assessed at McLean Hospital in Massachusetts. They were first treated as inpatients during brief hospital stays.

Method of Study: This was a longitudinal-observational study. The patients were interviewed every two years for at least 10 consecutive years, starting in the early 1990s. During interviews, their level of functioning in work/school, satisfaction with interpersonal relationships, and degree and frequency of borderline symptoms were measured. After 10 years, 90% of the original cohort of 290 patients were still participating.

Therefore, this study followed the “natural course” of BPD. This medical-model idea is misleading (the notion that BPD has a “natural course”), but I won’t go into that now. Suffice it to say that the researchers in this study did not “treat” the patients – they just followed them after hospitalization and went to great lengths to see how they were doing every two years.

High Remission of Symptoms: After 10 years, 93% of the formerly borderline patients had experienced at least two consecutive years during which they no longer qualified for the BPD diagnosis, according to DSM criteria:

Time to Remission

Low Recurrence of Symptoms: After 10 years, among the 93% of patients who achieved symptomatic remission, only 29% became “borderline” again. In other words, once they improved to the point of no longer being diagnosable as borderline, a large majority did not get worse and become “borderline” again:

Time to Recurrence

Good Social and Work Functioning: After 10 years, 78% of patients had achieved good psychosocial functioning – defined as good performance in a job for at least two years, along with at least one emotionally sustaining relationship with a partner or friend:Good Functioning

To me this last slide is questionable, as it’s not clear how “good work performance” was defined (and a certain period of work is not a prerequisite for “recovery”, anyway). Nevertheless, this study shows how, in a group of previously hospitalized borderlines, most people improve to the point where they are able to function in a job and have an intimate relationship. Again, the study authors provided these patients with no treatment beyond brief hospitalization, although many probably sought help on their own.

Other Longitudinal Studies of Borderlines Are Also Positive

There are many other ways to critique this study; for example, one could say it only applies to “borderlines” in the northeastern United States who went through McLean hospital. However, other studies following borderline patients for decades reach similar conclusions.

These include Thomas McGlashan’s Chestnut Lodge study (Maryland, USA), Michael Stone’s “Fate of Borderline Patients” study (New York, USA), and Joel Paris’ longitudinal study of borderlines (Montreal, Canada). All of these studies concluded that a large majority of borderline patients improved significantly, and many recovered in the long term. Collectively these studies included over a thousand patients. These studies can be found by searching online, as well as through the books by McGlashan, Stone, and Paris on Amazon.

The Limitations of Naturalistic Studies Based on Diagnosis

The anti-psychiatry side of me says that these longitudinal studies reveal what a meaningless and unreliable diagnosis BPD is. It doesn’t make sense that some percentage of people are initially borderline, then at varying points in time they are suddenly no longer borderline, then a few of them are borderline again, and so on.

Maybe BPD was never a valid illness to begin with. But such common sense seems to escape Harvard-educated researchers like Zanarini 🙂 Then again, to admit that what they’re studying is an unscientific fabrication wouldn’t be great for their careers, nor for receiving funding from the National Institute of Mental Health.

Although these studies have flaws, I hope readers will see that people diagnosed with BPD do seek help, and that they can recover to be emotionally well and free of “borderline” symptoms. These are not just opinions. They’re facts.

On The Nature of Quasi-Experiments

Lastly, it is important to understand that these studies – like most in psychology – are quasi-experimental. This means they are not perfectly controlled experiments, because when studying human beings many factors simply cannot be controlled. One can never study a person as reliably as one studies solar radiation or the molecular structure of uranium.

No one quasi-study can “prove” a point definitively. Nevertheless, quasi-experimental studies can estimate the effect of a variable(s) on a group of people under certain conditions. And a pattern of quasi-studies with similar results can show that something real is happening

These studies should also not be interpreted as applying to any particular person. Rather, they are averages of many different people’s outcomes, and only have meaning on a group level.

Wow, I am exhausted thinking about all this data. Time to get a beer!

——————————–

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

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#21 – My Nightmare of Psychiatric Hospitalization

“Mood disorders are biologically-based mental illnesses”, the psychiatrist announced authoritatively, surveying the 15 young-adult patients in front of him. “But while these illnesses might be biological, it doesn’t mean you can’t manage them effectively.”

My mind reacted explosively: How the fuck could you possibly know this, you pathetic excuse for a mental health “professional”? What actual evidence do you have?!

I desperately wanted to shout at him. But I remained silent, slouching backward in my chair in the mental hospital’s group therapy room.

After concocting a suicide plan that almost succeeded, I had been involuntarily committed to this hospital for my own protection. But I was now becoming a captive of a different kind: a prisoner of psychiatry’s hopeless ideology.

This is the story of my time in a mental hospital – what it taught me about myself, about my fellow human beings with “mental illnesses”, and about the web of lies that is American psychiatry.

Descent Into Hell

In my early 20s, having suspended my college career, I returned home to live with my family.  Living three hours away at college had become increasingly difficult – I felt isolated, depressed, scared, and hopeless. I couldn’t live on my own – my father’s physical abuse, and the lack of love in our family, had left me not knowing how to make friends, date girls, or feel secure living alone. But once I got home, the feelings of hopelessness continued unabated.

It’s hard to describe how bad things were to someone who hasn’t experienced these feelings.  I remember wishing that I could escape my mind and teleport into the body of another person whose mind was not as “diseased”. I read Dante’s The Inferno, and felt that I was literally living out the punishments of those condemned to the seven circles of hell.

Something felt profoundly unstable and “wrong” at the core of my being. It frequently felt as if my existence was under threat, that my core self might at any moment disintegrate. I remember reading an astronomy book describing how comets orbited the event horizons of black holes, constantly at risk of being sucked in and destroyed forever. That was how I felt.

To put these feelings into a more understandable context, they were based on the belief that I had no chance of a successful adult future. I saw other young people having relationships with the opposite sex, but I had no idea how to talk to a girl at the time. I couldn’t think clearly about getting a degree or starting a career, because getting through the next day felt overwhelming, let alone concentrating on schoolwork. I couldn’t enjoy anything – movies, reading, friends, etc. The all-consuming anxiety made every day a struggle.

Suicidal Intent

This horrific state of emotional affairs set the stage for me to become seriously suicidal. After returning home, I decided that I had tried everything and didn’t deserve to suffer like this. I formulated a plan to end my life, which won’t be elaborated except to say that it involved a lethal method and might have succeeded. I prepared loving letters for my family and friends, and planned the date I would end everything.

After I made my suicide plan, I remember walking outside during a sunset. We lived near the ocean at the time. In my fragmented state of mind, I looked at the beautiful sea, the sunlight glinting off the waves, and felt an overwhelming sadness. Part of me was urging myself to find a way to survive, but I couldn’t see any hope. Despite the despair, I still appreciated the natural beauty of the ocean.

My Plan Fails

My plan failed because I am a bad liar. My friends noticed that I had withdrawn socially, was barely communicating, and had stopped taking physical care of myself. All my energy was focused on ensuring the suicide attempt’s success by planning it down to the smallest detail. But knowing my history of abuse, my closest friend sensed something was wrong. When he asked me what was going on, I denied any suicidal intent. But the next day, he found an opportunity to look through my bedroom while I was out of the house. Showing a remarkable sixth sense, he rapidly located my suicide notes stashed in the side pocket of an old backpack. I will always owe him for this.

When I returned home, my friend had told my parents everything and the emergency psychiatric response team was rushing to our house. I was completely taken by surprise. Two policemen and two psychiatric specialists soon entered our house and questioned me. I tried to deny that I was actually planning to kill myself, but it was no use.

After a brief discussion, I was led out of the house – in handcuffs – and put in the back of a police car. I was to be taken to the local emergency room, since space was not yet available at the mental hospital. The police explained that I was not being arrested; handcuffing someone was their protocol when someone is involuntarily committed to a mental facility. This made little sense, but I was in no position to question them.

The Emergency Room

The next day or so is a blur. I had to stay overnight at the hospital emergency room, where I could not sleep because of nurses talking loudly. A guard constantly watched my room; at one point he explained that I was being put on a “5150 hold”, which meant I was to be detained for at least 72 hours for evaluation. My mind churned the whole night, going through endless scenarios: Where was I going? What were my parents thinking right now? How dare my friend get them to call the police without asking me? Am I crazy? Should I lie to the doctors, get out of the hospital, and follow through on my suicide plan? Had I been wrong to give up hope? Might hospitalization not give me some time to find a better escape, one that allowed me to survive and live? Shouldn’t I give myself another chance? How could life be so hard?

The Mental Hospital

In the morning the guard told me to get ready because we were going to the psychiatric hospital. I expected to travel normally in a car, but instead I was strapped to a hospital stretcher and rolled into the back of a locked ambulance. I had the humiliating sense of being a prisoner, with everyone knowing why I was held hostage – because I was crazy and wanted to kill myself. The trip took almost an hour; at this point I hadn’t slept for about 36 hours. We finally arrived at the hospital, where I was wheeled inside a self-locking gate that led into “the ward”.

A Moment of Humor

Despite my horrible mental state, part of me was fascinated to see inside a real-life “asylum” for the first time. I was thinking about the movie One Flew Over the Cuckoo’s Nest, which I had recently seen. The ambulance drivers were pushing my stretcher along a hallway, taking me for evaluation in the Intensive Care Unit (ICU) – the place for the hospital’s craziest patients, as well as those arriving for initial assessment.

