Tag Archives: borderline personality disorder healing

#29 – “The Borderline States” – An Essay by Lloyd Ross, Ph.D., Therapist with 40 Years’ Experience Treating People Labeled BPD

I recently emailed Dr. Lloyd Ross, a clinical psychologist from New Jersey with 40 years’ experience treating individuals labeled borderline. I asked him for his views on the DSM model of BPD, the causes of borderline states, what is the best treatment for BPD, and can it be cured. Here are highlights of his responses, with my emphases in bold:

Highlights of Lloyd Ross’ Viewpoints on BPD, excerpted from his essay below:

On therapists who don’t want to work with people labeled BPD:

Lloyd Ross: “To avoid their own discomfort, poorly trained therapists describe borderline individuals as untreatable. Well trained therapists do not have that opinion. Well trained therapists have done well with these individuals, provided the therapist knows both what to expect and what he is doing.”

On good outcomes for people labeled “BPD”:

Lloyd Ross: “With proper insight oriented therapy, people labeled as borderline do go out in the world and function quite well in relationships, employment, etc. Like the rest of us, the goal is not to be cured from some non-existent disease, but to simply resolve the issues in our development that stop us from functioning in a relatively comfortable manner.”

On BPD as a medical diagnosis:

Lloyd Ross: “(As a medical diagnosis) the only “borderline states” that have any validity for me are on the border of Mexico or Canada… In addition, there is absolutely no real science behind any of the DSM/ICD diagnoses.”

On how the word borderline can be useful:

Lloyd Ross: “To use the term “borderline” from a developmental point of view is very different… Using the term “borderline developmental issues” enables us to go back in time and try to help the individual to undo, modify, and soften development that did not go smoothly the first time around.

On the developmental approach to working with people labeled BPD,

Lloyd Ross: “Using this model, the therapist works toward a stronger continuum of emotional development so that a person can function in a more whole way. Borderline states are not a disease or medical issue and therefore, nobody is “cured.” People just learn to handle various issues in their lives in a smoother, more comfortable manner for them.

On suicide prevention:

Lloyd Ross: “According to Bertram Karon, Ph.D., one of the world’s most prolific researchers on effective psychotherapy with patients labeled schizophrenic, suicidal, and borderline, ‘The best suicide prevention is effective psychotherapy.‘ ”

On the value of medication in treating people labeled BPD:

Lloyd Ross: “The medication approach (anti-depressants and/or anti-psychotics) is useless in people with borderline, suicidal, and PTSD symptoms. In fact, anti-depressants are probably one of the major causes of iatrogenic (doctor induced) suicide in this country in the past 15 years, especially with individuals labeled borderline.”

On trauma as the cause of borderline states:

Lloyd Ross: “The cause of “Borderline Personality Disorder” as with all of the “made-up” psychiatric diseases, is trauma at various times and stages in a person’s development… The failure of all-good and all-bad perceptions to fuse is the genesis of all pathologically borderline states.

My Interaction with Dr. Ross

So (this is Edward writing again) these were my favorite parts of what Dr. Ross said about BPD; for the full context, see his essay below. I had originally found Dr. Ross because he is a member of ISPS, the International Society for Psychological and Social Approaches to Psychosis, with which I’m also involved. In my first email, I asked Dr. Ross for detailed answers to my questions about what causes BPD, what best treats it, is it curable, and how best to understand Borderline Personality Disorder.  I wanted to see how much his viewpoints agreed with mine, and to share an informative and hopeful professional viewpoint on BPD with readers of this blog.

In response, Dr. Ross decided to write a single essay incorporating his responses to all the questions. That essay, “The Borderline States” forms the main part of this post. I highly recommend reading it to see how a psychologist who’s worked with over 100 people labeled BPD understands the condition. To Dr. Ross, thank you for taking the time and for giving me permission to post your essay here.

For anyone wanting to know more about Dr. Ross, he is a leading member of the International Society for Ethical Psychiatry and Psychology (ISEPP), and is listed halfway down this page: http://psychintegrity.org/isepp-leadership/

LloydRoss1

Lloyd Ross, Ph.D.

Dr. Ross also features in a Youtube interview about helping people labeled schizophrenic here: https://www.youtube.com/watch?v=wyL0jjI93OI . I want to note that Dr. Ross did not edit this video (the silly cartoonish elements, which in my opinion detract from its message, were added by the filmmaker Daniel Mackler). But you can see from the way Dr. Ross talks that he is an experienced, committed therapist.

