Tag Archives: borderline causes

#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

#4 – Is Borderline Personality Disorder Caused by Faulty Genes?

This site aims to consider contentious questions about BPD head on. In that light, I will address the “broken brain” theory of borderline personality disorder. What is this theory?

The Broken Brain / Genetic Causation Theory of BPD

The broken brain theory states that children who grow up to become borderline are born with a specific constitutional weakness based on unfortunate genes passed down to them by their parents. Supposedly these children, unlike healthy individuals, are constitutionally unable to regulate their emotions from birth. Their severe emotional problems therefore have little to do with environmental influences, and are instead a consequence of bad genes which prevent their limbic system from functioning properly. This idea is discussed on many online forums about BPD. Although I find it difficult to take seriously, I will discuss this notion at length because many borderlines and their family members believe it.

Cui Bono?

It is useful to first consider the possible benefits of this belief before contesting it. “Cui bono?’ is a Latin phrase meaning “Who benefits?”, and in its idiomatic form it implies the existence of a hidden motive. Understanding how pharmaceutical companies, psychiatrists, and family members benefit financially and emotionally from the promotion of such a belief system is important in understanding how the belief system develops.

The benefits of promoting a genetic basis for BPD include:

1) Simplification – Viewing the often-difficult person with BPD as having a broken brain relieves that person’s therapists and/or family members from having to consider them as a complex human being with a unique history that has contributed to their condition. The simple idea that their brain doesn’t work replaces an in-depth understanding of the borderline as an individual. This way of thinking crucially eliminates the possibility that a broken brain might be partially or wholly the result, rather than the cause, of their past and present emotional problems. In other words, it seeks to minimize the role of the environment and past interpersonal relationships.

2) Relief of Guilt and Shame – The broken brain theory relieves family members from feelings of guilt or shame about how they related to the borderline individual in the past. If the borderline’s problem is genetic, nothing different could have been done to stop them turning out this way. For a formerly abusive and/or neglectful parent, it might be a great relief to think that their child’s problems are due to genetic bad luck, rather than to physical abuse and lack of love. For an ineffective therapist, it might be comforting to feel that the patient’s continued suffering and seeming inability to change is due to misfiring neurons, rather than the therapist’s own lack of knowledge about how to treat BPD.

This is not to blame the parents. Parents who mistreat and neglect their children, as parents of borderline-children-to-be often do, usually have their own severe emotional problems passed down to them from their own parents. They cannot be held morally responsible for continuing a generational legacy of poor parenting that often began before they were born.

3) Financial Benefit – Pharmaceutical companies make billions of dollars by over-medicalizing BPD and hundreds of other “disorders.”  It is well known that the Diagnostic and Statistical Manual of Mental Disorders continually expands to encompass dozens of new mental health “disorders.” In the last few decades, these companies have made massive gains in sales of their products, developing pills for patients with almost every emotional problem imaginable.

In this light, promoting the idea that Borderline Personality Disorder is caused primarily by genetic and biological factors, and thus requires long-term medication to treat its symptoms, makes financial sense for drug companies and psychiatrists. It is part of a long-term movement in the US and global mental health industry. Pharmaceutical companies make tens of billions of dollars annually by promoting the pharmaceutical treatment of hundreds of supposed emotional disorders. Psychiatrists make hundreds of thousands of dollars annually for prescribing pills which have dangerous side effects and often do not work.

It is no surprise then that these companies and psychiatrists are heavily invested in promoting the genetic/biological-causation viewpoint, since it supports their income and continued existence. Even if the validity of certain diagnoses and treatments are doubtful, Big Pharma attempts to profit from them anyway. If one doubts that Big Pharma companies would distort the truth to protect their profits, one should look at how Big Tobacco companies lied on a massive scale about the true harm of tobacco during the 1970s and 1980s.

(Aside: I was recently entertained to read about the new disorders in DSM V. Do you have Hypoactive Sexual Desire Disorder, Caffeine-Induced Sleep Disorder, or Disruptive Mood Disregulation Disorder? Do you think that your psychiatrist can reliably diagnose these disorders, and prescribe you the appropriate pills to treat them? If yes, then you should be a supporter of DSM V!)

Evidence for the Genetic Basis of BPD – The Problem of Diagnostic Validity and Reliability

So, is there good evidence that Borderline Personality Disorder is caused by a broken brain, i.e. by genetic and hereditary factors?

To begin addressing the genetic argument, it is useful to note that in scientific research, the burden for proving a theory is placed on the person who proposes it. In other words, a theory is not accepted until it can be proven via repeated, observable experiments that it has validity and reliability. Validity means that a given result is true, accurate, and meaningful, and reliability refers to the notion that a process can be consistently repeated and yield the same result.