As we turned a corner, we came upon a long-haired, wild-looking young man. He looked like a young Jon Bon Jovi and wore an ill-fitting blue hospital gown. Four or five nurses faced him with looks of frustration on their faces.

“You’re nothing but a bunch of vaginas and penises to me!” shouted the young man in a loud, high-pitched voice. “Vaginas and penises! That’s all you are! You can go fuck each other for all I care! Go fuck each other, you hear me? What do you think about that, you motherfuckers?”

I could not help smiling at this. I was thinking, What kind of place is this? Are these people all crazy?

The nurses tried to convince him to go to his room, but the patient continued his verbal assault, eventually challenging a male nurse to fight him in single combat. At this point, two of the male nurses forcibly wrestled him to the ground. They pulled up his gown, and a female nurse plunged a syringe into his bare bottom. It must have been a fast-acting tranquilizer. With this done, the male nurses dragged his limp body to a nearby room.

I made a mental note not to call the nurses “vaginas and penises.”

The Strange Ward

Upon arrival, I was assessed by a series of nurses, who asked questions like the following:

“Are you planning to hurt yourself right now?” (No…)
“What’s your height and weight?” (6’2, 175)
“Are you carrying any weapon or sharp object?” (No… Of course, they had to body-check me)
“Will you tell us if you start feeling like you want to hurt yourself?” (Yes…)
“Are you feeling pain anywhere in your body?” (No…)

It was all so awkward. No one asked why I was there, or what had been going on to make me suicidal. They said the psychiatrist would talk to me. I had to fill out a superficial anxiety and depression questionnaire, and was then shown to my room.

The ward was a spartan place of accommodation. The rooms didn’t differ much from prison cells seen on shows like MSNBC’s Lockup. Each room had a small, uncomfortable bed bolted to the floor along with a basic toilet. They also had some old wooden cabinets, which made them luxurious compared to jail! Almost nothing else was in the room. Every 15 minutes, all day and all night long, a nurse would come to check that I hadn’t discovered some ingenious way to hurt myself. This made it hard to sleep at night.

Soon I wondered into the ward’s common area, a large square space with old sofas and a TV. Ten or twelve mostly young adults were sitting there, watched by three or four nurses. Some were staring into space, others watched the TV, one woman was talking to herself. Everyone seemed to be quietly doing their own thing. I had no interest in talking to anyone at first. I thought they were all crazy and hoped I didn’t become like them.

A nearby board listed group therapy sessions that occurred each day. I cannot remember what type of therapy they all were, but there was at least one Dialectical Behavior Therapy and one Cognitive Behavioral Therapy session.

Group Therapy

I went to a couple of these group therapies the first day. The CBT session featured a young psychology intern lecturing. He drew pictures explaining how thoughts, feelings, body, and the outside world were interrelated. I found it so superficial as to be no help in understanding anything (I was in a very negative mindset at the time). I wondered why they were not asking people to tell their own stories, or at least for their responses to the information provided.

I would soon find that exactly the same lecture was repeated every two days, with no variation based on the patients. Anyone new got to hear it for the first time, while everyone else got a repeat.

In the DBT session, the speaker explained the concept of wise mind, the place where emotions and thoughts overlap. He described how to distract oneself from negative feelings and be “in the moment.” He also stressed repeatedly “thoughts are not facts!”. The tone of this session annoyed me, because it felt like we were being talked down to like simple-minded children, or like computers needing to have our software reprogrammed.

The Psychiatrist

Being horribly depressed and ashamed, I was not in a mindset to appreciate these sessions anyway. I spent most of the time in my room brooding about the thwarted suicide plans, thinking bitterly about how unfair life was. On the second day, the psychiatrist assigned to my case called for me. I went into a small office to find myself facing an old man who looked like a mob boss out of the Godfather. He appeared Italian, with dark, tanned skin, and a smooth sense of accomplishment about the way he spoke.

“What’s so bad that you want to kill yourself?” he asked me.

I remained silent for a while, then told him about how depressed I was, how I couldn’t stop obsessing over negative thoughts, and how my father had physically abused me.

The psychiatrist thought about this, then asked for my family history of “mental illness.” I described how my dad had severe OCD and depression.

“It sounds like you have OCD too, plus depression” the psychiatrist said. “We have medications that will really help your obsessing, and they’ll help the depression too.” He prescribed three medications – including two antidepressants and an antipsychotic mood-stabilizer, if I remember right – all of which I was to start taking right away. At that time I didn’t know much about medications, otherwise I would have refused his prescription, or at least refused to take that many.

The psychiatrist also prescribed writing exercises. I was to “obsess” in a journal for thirty minutes a day – writing down every negative thought that came to mind. And the rest of the time I was meant to tell the negative thoughts to “go away, I’ll deal with you later!”

Toward the end of the session, I told the psychiatrist about my BPD diagnosis also. He responded that this was a tough condition that could be “comorbid” with OCD and depression. He said something like, “We don’t have a cure for borderline personality, but the symptoms can be managed”. I hated this idea right away. If I couldn’t really get better, what point was there in trying?

“These type of things can get better. We want you alive, that’s why you’re here and that’s why we’re treating you,” the psychiatrist said. I didn’t like this one bit – the messages seemed to be all confused – but it was more positive than some of the other things he said.

My View of the Psychiatrist

The psychiatrist’s worldview was alien to me. I intuitively felt that the medications would not help, while the writing exercises seemed ridiculous. The psychiatrist didn’t appear to see me as an individual. Instead he saw “borderline” and “depression” and “OCD” sitting in the chair, and he was trying to manage these “illnesses.”

When the psychiatrist said that BPD could not be cured, I felt furious. If I had a gun, I would have liked to shoot him right there and then. I imagined how satisfying it would be to put a bullet through his forehead, see his chair topple over onto the ground, the blood spilling everywhere, and for there to be one less idiot psychiatrist able to medicate patients into oblivion. It made me think of the opening scene in the movie Casino Royale, where James Bond confronts the traitorous section chief, whom he dispatches with a handgun (shown in the last 30 second of this clip):

Of course, I did not execute the psychiatrist. Nor would it have happened if I had had access to a weapon. Even in my crazy state, some part of me knew that this man probably had a family and didn’t mean badly – he just didn’t know how to understand people other than as illnesses. But my fantasies of hatred for his views were vivid, and I wanted to destroy what he stood for.

The Dead Zone

Over the next few days, I went to several more group therapy sessions, which continued to feel superficial and boring. I wanted someone to listen to my experience, not hear lectures about the mind and how to rigidly cope. But I started to become less suicidal and began talking with some of the other patients.

I continued meeting with the psychiatrist daily. He would only see me for a few minutes, asking how the medication was working and if I was having any more suicidal thoughts. I thought it was ridiculous that he was not talking to me for a longer time, getting to know me and understanding what might have caused me to become so hopeless. I would always say that I didn’t know how the medication was working, because I couldn’t possibly tell what was the effect of the medication and what was due to other factors. This frustrated him.

Before I spoke to other patients, the atmosphere on the ward often seemed stagnant, tragic, empty. It felt like being in a morgue with dead people walking around. The nurses “managed” the patients – watching them take their medications, controlling the difficult patients, coordinating mealtimes. Their were some kind nurses, but the majority seemed not to care about getting to know the patients. The most positive thing about the ward was its breakfasts – I remember we got French toast, bacon, eggs, and cereal most days!

The Other “Crazy People”

After about four days, I asked the psychiatrist when I could leave the hospital. He wanted my family to meet with the social worker and establish a plan for my starting therapy, plus establish ground rules to prevent me from hurting myself. This involved restricting my access to money for a period.

I was to stay for a few more days and, if it seemed like I was functioning ok, attending some groups, and not feeling suicidal, then I would be released. Until my release, since there was not much to do most of the time and I was feeling better, I began talking to other patients. That was one of the most interesting things about my stay. Let me describe a few of my fellow “crazy people”:

“Paul” was a big Latin-American man in his late 50’s with a jovial, outgoing personality. He spoke a little strangely, but was very friendly. He would always call me “Sir Edward” for no apparent reason. I told him about my English heritage; he was fascinated by my grandfather, a Jewish scientist who escaped from Nazi Germany. He told me how his family emigrated from South America to the US and established their own hotel business. Like me, Paul was a big racquet sports fan. We would talk about Agassi, Sampras, Federer, etc. debating who was the best. We had several table-tennis battles in the court-yard of the hospital ward. I would always beat him but it was close. I eventually asked Paul why he was there – to me, he wasn’t crazy at all. He said he had bipolar episodes, but they were now controlled with medication. I never saw any evidence of him being manic or depressed.

“Nicky” was a young woman in her early 20s. She was an attractive brunette, the kind of young woman to whom I was attracted but scared to approach. Eventually I struck up a conversation and found out that she had been hearing critical voices after using drugs, which led her to be hospitalized. She had a difficult relationship with her parents that led to the drug use and breakdown. But she kindly supported me when I told her how difficult things had been with my family. She also had coloring books which she would bring into the common area and get me to work on with her.