To start with, a valid, reliable theory about a mental health disorder should involve a disorder which can be reliably diagnosed. On this measure, the broken brain theory of BPD is a failure. The problem is that BPD itself, along with most other mental health “disorders”, is not a a valid or reliable diagnostic entity. Rather, the entire notion of BPD is built upon a fragile foundation, involving subjectively assessed traits which no brain scan, blood test, or gene test can reliably diagnose.

Since there is no physical test which can reliably diagnose BPD, therapists must use their subjective judgment about whether or not a person meets at least 5 out of 9 DSM criteria. As noted in the books listed below, different therapists often disagree as to whether the same individual has a given mental health disorder, and this certainly applies to BPD. Where does one draw a line before which one is non-borderline or even healthy, and beyond which one suddenly has BPD?

When I began to consider this question, BPD’s weak position as a scientific diagnosis became apparent. Are there great therapists who can reliably detect when someone has just enough fear of abandonment, or just enough evidence of black and white thinking, or just enough self-destructive acting-out, for these traits to collectively qualify them for the clinical picture needed with a BPD diagnosis? Who decides exactly what degree of poor self-esteem, how severe of an identity disturbance, or how much splitting, counts as a trait contributing toward a BPD diagnosis? How does one scientifically and reliably include or discount such symptoms in all their different degrees and presentations?

If these questions cannot be reliably answered, the whole notion of establishing a genetic basis for BPD is undermined. If mental health professionals cannot reliably diagnose who has BPD at a given time, how can researchers reliably test what causes it? How can one be sure that the people one chooses for testing do have BPD, and they they continue to have it throughout one’s experiment? It makes little sense to test a theory based upon a condition which has not been proven to exist as a discrete entity, and which cannot be reliably diagnosed.

This argument might strike some as outrageous, crazy, or outside the norm. If so, that is fine, since I am merely stating my opinion. My view of BPD is unconventional, but that is not a bad thing. Rather, it is something that has helped me. I do not think that BPD is a useless concept. Instead , I view BPD as a developmental metaphor – one that symbolizes the lower part of a continuum of human functioning stretching between emotional health and psychotic illness, rather than a scientifically valid, reliable diagnosis. I understand why some people simplistically believe that BPD exists as a discrete disorder that one “has” just like one has diabetes or cancer. But that is not my viewpoint.

Can Brain Scans Prove a Genetic Basis for BPD?

Back to the issue of whether the genetic basis for BPD has been proven. Let us assume for the sake of argument that BPD is a valid diagnosis that can be tested scientifically. One possible way of proving a genetic basis for BPD might be to identify the existence of long-term abnormalities in the brains of those diagnosed with BPD when compared with healthy controls. Both groups – those who grew up to become borderline, and those who grew up to become healthy adults – would have to be studied from a young age, with their brains scanned repeatedly to detect changes in structure and function over time. Such a study would have to be massive in scale and timeframe, relying on repeated, costly brain scans over many years. To my knowledge, no one has yet attempted such a study for BPD.

Even if such a study were made, it would face the thorny challenge of conclusively proving that differences in observable brain function between borderlines and healthy control subjects were the cause of past and current emotional problems, rather than the result of past environmental problems. It would have to demonstrate that similar environmental  conditions (i.e. a similar amount of traumatic childhood experience) existed both for those who became borderline and those who remained healthy. Otherwise, the presence of environmental trauma could be a confounding factor, as the greater contributor in the cases of those who became borderline.

One might say that it is enough to simply scan the brains of borderlines versus non-borderlines, and identify differences that prove a genetic basis. This is scientifically baseless. Identifying present-day differences in the brains of borderlines and non-borderlines does nothing to prove the degree to which genes and/or past environmental influence caused these differences. This would be a circular argument.

Twin Studies

Several recent studies have indicated that a genetic basis for BPD has been established based on studies of identical versus fraternal twins. These studies usually find a higher concordance (diagnosis rate) for BPD among identical twins, who share 100% of their genetic material, versus fraternal twins, who share 50% of their genetic material.

However, such studies have come under severe criticism, with detractors asserting that they suffer from faulty assumptions and research methods. The most serious issue is the Equal Environment Assumption (EEA). The EEA, which is crucial to the twin study method, means that researchers assume the environments of identical twins and fraternal twins to be extremely similar, or at least not different enough to influence a study’s outcome. The problem with this is that in-depth observational analysis of twins’ home environments have undermined this assumption, a fact many twin researches have already admitted. It is clear that identical twins are often treated more similarly, pushed to engage in more similar activities, and experience a closer psychological bond with each other compared to fraternal twins. This environmental difference could easily confound studies,  accounting for the variation in rates of diagnosis for disorders including BPD.