“Susie” was a middle-aged bipolar woman who had been experiencing hallucinations of sharp-fanged animals invading her apartment. She had had a difficult childhood with physically abusive parents. Nevertheless, she was an intelligent, interesting lady who had a successful career in a professional field. We would play board games together and she would beat me at Scrabble. I shared with her what had brought me to the ward, and she was warmly supportive. She reminded me of how important I was to my family; how hurt they would be to lose me.

“Ray” was a young man diagnosed with schizophrenia who had hallucinations and had been hospitalized several times. But he was a sweet person. It was clear that he wanted to be liked and to connect with other people, despite his “illness”. He didn’t even seem crazy to me. It turned out he had been able to work part-time on-and-off for several years, but the psychotic episodes, which I saw no overt evidence of, kept interfering with his functioning. He was on at least four or five different medications, which seemed like a lot. His mother would visit the ward every day and she clearly cared about him a bunch, sitting with him and holding him as if he were a young child. I was touched by her devotion, and introduced myself to the mother, telling her how nice I thought Ray was. I hope he got better going forward.

“Anouk” was a Middle-Eastern woman whose husband had physically assaulted her, leading her to flee from him, become severely depressed and suicidal, and eventually require hospitalization. She had a warm, motherly personality that was attractive to me at the time, lonely as I was. She told me about her five daughters and her dreams for their careers, and about how evil her husband was! She took a particular liking to me, and would give me high-fives and hugs when she saw me in the corridors. This went on even though patients weren’t meant to touch each other; somehow it seems that psychiatry has forgotten that friendly touch can be a healing thing.

“Jeanette” was another pretty girl in her early 20s. She had been admitted after running away from home and hitchhiking cross-country to “find herself”. She believed that plants had personalities and that you could be friends with them. She would keep a special hard-boiled egg in her room that had significance to her. Apart from these things, she spoke just like a normal person. I found her energetic personality quite likeable. But she was a social rebel and frequently argued with the nurses about rules. When they wouldn’t let her family bring in an I-pod, she became furious and acted out by stripping down naked and running through the common area with no clothes on! She was an absolutely gorgeous blonde. Hopefully she got better, and some lucky guy got to experience her beauty in a more private setting!

Reflections on The Patients Versus the Staff

Ironically, I got much more help from talking to patients than from the staff. The nurses mostly didn’t care about the patients as people, simply wanting to keep them under control. All the patients could sense this. The psychiatrist was worthless since we spoke only a few minutes a day about medication and practical matters.

But several patients treated me with genuine kindness. I kept in contact with a few of them afterwards via email and phone (even though the hospital warned against contacting other patients post-discharge… another stupid policy). To me, these patients didn’t have “mental illnesses”; they were just people dealing with serious challenges in living. I felt as if anyone could have reacted the way they did facing the same life challenges; but that wouldn’t make them “schizophrenic” or “borderline” or whatever. This experience influenced my thinking about BPD and other so-called “mental illnesses” being invalid diagnoses.

Several patients told me they hated taking medications, that they didn’t feel these medications helped, and that they got little out of the group therapy. One depressed man refused to take any medication; he just wanted to be there to be safe. The one good thing about the hospital – and I must acknowledge this for my own case – was that it kept me safe during a time when I might otherwise have hurt myself. For that protection I am grateful. I improved somewhat by the time of discharge, and was less of a risk to myself afterwards.

Psychiatry Doing More Harm Than Good

I believe that in many cases, mental hospitals dominated by psychiatry’s medical model do more harm than good. Ironically and perversely, psychiatry thereby becomes an obstacle to the recovery of the very people it is supposed to help. It promotes the message that people have biologically-based “illnesses” that they are stuck with for life. As I discuss in many other articles, this is a complete lie. And yet, it is presented as if it is the best that people can hope for.

Why limit people’s dreams with this type of reductionistic thinking for which there is scant evidence? Why not tell them that they are heroically dealing with understandable reactions to extremely challenging life situations, and that with understanding and love, they are likely to get better?

The answer, in large part, is that psychiatry’s reductionistic view of emotional problems as “mental illnesses” has infected the minds of most psychiatrists, who in turn infect their patients. And thus is promoted the pessimistic view of mental illness as a lifelong “disease”, rather than as a primarily psycho-social experience that can be overcome with sufficient support.

Psychiatry is also eager to prescribe as many medications as possible, which unfortunately do nothing to address the root causes of people’s problems. A prime motive is to perpetuate the billions of dollars in profit that companies like Eli Lilly, Janssen, Pfizer, etc. make, and to support the psychiatrists and shareholders allied with these companies. Helping the patient comes second, and if these patients could have done better with other forms of treatment and/or without medication, then too bad.

In my opinion, the network of drug companies and psychiatrists who weave lies about medication represent a fraudulent house of cards. Patients can protect themselves by learning just how ineffective medications really are over the long term. If more of us educate ourselves, then psychiatry will be progressively undermined. Newer studies are showing that most psychiatric drugs are barely or no more effective than placebos, and that the long-term side effects can be very dangerous. This is discussed in detail in the many articles on http://www.madinamerica.com

Lastly, the whole approach of the hospital was to “manage illness”, not promote healing and recovery. Even though there were signs on the walls extolling positive values like Hope and Responsibility, the interactions with the nurses, psychiatrists, and group therapists did not promote a sense of “we’re in this together” or “you can recover and do what you want.” Rather, the emotional message was, “You are the sick people, and we are the “normal” ones who will teach you how to manage your unfortunate afflictions.” Ironically, many of the patients were more helpful to me than the mental health professionals.

Conclusion: A Sad Reality

Such is the reality of inpatient mental health treatment for many in 21st century America. I urge people to avoid inpatient facilities wherever possible, unless they are in real danger of hurting themselves or others, in which case hospitals can provide a critical protective function. As much as possible, seek help from outpatient therapists, family, and friends who are outside of the traditional psychiatric system. I believe the chances of recovery from BPD and other conditions is greater following this path. Getting stuck in a cycle of going in and out of hospitals, being overmedicated, and being treated as if one is an illness, doesn’t promote recovery.

I would also direct readers to these websites that are great resources promoting recovery outside of the traditional psychiatric system:

http://www.madinamerica.com – Many fascinating articles about the worthlessness of psychiatric diagnosis, the ineffectiveness of medication, and the value of therapy, understanding, and love.

http://www.mindfreedom.org – Another anti-diagnostic site that rejects labels and is similar to Mad In America.

http://www.isps.org – The International Society for Psychological approaches to Schizophrenia and other psychoses. Many of the clinicians listed on this site are also well-trained in treating Borderline Personality Disorder. Much of their writing about psychosis could be applied to BPD. They are an extremely empathic, innovative, and optimistic group.

Feel free to share any experiences you have with “the psychiatric establishment” in the comments!

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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

#20 – Splitting Explained and Thoughts on DBT

Splitting is often mentioned in blogs and books about BPD. Here I’ll give an overview of this defense mechanism, offer ways of understanding it, and suggest ideas for overcoming it.

What does splitting mean? It describes how someone views themselves and others as all-good or all-bad at a given time, not as a mix of good and bad qualities. It can be illustrated with examples. Here are three scenarios that show splitting in action:

Example 1: The Mean Professor

In our first example, a “borderline” woman gets back a paper in her college English class with a grade of C. The professor notes that the grammar, syntax, and thesis need to be improved, and suggests a revision. He adds that the overall organization was on the right track, making encouraging remarks about several ideas. Nevertheless, the student feels rage in response to the grade of C. She views the professor as mean, as a harsh grader, and as “out to find and punish any mistake.” The student does not take in the positive remarks, which could have balanced her thinking by preventing the professor from appearing totally negative. By only focusing on the bad aspects of the situation and cancelling out the positive, the student remains internally attached to an “all bad” view of the outside world. This is an example of negative or all-bad splitting.

An important thing to notice about splitting is that the individual becomes actively involved in maintaining their view of the world in a “split” way, via the way they fantasize about and color external reality. In other words, the person’s mind only recognizes or takes in a certain kind of emotional stimulus – e.g. critical remarks in this case – and the person either does not recognize, or actively rejects, the opposite kind of stimulus – balancing, positive remarks. In this way the person does not experience any ambivalence, thoughtfulness, or reflective-capacity in relation to what is going on. Rather, the (only partially negative in this case) experience is responded to as if it really were 100% bad emotionally. This severely limits the ways in which the individual can respond to the outside world.

The origin of all-bad splitting was further discussed in the article on Fairbairn’s developmental model, here:

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

With regard to a person not recognizing positive experiences, or rejecting positive stimuli, these are examples of the out-of-contact and ambivalent symbiotic phases respectively. More on these phases can be found here:

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

Example 2 – A Date Turned Bad

In this second example, a “borderline” young man goes on a date with a young woman, meeting her for lunch. The pair have a relatively good conversation, finding some shared experiences in music, sports, and the schools they attended. At the end, the woman hesitantly says she would be interested in meeting again, and she gives an awkward, tentative hug to the young man.

This man had a difficult relationship with his own mother, who was distant and cold emotionally. Although he enjoyed parts of the date, he forgets the main conversation and becomes preoccupied with the awkwardness that ended their meeting. After going over it in his mind, he decides that the young woman did not like him, was just being nice out of pity, and has no interest in seeing him again. He can only understand her awkwardness at the end of the date as an unconscious communication of rejection.