Recently, twin researchers have attempted to take the position that identical twins’ genes cause or elicit more similar treatment from the environment, and that genes therefore explain the more similar environment of identical as compared to fraternal twins. In this way, the researchers maintain that the EEA is still valid, since genes are supposedly still the cause of observed environmental differences in how identical twins are treated, rather than these differences stemming from any choice by people in the external environment.

To me, and many other critics, this position relies on circular reasoning and is extremely weak. It is circular reasoning because it brazenly asserts that its conclusion proves its premise – i.e. it assumes to begin with that genes are the cause of the more similar treatment of identical twins versus fraternal twins. It then states that therefore the environment itself is not the cause of the more similar treatment of identical as compared to fraternal twins. In fact, without such circular reasoning, that “fact” has not yet been proven. For some people, this might be hard to wrap one’s mind around, but it is important to understand in order to undermine the basis of twin researchers. Without the Equal Environment Assumption, the whole foundation of twin research collapses.

There are many other problems with twin research, including small sample sizes, unreliable diagnoses of disorders under study, and investigator bias. Anyone seriously considering twin studies as indicative of a genetic basis for BPD should read the work of Jay Joseph, the preeminent critic of twin studies worldwide. Josephs’s books, The Missing Gene and The Gene Illusion, mercilessly expose the weaknesses of twin studies. Joseph’s work is notable for its meticulous attention to detail and to the importance of the scientific process.

Of course, even if twin studies themselves were to be valid, they would still face the problem, with Borderline Personality Disorder, of studying a diagnosis that has not been demonstrated to be scientifically valid or reliable. Therefore, twin studies of BPD face the Scylla and Charybdis of the severe methodological problems of twin research on the one hand, and the inherent unreliability of the BPD diagnosis on the other.

Views of Present Day Psychiatrists, Therapists, and Family Members

Psychiatrists and family members of borderlines often promote the idea that Borderline Personality Disorder is caused by a broken brain, without relying on any experimental evidence that proves that notion. In my view, the more plausible reality is that the symptoms collectively called BPD arise from a complicated, long-term interaction between the individual and their environment. In this view, constitution and genes are not unimportant. A person’s genetic endowment affects their level of vulnerability to stress and trauma, and therefore their vulnerability to developing “borderline” symptoms. But genetic endowment has not been proven to be the primary force that causes these symptoms, as in the broken brain theory of BPD.

Many more evolved psychiatrists and therapists actually subscribe to this dynamic or broader view, in which both environment and genetic endowment are important. Such therapists believe that the relationship between nature and nurture is complex, and therefore the proportional influence of each varies from case to case. In my experience, the therapists who have worked the most extensively with borderline individuals give a heavy weighting to the influence of environment trauma versus genetic contributions, while still acknowledging the importance of both. In my personal opinion, the environment is usually more important than genetic endowment in causing severe emotional problems. Everyone has a bias, and that is mine. Without the severe physical abuse and emotional deprivation that I endured over many years as a child, I highly doubt that I would have been diagnosed with BPD at age 18.

Many psychiatrists without in-depth therapy training, who do not understand the psychodynamic and/or psychoanalytic viewpoints on emotional illness and how to treat it, believe that “it is all biological”, regarding the environment as relatively important. Genetic researchers in universities and foundations sometimes subscribe to an almost entirely genetic viewpoint on mental illness. These researchers rarely work with or even encounter mentally ill people in person like therapists do. To me, their position is difficult to take seriously. However, given that their academic funding for research often depends on their promoting a genetic basis for emotional problems, with Big Pharma companies expecting them to find genes that cause the conditions under study, it is easy to see why they might cling to flimsy evidence for genetic causation.

The extremists who promote purely or mostly genetic theories of BPD need to be called out and discredited. They should not be given serious attention until they provide proof that BPD can be reliably diagnosed, along with experiments that clearly separate the causes and effects of brain-based biological differences.

The Tragic Effect of Genetic Theories of Mental Illness and BPD

The worst effect of genetic theories of BPD is to promote a sense of hopelessness in the person diagnosed with the disorder and their family. If the borderline has problems that are caused by a broken brain and bad genes, problems that can only be managed but not cured with medication, then they are doomed to suffer for life with a severe set of emotional problems from which deep recovery is not possible. This is often the underlying belief of biologically-based psychiatrists who treat BPD primarily using medication. As I have said elsewhere on this site, nothing could be further from the truth.