This is partly an example of projection. However, it is also an example of severe splitting, in that the young man sees the woman’s attitude as all-negative while rejecting any balancing possibilities. For example, rather than viewing the woman as not liking him, he could consider that she might be nervous about expressing affection on a first date, or that she is relatively inexperienced with dating overall. These thought patterns would move away from the feeling of rejection. However, these ideas never occur to him, which is partly because he makes buries the memory of the good conversation, and fixates consciously on the negative (from his perspective) ending. Again, we can see that internally this young man is creating or “making” reality more negative than it really is, via the splitting of the woman into all-bad in his mind.

Example 3 – The Savior Parent

For a last example, a lonely, middle-aged “borderline” woman becomes involved with an older, successful professional man who wines and dines her, gives her gifts, and in general treats her with kindness. During these early good times, the woman views the man as a “savior”, the perfect gentleman, and the solution to all her problems. Even when he makes small mistakes, like his habit of being late to dates, she isn’t bothered.

However, after a few months, the man stops spending so much time with her, gives more energy to his other friends and hobbies, and has to travel more for business. He tells her he wants to take his time with the relationship. Once this happens, the “savior” image disappears, and the woman feels rejected. The “good child – perfect parent” internal images are replaced by her feeling like an unwanted, lonely child, with the man seen as an uninterested, rejecting parental-figure. Now, when they do meet and the man is a little bit late, she notices it immediately – it feels like a concrete example of how he is not concerned about her. Her feeling rejected by the lateness (all-bad splitting) is the polar opposite of when she would not even notice his lateness before, during the idealizing phase (all-good splitting).

In these examples, I use the quotations around “borderline” because these examples represent not “borderlines” (do we ever see a borderline walking down the street?), but unique human beings facing challenging past and present circumstances. As noted in other articles, I don’t believe that BPD is a valid diagnosis; nevertheless, “Borderline Personality Disorder” is a diagnostic word commonly used in association with splitting. Thus I will sometimes use the term, albeit reluctantly.

Understanding Splitting as a Normal Developmental Process

Splitting in itself is not something “bad”. Rather, it is a normal developmental phase that children pass through; the young child first takes in satisfying experiences and unsatisfying experiences separately, classifying them in different compartments in its mind. The problem of splitting continuing into adulthood only develops when the negative experiences outnumber or outweigh the positive experiences.

Integration (seeing the world ambivalently, as mixtures of good and bad qualities) begins to naturally occur in a child’s mind if more good than bad experiences accumulate over time. Let us look back at the three examples to see how someone with a higher capacity for ambivalence might have processed the same events:

Example 1 – The Constructively Critical Professor

Rather than “mean” and “out to punish any mistake”, a healthier student would have seen her professor’s remarks as constructive criticisms meant to improve her writing. She would have noted that the positive remarks indicated a concerned side of the professor, and then – holding them in her mind along with the critical remarks – she would not have twisted his image into that of a rejecting authority figure. These differing perceptions would probably affect her future behavior; making her more likely to rewrite the essay well and receive praise from the professor.

In contrast, the more troubled woman in the original example might do a lackluster revision in response to the criticism, lacking motivation due to her belief in the professor’s all-negative attitude toward her. This might lead to more trouble with the professor on future assignments, resulting in more all-bad perceptions by the student, and so on. In this way, all-bad splitting tends to form a vicious cycle where the same people are repeatedly seen as “all-bad”, related to unrealistically as “bad”, and then in reality they often do become more “bad”, treating the person less well than they otherwise would have. In other words, the person is modifying how they experience own reality via the splitting. The internal and external worlds of the person interpenetrate so that the internal negative perceptions come to shape and be shaped by how the person interacts with the outside world.

Example 2 – Ambivalence Over A Young Woman on a Date

As mentioned in the original example, a healthier man might have considered that the young woman’s awkwardness at the end of the date might not indicate lack of interest. Rather, a whole range of reasons could account for her behavior, including nervousness, lack of experience with dating, not being comfortable with expressing physical affection, a conservative upbringing, and so on. Keeping any of these ideas in mind, along with the memory of the positive aspects of their conversation, would have supported the idea that the woman could still like him despite her awkwardness.

Example 3 – A More Independent Woman

This woman’s idealizing reaction to the generous man in the initial phases of dating is not unusual. However, her reaction would be stronger than most, in that a lot of neediness underlies it. Her need for emotional support results in her wanting a perfect, all-giving parental figure, rather than just a lover. The need is not a bad thing in itself – it reflects a child’s developmental level emotionally – but it makes continuing an adult-adult relationship difficult. Because the woman wants a perfect parent, she is inevitably disappointed when the man starts to devote his energy elsewhere. At this point, the splitting shifts from all-good to all-bad, and things that did not bother the woman previously (like the man’s lateness) become upsetting.

A healthier person would not have such a strong need for the man in the initial phase of dating. Therefore, she would not be so vulnerable to disappointment when the man started to reveal imperfections later on. The man would neither be seen as so perfect initially, nor viewed as so bad and disappointing later on. Both of these differences in perception would result from increased ambivalence – the absence of all-good or all-bad splitting.

Why Does Splitting Continue Into Adulthood?

We have seen in these examples how a healthier person tends to use an integrated view of other people, containing good and bad elements together, to relate to others in a more complex, realistic way. This capacity is based on a predominance of positive experiences in these individuals’ life experience. As noted, integration naturally tends to occur when good life experiences outweigh bad ones, because a person feels safe to look at the small “bad” packet of experiences alongside the “good” group of experiences.

However, if a person’s negative experiences in life largely outweigh the good ones, then integration cannot occur in a way that feels safe. Very often, abuse, neglect, and a lack of positive relationships in childhood and/or early adulthood underlie this “structural deficit” – the lack of good experiences on which to base a capacity for ambivalence. The lack of feeling secure in childhood, and the related need to maintain hope in an overwhelming situation, are reasons that splitting gets maintained into adulthood in many adults who get the “borderline” label. Because their experience in reality – often with parents who neglect or abuse them – has been more negative than positive, they have to preserve hope of things getting better somehow. They do this using the splitting defense. With splitting, it is possible to pretend, on the basis of the few good experiences that one actually did have, that a perfect, good savior-parent or partner is still out there who can provide salvation. By contrast, it feels dangerous to the child (and later adult) to truly see that he is in great emotional danger as a result of his interpersonal world being more “bad” than “good”.

In colloquial language, one could say that it feels safer to ambivalently reflect on what is going on in one’s life when one’s experiences with others have been primarily positive. When one feels threatened most of the time, it’s not possible to be consistently aware of just how bad things are. Such an awareness would be emotionally overwhelming. In this way, at least at first, splitting is a brilliant defense mechanism that can be emotionally life-preserving

How To Move Beyond Splitting

Here I would refer the reader to blogs, books, and essays that were discussed in earlier articles. Many sources describe how building a long-term good relationship with another person and/or group is crucial to recovering from what is called Borderline Personality Disorder. The borderline individual needs to build their internal positive images up – taking in many good, supportive, loving experiences with other people in the real world – until these memories become stronger than the negative images. Eventually, integration of good and bad perceptions will naturally start to occur, and splitting will begin to be overcome.

I like to use the framework of four phases, artificial as they are, to conceptualize progress from all-bad splitting to all-good splitting to integration. The essay below describes the phases of Therapeutic Symbiosis, meaning dominance of positive images over negative ones, followed by Resolution of the Symbiosis, meaning the integration of good and bad images. These are the phases that a borderline individual usually wants to aim towards, starting from either the out-of-contact or ambivalent symbiotic phase. These earlier phases represent periods in which all-bad splitting dominates, i.e. the person’s negative views of themselves and others predominate over their positive ones, preventing ambivalence:

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

Types of Therapy for Overcoming Splitting

From my experience, I have a bias toward psychodynamic-psychoanalytic therapy; I think it’s a great way to build the positive relationship needed to overcome splitting. In long-term psychodynamic work, one can painstakingly build a trusting attachment that serves to replace the negative relationships of the past. The therapist first helps the patient to understand (via the transference relationship) how their negative, splitting-based ways of viewing the world are unrealistic and serve to block the need for more positive relationships. They also help the patient to manage difficult feelings in a way the original parents could not.

Later on, as trust and attachment develops, the therapist functions as a good parental figure, helping the patient develop their internal positive self-and-other images to the point that the good images dominate over the negative images. The positive relationship inside therapy gradually transfers to relationships in the outside world. The therapist is eventually experienced as an independent, separate person that the (formerly borderline) individual can have a mature adult-adult relationship with. During this period, the patient becomes more able to experience relationships ambivalently, as good and bad at once.

A Critique of CBT and DBT

Cognitive-Behavioral Therapy or Dialectical-Behavior Therapy can certainly be helpful, and are great for helping people stabilize their lives on a short-term basis. While I do not that think that CBT and DBT are “bad”; it’s my opinion that they are sometimes formulaic and superficial. They can have a narrow, present-day focus that limits a deeper understanding of someone’s problems based on their life history. Also, some of these shorter-term therapy approaches have the following problems:

1) They focus on coping with symptoms of one’s “illness”, thus conveying the impression that BPD is a life-long condition that must be managed, not overcome.  This may be partly my perception; not all forms of short-term therapy are like this and some focus on strengths. From my direct experience with it, I remember that there are positive aspects to the DBT conceptualizations, like the “wise mind” concept.