There are many great books that carefully consider the proof or lack thereof for gene-based theories of the etiology of mental health problems.  Some of my favorites are listed at the bottom of this page. My favorite author in this regard is Jay Joseph, the California psychologist who was noted above.

My Own Experience as a Refutation of Genetic Theories

Several years ago, my therapist told me that you can only truly know something if you experience it for yourself. At the time, this was a new idea for me, since I did not trust my own thoughts and feelings.  This statement came in the context of my starting to feel much better in several areas of my life, but having trouble believing in that feeling. I had trouble trusting my own progress partly because of my fear that if BPD were a hopeless, genetically-based condition, then my experience could not be real or would not last. My therapist encouraged me that if I felt better, that was real. Over time I came to trust my own experience more.

My own experience has been the best guide informing me about the validity of biological, genetically-based explanations of mental illness. The severe physical beatings that I received from my father, along with my mother and father’s inability to communicate love and make me feel secure, were massive factors in my development. They destabilized me emotionally as a young child and teenager, causing me to develop the symptoms that comprise Borderline Personality Disorder. I simply never had the chance to develop a secure sense of identity, self-esteem, and healthy, intimate relationships with my parents and peers. In its place, I was forced to use the primitive defenses of denial, avoidance, projection, splitting, acting out, etc. to defend against overwhelming fear, rage, and grief. The use of these defenses and my inability to trust others to help me as a teenager led me to develop all nine of the symptoms of BPD to varying degrees.

To me, it is obvious that genes and biology – while they are not unimportant – are not the primary causative factor for borderline symptoms and Borderline Personality Disorder. I understand why that might be hard to understand for those who have not experienced the symptoms and history of BPD. Although it is controversial, I believe that family members of borderlines are sometimes motivated by the oversimplification and the avoidance of guilt and shame that genetic theories of BPD allow for. If anyone has experienced a genuinely happy, secure childhood, and then gone on to inexplicably develop chronic, long-term BPD (and not just normal teenage angst), I would be morbidly fascinated to hear about that. However, I doubt that I will be hearing from too many people with that history, given the statistics on how frequently neglect and abuse are associated with the disorder.

In sum, I am proud to reject the idea that Big Pharma and many psychiatrists promote about BPD – the notion that it is caused primarily by biology and bad genes. My childhood experience of abuse, along with my successful recovery from BPD over the last 10 years, is all the evidence I personally need to conclude that the genetic theories are faulty and do not universally apply. Beyond my personal experience, the analysis above, which questions the validity of BPD itself and of the associated twin and gene studies, are more evidence that the issue of causation is not settled.

When it comes to those who promote genetic theories of the cause of BPD, people like me are their reckoning, here to end the borrowed time their theories have been living on.

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Further Reading

If you would like to learn more about the problems surrounding modern psychiatry, here are a few relevant texts. I bought these books used at Amazon for very low prices, often only $5-10 including shipping.

Saving Normal, – by Allen Frances – In this book, the former chair of the DSM Task Force fiercely criticizes the new DSM-V. Frances asserts that the DSM V, without any scientific proof, turns every possible aspect of normal emotional struggle into a new mental health diagnosis.

Mad Science: Psychiatric Coercion, Diagnosis, and Drugs – By Stuart Kirk and David Cohen. In this book, the authors assert that American psychiatry’s claims about mental health diagnoses are riddled with unscientific claims, faulty reasoning, and missing evidence.

Bias in Psychiatry Diagnosis – By Paula Caplan. Caplan cogently illustrates how therapists frequently make unreliable psychiatric diagnoses. Caplan shows how therapists often misdiagnose individuals based on gender and race, and how this can have serious adverse effects in the courtroom and workplace.

The Heroic Client – by Barry Duncan. While this book is mainly about a positive vision of the therapist-patient relationship, it contains a large section critiquing current methods of diagnosis and treatment based on the DSM and psychiatry.

Warning: Psychiatry Can Be Hazardous To Your Mental Health – by William Glasser. A brutal indictment of modern psychiatry, which lays bare its unscientific assertions and points the way toward a better, client-focused form of treatment.

The Missing Gene – By Jay Joseph. A fantastically-detailed exposition of twin research and all the unfounded assumptions it is based on.

The Gene Illusion – by Jay Joseph. Another devastating critique of twin research. Joseph’s books focus on schizophrenia, but his methods of reasoning are easily transferable to twin research which addresses BPD.

Some of Jay Joseph’s articles on twin research from 2013 and before are available for free here – http://jayjoseph.net/publications

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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