2) In some cases, CBT and DBT keep the borderline person stuck, allowing them to “cope ” a little bit better, but using the same defensive structure and split views of reality that they have had throughout life. Readers can probably relate to feeling that a short-term therapy has only been palliative, rather than helping them break through their suffering to experience the world in a new way. I think deep improvement requires much longer than short-term therapies allow for, and that it involves understanding one’s history and defenses in depth.

In my opinion, CBT and DBT (both of which I’ve also experienced myself, years ago) do not often continue long enough to build the positive self and object-images to the point needed to overcome splitting; CBT and DBT are often given for periods of only weeks or months. Again, in my opinion, overcoming splitting and associated defenses usually requires at least a few years. That is not meant to be pessimistic – while years may sound like a long time, things can gradually get better and better. Also, CBT and DBT can definitely help a person toward stabilizing a difficult situation, coping better with difficult feelings, and starting to be experience the world more ambivalently. It is not that shorter-term or manualized treatments are bad; but they may be limited in what they can achieve.

3) Going deeper, CBT and DBT create the illusion that BPD is a valid diagnosis that means the same thing for different individuals, but let’s not go there this time. If I get started on that train, it will take a long time to stop! 🙂

Having made these criticisms, I should admit that they might be wrong. That is why I noted that these thoughts are only opinions. Generalizing about therapy is a dangerous thing to do – a lot of success depends on the quality of the individual therapist, regardless of orientation, and the resources and motivation of the patient. Also, people have many options that can help outside of therapy. Therefore, my critiques should be taken as generalizations that have little meaning for an individual. No doubt, many people have benefitted from CBT and DBT, and if it works for them, that is all that matters. As one of my old therapists said, we should “take what is useful, and leave the rest.” If you have positive experiences with any of these forms of therapy, please share it in the comments.

Other Approaches to Overcoming Splitting

The discussion above assumes that people want to use psychotherapy as the main vehicle to overcome their problems. Of course, this is not always true. My first recommendation for those looking for another approach is to check out Clare’s writing on overcoming BPD, at:

http://www.my-borderline-personality-disorder.com/2013/03/recovery-bpd-mbt.html

http://www.my-borderline-personality-disorder.com/2013/07/the-process-of-overcoming-bpd-follow-up.html

Clare has many great articles about how she recovered from her problems without using intensive psychotherapy. I find her way of thinking about “borderline” problems to be humble, helpful, and wise. At the very least, her approach is more mature and encouraging than a lot of the pessimistic ideas discussed by “non-borderlines” on other forums! I hope I don’t offend anyone with this 🙂

Second, self-help groups like 12-step and other similar organizations can be very helpful, and I recommend at least trying them to everyone. These groups can help to establish a foundation of positive, trusting relationships, and can therefore be crucial to eventually overcoming splitting.

Third, for many people it can be helpful to educate oneself skeptically about BPD! What skeptical education means is to read widely, taking in many differing viewpoints on borderline issues without accepting one viewpoint as right. In my opinion, a lot of information about BPD on the internet is either so superficial as to be useless, or just plain wrong (this especially applies to viewpoints that involve strong pessimism toward borderlines, as well as viewpoints that consider BPD to be an “illness” with a genetic or biological basis).

Unfortunately, negative viewpoints on BPD may have a strong influence on people who become identified with the term, causing them to think negatively about their future. In this way, the very concept of BPD can sometimes become yet another obstacle to taking in positive experiences, making an already challenging task of recovery harder. So, my thinking is that changing one’s view of BPD to something more hopeful and flexible, or even rejecting the diagnosis model entirely, can be useful.

Fourth, and this is a truism, but friends and family can be so crucial to getting better. I understand that for many people who identify with BPD, family are a problem. But this is not always the case. Whenever family and friends can be turned into supporters, and relationships with them used for growth, it helps. In my experience, the more isolated that people are, the more prone they are to all-bad splitting. This is because isolation maintains the deficit of positive internal experiences, leading a person to feeling less secure and supported. While in this state people are less able to reflect on their experiences ambivalently.

Fifth, Helen Albanese gave a good overview of how splitting can be resolved in BPD in her book, The Difficult Borderline Patient: Not So Difficult To Treat. It is a brief, non-technical introduction to psychodynamic thinking about splitting and BPD, and Albanese conveys a lot of optimism that the condition can be overcome. It is accessible to the layperson in a way that most psychoanalytic books are not. I recommend checking it out in the used books on Amazon! (I have no affiliation with the author).

Understanding Splitting When One Is “Borderline”

To conclude, I think people working through borderline issues can benefit from understanding in greater depth how splitting operates – how viewing themselves and others as “all-bad” traps them in a negative cycle of seeing the outside world as all-bad, expecting bad things to happen, inducing others to respond negatively, feeling negative in response to treatment which they are partly responsible for, and so on.

This is an encouraging perspective, because if one gains insight into how one is misperceiving reality as “all-bad”, one can then start to understand how to move past the distortions. In other words, a person can become aware that they are seeing reality in a “delusional”, one-sided way, and that there are more good parts to outside reality than they often perceive. This can be an eye-opening, sometimes amazing experience to a person who starts to see things as good and bad together for the first time.

Getting past splitting sometimes makes me think of the movie Inception, where there are different levels of reality symbolized in different levels of dreams. In the early phases of mostly all-bad splitting (like in one level of a dream), reality is viewed all one way or the other. But on the higher level, where integration or ambivalence reigns, the world appears totally different, more complex and complete. It’s like the difference between seeing things as three-dimensional and in color, versus black or white.

Ok, I will finish this here! I hope this had some useful ideas, and feel free to share any thoughts with me via email or in the comments.

#19 – Hope, Meaning, and the Elimination of Borderline Personality Disorder

My goal for this blog has been to promote a new, more hopeful understanding of what is today called Borderline Personality Disorder. In writing this post – which will discuss hope for recovery from emotional trauma, but later argue that this hope might be better served by eliminating the diagnosis of BPD entirely – the following quote from Macchiavelli comes to mind:

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order; this lukewarmness arising partly from fear of their adversaries, and partly from the incredulity of mankind, who do not truly believe in anything new until they have actual experience of it.”
– Niccolo Macchiavelli (1469-1527), The Prince

For the purposes of BPD’s validity, this quote can be understood in terms of the “old order” of psychiatry – which profits both financially and via creating the illusion of scientific knowledge in psychiatrists – being opposed by those of us who argue as “reformers” that psychiatric diagnoses are invalid, unreliable and unhelpful. The reform position is that recovery from severe emotional trauma can be achieved without the need for psychiatric diagnosis. As the quote suggests, the idea that BPD does not exist as a valid diagnosis can initially be hard to believe.

Hope for Recovery, In All Its Forms

Today I’ll discuss what is among the most important topics for Borderline Personality Disorder: Hope. When a person is struggling with “borderline” symptoms – meaning intense difficulty managing their emotions and relationships, among other things – having realistic hope for improving one’s situation is critical. During difficult times, hope has felt as important for me as the oxygen a climber on Mount Everest carries for survival, or the fuel that a rocket returning from deep space uses, without which an astronaut would be doomed.

People may prefer to think of their hoped-for state as recovery, freedom, improvement, achieving goals, or something else; it is very individual. However their hope is defined, most BPD-diagnosed people express a strong desire to improve their situation.

Realistic hope

What makes hope realistic? I would suggest at least two things; 1) That hope is not taken for granted, and 2) That it is based upon convincing data.

#1, “Not taking hope for granted”, means realizing that improving one’s situation demands serious commitment and work, requires a willingness to confront oneself about difficult issues, and involves depending on other people for help.

#2, “Based upon convincing data”, means that realistic hope (for one’s desired outcome) must be based upon reliable and trusted information. To hold onto hope, a person needs a view of reality that is as accurate as possible in terms of representing the external world.

When I first searched for information about improving from BPD, a lot of what I found appeared pessimistic or even hopeless. Many publications said that the best outcome possible involved learning to better manage this painful lifelong “illness”, and some said that borderlines were untreatable or evil. Family members ranted about how difficult and unchanging their “borderlines” were. None of these things made me feel hopeful.

In earlier posts, stories and data were presented that, for me, provide realistic hope for recovery, healing, and achieving a “cure” of symptoms approximating what is described in the BPD diagnosis:

https://bpdtransformation.wordpress.com/2014/08/07/five-myths-about-bpd-debunked/

https://bpdtransformation.wordpress.com/2013/11/23/how-did-i-recover-from-borderline-personality-disorder/

The “Information War”

This data contrasted sharply with the earlier pessimistic, hopeless accounts about BPD I’d encountered. Sometimes it felt as though I was reading about two completely different conditions. For some time I fought an “information war” in my mind, trying to judge which of these conflicting versions of reality was right – or perhaps, whether both were correct, acting as self-fulfilling prophecies in different situations.  The increasingly numerous accounts I found of individuals with BPD diagnoses doing well, combined with my own life experience, eventually convinced me that realistic hope for getting better from what I then thought of as BPD did exist.

In my case, realistic hope meant that with sufficient support from family, friends, and my therapist, I had a very good chance of doing well, like many others who had encountered similar challenges before me. For other people, the hopeful narrative may be somewhat different; this makes sense given that we are unique individuals, and given my contention that BPD is an invalid, unscientific label which does not represent the same phenomenon from person to person.

Now, let us turn to look at some societal obstacles that impede realistic hope for BPD recovery.

The Failure of the American Mental Healthcare System

It can be useful to analyze the notion of realistic hope in the context of American psychiatry and its conceptualization of Borderline Personality Disorder. It is my position that psychiatry’s “medical model” approach to psychiatric diagnoses, its biological reductionism, its overemphasis on medication, and its oversimplification of an individual’s emotional struggles, all impede the spread of realistic hope regarding BPD (or more correctly, the hope for recovery from severe emotional trauma and/or the lack of healthy emotional development, in all its variations).

A Story: Emma

Let us discuss these ideas with a fictional example. Emma is a 21-year-old woman who grew up with an alcoholic, abusive father and an overstressed, emotionally neglectful mother. As a young girl, Emma was sexually molested several times by her father. Since finishing high school, Emma has lived at home with her mother, who works two jobs to provide for Emma and her younger sister. The father abandoned the family several years before, increasing the stress on the remaining family members.

Over the past three years, Emma has felt increasingly depressed and anxious most of the time. She is unsure how to make meaningful relationships with other young people. Never socially confident, Emma has become increasingly socially isolated as her old high school friends move out of town.  Due to her depressions, she cannot keep a regular job, and she goes through a series of short-term boyfriends who use her for sex and then abandon her, reminiscent of her father’s behavior. Unable to tolerate her increasing feelings of aloneness, and frustrated with her mother’s lack of understanding, she begins binge eating and purging, and also cuts herself when feeling particularly hopeless.

Finally, Emma overdoses on psychiatric medication in a desperate gesture that is really a call for help, leading her to be hospitalized for the first time. When evaluated by a doctor, she is seen as fearing abandonment by her mother, having an unstable self-image, practicing self-injurious behaviors, being unable to regulate her feelings, seeing others as all-good or all-bad, and so on. Obviously, she would be a prime candidate for receiving a BPD diagnosis according to traditional American psychiatry.

However, I want to focus on two possible ways that the hospital doctor could respond to Emma, and how these approaches might or might not promote realistic hope in Emma’s mind.

The Medical Model’s Diagnostic Approach

In the traditional psychiatric (medical model) approach, the treatment provider might communicate something like the following, “Emma, you’re suffering from a psychiatric illness called Borderline Personality Disorder. We don’t know what causes this condition, but it’s believed to result from a combination of genetic, biological, and environmental factors. BPD causes people to have problems regulating their emotions, and that is what is creating your symptoms like depression, anxiety, and rage. This is a tough condition to have – there’s no cure for it – but if you take medication and attend therapy, the symptoms can be managed.”

Usually, such an approach involves the doctor asking Emma what her symptoms are, but not going into detail about possible causes for these symptoms based on her personal history. Several emotional messages are conveyed by this approach. The first would be that there is something innately wrong with Emma. Emma would probably feel that she has a mental “disease”, that she is stuck with this illness for life, and that her prospects for finding personal fulfillment are poor.

The second message is that Emma’s past history and relationships are unimportant in relation to her “diagnosis”, or perhaps not related at all to her present problems. Rather than her current feelings and actions being understandable reactions to the deprivations she has experienced throughout life, she is told that a “disorder” is mysteriously causing her symptoms. Paradoxically, getting diagnosed with BPD does not give Emma any deep insight into why she is behaving or feeling the way that she is. The last, related message is that Emma is seen as a label, rather than as a person.

In my view, the ideas presented to Emma in the above example – i.e. “you have a psychiatric disorder called BPD, this mental illness is causing your symptoms, there is no cure for it” – are examples of outrageous lies coming from the pseudoscience that is psychiatry. In the posts below these distortions are expanded upon:

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

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

https://bpdtransformation.wordpress.com/2014/01/16/a-unicorn-the-paradox-of-the-bpd-label/

In this last article – “A Unicorn: The Paradox of the BPD Label” – I originally wrote that BPD has value as a label allowing people to find help and support. My thinking here has changed, such that I would now strongly endorse only the second half of the article – i.e. starting with “Why I Do Not Believe in BPD.” As I’ve read more about how psychiatric diagnoses oversimplify people’s stories, fail to meaningfully address the causes of people’s problems, and lack scientific validity, I’ve become increasingly reluctant to attach value to the label “Borderline Personality Disorder”.

Formulation: An Alternative to Diagnosis

Returning back to Emma’s case, if labeling her with BPD is not helpful, how might she be understood instead?

The Formulation approach, which has been pioneered by mental health workers in the United Kingdom, would offer something like the following:

“Emma, you’re obviously in a lot of pain right now. From what you’ve told us, things have been incredibly hard over the past few years, and you’re not able to rely on your mother for emotional support. The way your father treated you has also had an incredibly powerful negative influence. Given your history, you must feel incredibly alone, and it’s no wonder that you feel hopeless, scared, and abandoned. Your behaviors of purging and cutting yourself make sense; after the trauma you’ve experienced, anyone might react this way to manage their overwhelming feelings.”

“Although it’s difficult, we feel that your situation is far from hopeless. But to feel better, you’re going to need help. You may benefit a lot with support from someone who can understand your story, assist you in managing your current feelings, and help you find practical ways to improve your current life. We have therapists who have successfully helped people with similar family histories to yours, and when you come to feel better and leave the hospital, we can refer you to an outpatient therapist who can continue to help you.”

Differences Between Diagnosis and Formulation

Obviously, this approach is starkly different from the traditional psychiatric approach. Firstly, Emma is not diagnosed with anything – the terms “Borderline Personality Disorder” or “BPD” are never mentioned. Rather, her symptoms are understood as perfectly logical reactions to the trauma she has experienced. In that way, Emma can start to make sense of what has been happening to her, and she will be less likely to feel crazy or defective. Emma’s past history and present circumstances are used to create a narrative explaining her present problems.

Secondly, a message of hope is strongly promoted, with the idea being that recovery is likely if Emma receives effective support. “Illness” and “disorder” are never mentioned as causes of her problems; therefore, Emma is not led to feel that there is something innately and irreparably wrong with her brain. Instead, Emma is told that her personal history matters, and that understanding how it relates to her presenting problems can help in managing her distress and improving her life.

Obviously, these approaches are poles apart, and might be considered black and white examples of how an actual mental health worker would deal with a patient such as Emma. Nevertheless, I have read about many people who are treated similarly to the first example, in which a psychiatrist diagnoses them with a mental “disorder”, while completely failing to understand the individual as someone with a history contributing to their problems. In my opinion, this traditional psychiatric approach is destructive to and precludes realistic hope.

Lucy Johnstone and Formulation

I must give much credit here to Lucy Johnstone, a British clinical psychologist whose writing on formulation inspired me. Here is an excerpt of her viewpoints on traditional psychiatry and the destructive effects of psychiatric diagnoses:

“Psychiatric diagnosis underpins the whole biomedically-based model of mental health. Any science needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge. If this cannot be established, the whole model breaks down and all psychiatry’s other functions – indicating treatment, carrying out research and so on – will be fundamentally undermined.”

“ ‘Diagnosing’ someone with a devastating label such as ‘schizophrenia’ or ‘personality disorder’ is one of the most damaging things one human being can do to another. Re-defining someone’s reality for them is the most insidious and the most devastating form of power we can use. It may be done with the best of intentions, but it is wrong – scientifically, professionally, and ethically. The DSM debate presents us with a unique opportunity to put some of this right, by working with service users towards a more helpful understanding of how and why they come to experience extreme forms of emotional distress. We already have a situation where the strongest defence of DSM is: ‘We know it’s flawed, but it’s the best we have – what could we do instead?’ The simple answer is, ‘Stop diagnosing people.’”

These quotes come from the following source: http://www.madinamerica.com/2013/01/time-to-abolish-psychiatric-diagnosis/

Lucy Johnstone’s positions are very close to my thinking on the pseudo-diagnosis of Borderline Personality Disorder. To promote hope in people who have been severely traumatized and have great difficulty managing their emotions, perhaps it would be helpful to stop diagnosing them as “borderline.” Instead, we could understand them as individuals with unique histories that have contributed to their current problems, while encouraging them that they have strengths that can lead to recovery.

And here are some of Johnstone’s thoughts on “Formulation” specifically, in this case related to a person labeled as “psychotic”:

“In Britain, formulation is considered to be the core skill of the profession of clinical psychology… Formulation can be defined as the process of co-constructing a hypothesis or ‘best guess’ about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It draws on psychological theory and evidence in order to suggest the best path to recovery.  Unlike diagnosis, it is not about making an expert judgement, but about working closely with the individual to develop a shared understanding which will evolve over time…”

“We can see that the formulation is personal to (the patient), and helps to make sense of her experiences… It suggests an individual pathway forward, which will probably include developing a trusting relationship with a worker or therapist, learning ways to manage and cope with her voices, perhaps gaining support from others with similar experiences, and talking through her past. All of this is in stark contrast to the messages of shame, damage, hopelessness and despair that are conveyed by a diagnosis, and that too often lead with tragic inevitability to medication, admission and a lifetime career as a psychiatric patient.”

Source: http://www.madinamerica.com/2013/01/thinking-about-alternatives-to-psychiatric-diagnosis/

When Belief in the System Fades

In my view, psychiatry and its zoo of imaginary diagnoses militate against hope, personal meaning, and understanding. Psychiatry’s diagnosis-based ideology could be likened to a precariously perched house of cards. As more people understand that diagnoses like “Borderline Personality Disorder” are scientifically invalid, they may increasingly question the medical model underlying them. Over time, increasing numbers of patients and professionals may become unwilling to accept these labels. At a certain point, belief in the current system – the ideas that psychiatric diagnoses are real entities, that they can truly explain a person’s emotional problems, and that medication should be the first line of treatment – may fade and then collapse.

The vested interests of psychiatry will inevitably resist these changes because of the threat they pose – to making billions of dollars for drug companies, sustaining psychiatrists’ high incomes, and maintaining the fiction of psychiatrists as authorities who can diagnose emotional “disorders”. As Macchiavelli implied, the old order profits from defining reality in a way that benefits it, and some people may have trouble even considering that emotional problems could be understood in a radically different way.

Nevertheless, it is my hope that people will be open to the following idea: that promoting hope and restoring meaning for those suffering from the symptoms associated with “Borderline Personality Disorder” might be better achieved in many cases without labeling people as BPD. If some people still find benefit from being labeled as borderline, then so much the better. People ought to be free to use what works for them. But if other people are helped more by a “formulation”-like approach, one which connects their symptoms to their personal history and life circumstances without labeling them as having an “illness”, then perhaps we should shift our mental health practices in this direction. There might be still other approaches that work better for some people than formulation.

These ideas, some of which may seem confusing, relate to the arguments I have repeatedly made in previous articles: that BPD is an invalid and unreliable diagnosis, that no biological or genetic basis has been found for BPD, and that the medical model approach with its emphasis on medication is not useful for many people. For more information, the reader is again referred to the articles linked to above and their links to other websites.

The Idea of a Borderline Spectrum

However, part of me remains sympathetic to the idea of a borderline spectrum of emotional problems, which does not mean that BPD is a literal psychiatric illness. Instead, it means that people with similar-appearing emotional struggles as adults can be understood as using similar psychological defenses (e.g. splitting and projection), resulting from related histories of neglect and/or abuse. In this model, people and their problems are understood as existing along a continuum of functioning and symptom severity, and they are not understood to have the same “disorder”.

This spectrum-based model may have some value in allowing people to relate their emotional problems to other people’s (similar) problems in a meaningful way, and in allowing treatments to be developed for similar-appearing emotional problems that might be called part of a “borderline” spectrum. However, this idea conflicts with some of what I have written earlier about the lack of validity of the borderline concept per se. As can be seen from the trouble I’m having writing about it, it can be quite tricky to discuss emotional problems without using labels!

To conclude, it is fascinating how the words we choose to describe emotional problems, along with the theoretical models we base them on, are such powerful influences on our thinking and feeling about what is possible for us. I would be interested in what others think about what makes hope realistic, about formulation as an alternative approach to diagnosis, about the (lack of) validity of the medical model of BPD, and about the idea of “borderline” symptoms as occurring along a spectrum. Please feel free to share your views in the comments!

#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.

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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!

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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

#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

#16 – An Eastern Approach to Recovery: Lao Tzu, Sun Tzu, and BPD

Below are five quotes from the ancient Chinese philosopher Lao Tzu, author of the Tao Te Ching.

Please consider them first for their beauty and their applicability to any human being. I will then suggest ways in which they relate to the person recovering from Borderline Personality Disorder.

1. “Being deeply loved by someone gives you strength, while loving someone deeply gives you courage.”

2. “At the center of your being you have the answer; you know who you are and you know what you want.”

3. “The snow goose need not bathe to make itself white. Neither need you do anything but be yourself.”

4. “If you do not change direction, you may end up where you heading.”

5. “Those who have knowledge, don’t predict. Those who predict, don’t have knowledge.”

Lao Tzu was probably an amalgam of several Chinese philosophers from the early centuries BC. As a symbolic figure, he is regarded as the father of the religious and philosophical movement called Taoism.

A statue of Lao Tzu in China

A statue of Lao Tzu in China

Some fundamental ideas of Taoism include: feeling contentedly at one with the “Dao”, which is an unseen, transcendent force flowing through all things; reaching a state of freedom from earthly desires called “wu wei”, which can be translated as “flowing with the moment” or “not acting”; and a return to nature. Taoism’s emphasis on inner peace make it an interesting philosophy for people with borderline issues who need to develop self-comforting capacity.

tangyin5a

A Taoist painting illustrating Taoism’s focus on nature and personal contentment

During the arduous years of getting better from BPD, I encouraged myself using quotes like these. They helped create a sense of purpose and motivation. I’ll discuss the quotes above one by one:

1. “Being deeply loved by someone gives you strength, while loving someone deeply gives you courage.”

This first quote implies the reason why borderlines feel emotionally weak. They do not feel truly loved, nor can they trust other people deeply. Being dependent on and vulnerable toward another human being is the most crucial experience a borderline needs to grow emotionally. It is trust in another person that leads to feeling deeply loved. This was described in the phase of “Therapeutic Symbiosis”, in article #10 on this blog.

I can attest that feeling loved as a person was the critical ingredient that helped me become non-borderline. It was a feeling I first reached in psychotherapy and secondarily with several trusted friends.

After one feels loved for oneself, one can then love others, and this gives courage. Loving someone else deeply makes one feel that one is truly alive, that nothing can stop you. It lessens the fears of failure, aging, dying, and unfulfilled potential.

2. “At the center of your being you have the answer; you know who you are and you know what you want.”

This is a lovely quote, but again not something that borderlines start with – they don’t know who they are. But at the center of their being, they have the answer – their innate desire to get better, to be loved, and to feel fully human.

This again relates to quote #1. Love, trust and dependence on other people is the simple answer to the question: What allows a healthy child, or adult borderline, to grow and become emotionally healthy? Finding the answer to this question allows borderlines to develop a personal identity, to know who they are and what they want.

After my abusive childhood, the awareness dawned on me that I fiercely desired to be loved and cared for. Following this desire led me to attend psychotherapy and support groups, to make new friends, and to take risks. These resources allowed me to grow into an individual with an identity, to know who I am and what I want. It’s really true what Lao Tzu said – in my heart I always knew what I needed to get better. The challenge was taking the risks, fighting through fears, and overcoming psychic defenses to reach human help and love.

3. “The snow goose need not bathe to make itself white. Neither need you do anything but be yourself.”

This quote is attractive in the simple self-acceptance it implies. In my late teens and early 20s I hated myself. On the one hand, I felt pressured to achieve in academics, sports, and work so that others would like me. On the other, I believed my personality and appearance to be unlikeable and unattractive, and so never felt genuine or spontaneous. Instead, I was always trying to mold myself into what other people wanted.

How different I am today! I’m not afraid to say what I think, and don’t adapt myself for anybody. I am what I am, and if people don’t like that, too bad. I take delight in being myself.

This quote represents the ultimate ideal of self-acceptance that human beings, including borderlines, can aspire to. Like the snow goose which is naturally white, you don’t have to do anything to be yourself. Again, to approach this ideal, borderlines need the experience of being loved and accepted by an outside person, so that they can adopt the same attitudes toward themselves.

In article #15 on Gerald Adler, and in article #10 on Seinfeld’s four phases, it was discussed how self-acceptance – based on internalizing and believing the positive support of another person – is crucial to becoming non-borderline and developing genuine psychological stability.

4. “If you do not change direction, you may end up where you heading.”

This obvious but humorous quote really strikes home. It reminds me of the old-timers in my 12-step group who used to say, “If nothing changes, nothing changes,” and “Doing the same thing over again and expecting a different result is the definition of insanity.” Hard experience has taught me that transforming oneself  – while very doable – requires a lot of work and time, plus a willingness to take risks and try new things. Radically changing one’s emotional status quo is not comfortable, but it’s much better than stagnantly staying in an unhappy place. This was discussed more in post #14, about how risk-taking promotes recovery in BPD.

5. “Those who have knowledge, don’t predict. Those who predict, don’t have knowledge.”

This is true wisdom! A wise person understands how complex, ambiguous, subjective, and unpredictable the world is. Therefore, they don’t try to predict exactly what will happen to themselves or others.

While it can be fascinating to make predictions, such predictions, especially about mental illness, ultimately demonstrate a lack of knowledge. If prognosticators appreciated how people are extremely “complex” systems (influenced by many unpredictable sources of input) rather than “linear” systems (influenced by a limited number of clearly known variables), they would show more restraint.

I learned much about this subject from reading Dan Gardner’s book Future Babble. Two of his points stand out. First, the statistical study of past predictions made in various fields, including economics, politics, sociology, medicine, etc. indicate that the more certain someone is about a given prediction, the more likely they are wrong. Gardner thus warns the reader against trusting people who seem very sure of their predictions. He argues that those who think about a range of possible outcomes and speak in terms of ambiguity and uncertainty are more likely to be correct.

Second, Gardner showed how astonishingly quickly predictions can go wrong if even one factor inside the complex system unexpectedly changes. For example, with the weather, if the moisture level, cloud cover, wind direction, or one of dozens of other factors shift slightly, the whole outcome can totally diverge from the original prediction.

This is why human life courses are so difficult to predict over the long term. Human beings are not balls rolling down a hill whose paths can be precisely laid out! 🙂 They are complex systems like the weather, subject to millions of influences that we cannot map out in advance.

I have no respect for therapists who try to predict the outcome (via a “prognosis”) of people with Borderline Personality Disorder. Human emotional problems are way too complex to be medicalized like a physical disease. How someone does emotionally depends on literally millions of personal and environmental factors. Thus over the long term, we can only suggest factors that tend to promote success or hinder progress, while remaining humble about our lack of foreknowledge.

It is not only love and dependence, but aggression, cunning, and taking action that drive recovery from BPD.  With that in mind, I love reading a Chinese philosopher of a very different nature. Here are quotes from Sun Tzu, author of “The Art of War”:

1. “The general who wins a battle makes many calculations in his temple before the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat.”

2. “The reason the wise general conquers the enemy and his achievements surpass those of ordinary men is foreknowledge.”

3.  “If you know the enemy and know yourself you need not fear the results of a hundred battles.”

4. “What is of supreme importance in war is to attack the enemy’s strategy.”

5. “The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim.”

6. “Let your plans be as dark and impenetrable as night, and when you move, fall like a thunderbolt.”

Sun Tzu was a Chinese military general and philosopher living around 500 B.C. during a period of warring kingdoms. In this era, rivals groups fought constantly over territory, and survival was a zero-sum game in which hesitation, unpreparedness, and lack of knowledge proved deadly.

sun-tzu

An artist’s impression of Sun Tzu

Sun Tzu recorded many of his strategic military insights in “The Art of War.” His writing emphasized the psychology of how to wage war, especially how to outmaneuver one’s enemy by understanding his emotional strengths and weaknesses. Sun Tzu believed that both objective (e.g. the physical landscape; the resources of each side) and psychological (e.g. the enemy’s mindset) considerations needed to be taken into account when conducting a military campaign.

Sun Tzu emphasized that a military strategy was not a fixed, unchanging list of actions to be followed; rather, the reality of war dictated that conditions and thus strategy constantly evolved. This meant that leaders had to be ready for the unexpected situations that arose when their plans interacted with the enemy’s plans in unpredictable ways.

A battle from the Warring States period of ancient China

A battle from the Warring States period of ancient China

Sun Tzu’s viewpoint has Macchiavellian qualities, in that it promotes doing whatever is necessary to survive and triumph. This is familiar for me, since I often felt forced to do “whatever it took” to survive the emotional war I was fighting after being diagnosed with BPD. I was somewhat ruthless back then, and am still a bit that way, as described in article 12, “Cracking the Borderline Code.”

So, how can someone apply Sun Tzu’s quotes to fighting for recovery from Borderline Personality Disorder? Here are his quotes again:

1. “The general who wins a battle makes many calculations in his temple before the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat.”

As I recovered from BPD, this insight helped because it indicated that if I did not plan ahead, I was unlikely to prevail in the long multi-front war against BPD. I had studied many books about BPD, seeing which patients improved and which did not, analyzing which factors promoted recovery and which hindered it. I plotted out a rough plan to overcome Borderline Personality Disorder in an analogous way to how a general calculates a military strategy.

From my reading, I knew the primary goal was to develop dependent, supportive relationships in which I could be “reparented”. This process would develop the positive self-and-object units (see article #9, “A Fairbairnian Approach to BPD) and develop healthy ego functions to eradicate the borderline symptoms. I also knew that medication was ineffective at achieving these goals and so I stopped taking it, as indicated in article #13 on medication. Instead, I researched psychoanalytic-psychodynamic therapists and found one who had experience and success treating borderline conditions.

I started going regularly to therapy and continued for several years. To supplement this supportive relationship, I attended 12-step groups and developed friendships with people like Gareth, the older man who helped me work through my childhood trauma as described in Article #2. I was quite conscious about working to trust and depend on other people, because my research and experience indicated that it was only through building long-term positive relationships that I could recover.

So I had a long-term plan, and it worked. Today I enjoy my relationships, am successful in my work, and have no remaining borderline symptoms. Like the general in SunTzu’s quote, I made many calculations in the “temple” of my mind before beginning my battle against BPD in earnest, and they led to victory.

2. “The reason the wise general conquers the enemy and his achievements surpass those of ordinary men is foreknowledge.”

This quote is similar to the first. It could be viewed as a bit arrogant and presumptive to apply this to BPD. In truth, I did not know for sure that I would recover, or exactly how things would work on the journey.

What Sun Tzu probably means is that the successful general is better informed than most people from the outset– in this case, about the terrain, the psychology of the enemy, the enemy’s positions, strengths, weaknesses, and how to engage him. He studiously prepares in order to know as much as possible about what is likely and how the enemy might act. It doesn’t mean the general is clairvoyant and can see the future, because as indicated in Lao Tzu’s quote about prediction, that is impossible. But the general plans for a range of scenarios and is as well-informed as possible.

As indicated in other posts, education about BPD and how it is effectively treated is crucial. To me, knowing a lot about BPD and how others recovered from it is the closest we can come to “foreknowledge” about what facing BPD will mean for us. I benefitted greatly from studying many books, talking to therapists, and reading websites and blogs about BPD. Educating oneself is in my opinion the “wise” thing to do with BPD and it provides a better chance of getting the results you want in recovery.

3.  “If you know the enemy and know yourself you need not fear the results of a hundred battles.”

This is another similar quote to the first two. It is of course simplistic to apply these quotes to a complex emotional condition, but it can be inspiring and motivating.  Knowing “BPD” means understanding how the condition works in depth. Borderline defenses like splitting and projection are initially powerful, tenacious, and deceptive mechanisms. It is useful to understand how they work, and I intend to write future posts on how splitting and projection/projective identification operate.

The early part of “knowing yourself” when dealing with BPD, in my experience, was understanding how defenses based on past trauma (“the enemy”) were constantly coloring how I viewed the external world. They tricked me into distrusting and rejecting other people’s help, since I misperceived everyone in my present day world as untrustworthy like my father.

With a better understanding of how my mind was working, I felt more confident in stopping my defenses from recreating past trauma in my present day life. Although I didn’t win every battle at first, I felt more confident about defeating BPD in the long term.

4. “What is of supreme importance in war is to attack the enemy’s strategy.”

This is more relatable to BPD than one might think. The “strategy” of defenses in BPD is that they cause a person to negatively distort the external world, tragically recreating their traumatic past into the present. It renders the borderline unable to take in support from other people in sufficient quantities to develop a healthy sense of self. In Article #15, Adler described the necessity of confronting psychic defenses which “block” the development of positive introjects, and in Article #10 Seinfeld analogously described how the bad internal object situation prevents the borderline from internalizing the therapist as a positive new person.

Although it’s a bit simplistic, and to repeat from the last quote, these defenses which “trick” the borderline into rejecting human help are “the enemy.” When I was borderline I had two selves – a “healthy” self which wanted to trust others and get better, and a “trauma” self which was emotionally frozen at the time of my physical abuse, distrusted others, and refused to believe that people cared.

I became able to track the operation of the “trauma” self and to reject its deceptive attempts to make me distrust others. I did this by understanding how splitting and projection pulled the wool over my eyes, so that I perceived emotionally only peopl’s negative aspects and refused to take in their good sides. I countered this tendency by putting myself in more and more “good” situations like therapy, 12-step groups, and with supportive family and friends.

Over time, I began to find more and more of the good in other people and in myself. Eventually others’ good intentions started to break through my resistance. I gradually learned that truly good people did exist, that it was safe to depend on others, that I was worthy of love, and so on. I attacked the strategy of the BPD defenses which were blocking my progress, and as Sun Tzu indicated, attacking the enemy’s strategy is paramount.

5. “The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim.”

I relate this quote to Article #14, “How Risk-Taking Promotes Recovery From BPD.” It’s a bit of a harsh description (poor victim!) but it emphasizes how good decision-making is decisive and timely. In the “Risk-Taking” article, I described how changing therapists, stopping medication, moving home temporarily after college, asking for help from Gareth, etc. were all situations in which I had to take decisive action. Over the years I’ve become more and more decisive about “pulling the trigger” on things that are in my best interest. The way the falcon quickly swoops down on its prey is a good metaphor for the way a tough decision must be made decisively to be effective.

There is only a very loose correlation between this quote and BPD, but effective decision-making is important when dealing with BPD or any other serious challenge.

6. “Let your plans be as dark and impenetrable as night, and when you move, fall like a thunderbolt.”

This quote doesn’t really relate to BPD. I just put it on here because it sounds cool! I’m a big fan of action movies, spy thriller novels, and adventure video games, and it’s too bad we don’t have Sun Tzu around to write snappy dialogue for them.

I hope this article gives the reader a different perspective on how to think about BPD reccovery. There are many useful approaches to healing from trauma, and we should not hesitate to use the insights from many  different people and cultures to help us.

The_Art_of_War-Tangut_script

Sun Tzu’s “The Art of War”