Lastly, I want to note that Dr. Ross’ viewpoints appearing on my site does not mean that he endorses or agrees with everything else on this site. His viewpoints are his own. Here is his full essay:

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THE BORDERLINE STATES

By Lloyd Ross, Ph.D.

During my 40 years as a clinical psychologist, I have worked with approximately 100 to 150 people who would be considered to fall into the developmental framework of what psychiatry, in its simplistic and arbitrary way, views as borderline. These people were seen by me for at least one year or longer, some multiple times per week, and others once per week. Some were also seen at multiple times in their lives with months or years separating periods of therapy.

Before discussing this topic, I would like to make clear the issue of psychiatric diagnoses of “mental disorders.” I am a clinical psychologist who was psychoanalytically trained from an ego-developmental point of view. I have been in full time practice for almost 40 years and have always avoided psychiatric diagnoses, as I see the various recreations of the DSMs/ICDs as nothing more than an attempt to medicalize things that are not medical to begin with (human behavior, experience, and development). On that basis, the only “borderline states” that have any validity for me are on the border of Mexico or Canada.

In addition, there is absolutely no real science behind any of the DSM/ICD diagnoses. All of them were developed in committee rooms inhabited by mostly elderly white psychiatrists, many of whom represented the financial interests of the pharmaceutical industry. When I do write down a DSM or ICD diagnosis for a patient, and only at a patient’s request, it is usually because they need it to submit their claim to an insurance company (Unfortunately, that is the way things are in this society). The diagnosis I use is almost always “Post Traumatic Stress Disorder,” for several reasons:

  1. It is the closest thing to a real diagnosis in the entire list of diagnoses, in that anyone who is having enough emotional difficulties to seek help has had personal trauma of some sort as one of the factors that caused their difficulties.
  2. From a developmental point of view, the stage of development we are in or approaching when trauma occurs is a good predictor of how, when, and where it will manifest itself in a person’s life.
  3. The term itself, “Post traumatic stress disorder,” is sufficiently vague and innocuous to the public to make the term less of a problem for an individual than terms such as schizophrenia, psychopathic or sociopathic personality or borderline personality disorder, none of which have any real scientific meaning.

I approach human (not medical) diagnosis as a strictly developmental issue. This is because of the influence of Margaret Mahler on my training, with some influence from Donald Winnicott, Edith Jacobson, Anna Freud, Renee Spitz, Heinz Kohut, and Ruben and Gertrude Blanck. I come primarily from Mahler’s framework and was supervised by her. Therefore, any real diagnosis that I do comes from an ego-developmental point of view.

The Causes of Borderline States

When looking at a detailed history of people commonly diagnosed by others as “borderline personality,” I and others have found that these people have experienced emotional trauma at around the time in development when children make and solidify their attachment to the mother figure. To be a bit more specific, it is associated with trauma during that time frame and there is always deprivation around that time frame also. I am sorry for making it such a complicated thing, but when you don’t simply slap a diagnostic label on somebody, but are instead dealing with a real live very unique individual and their complex developmental problems, the issues are no longer simple. In addition, to perceive a human being as literally being a diagnostic category—a “Schizophrenic” or a “Borderline” –dehumanizes that person.

The cause of “Borderline Personality Disorder” as with all of the “made-up” psychiatric diseases, is trauma at various times and stages in a person’s development. That is why taking a carefully detailed history of that person’s development, events in his life, and memories in his life is so important. All extreme mental states, whether with someone diagnosed as schizophrenic, borderline, neurotic, etc. which are meaningless terms, are the result of things gone awry or not having been negotiated at various stages in development, resulting in trauma.

Even if a child seems to progress just fine, if and when trauma occurs, it lingers or appears dormant. When, even years later, that trauma is reactivated by another trauma, that person seems to exhibit or feel the original trauma again without ever connecting the two. That is why I use the diagnosis “Post Traumatic Stress Disorder” with insurance companies, for everyone, and not just those who come for help. There is no human being that I have met who has never experienced trauma, although the ramifications for some are more disturbing than for others.

A Personal Example of Trauma

I will give you a vivid example of trauma in myself. From the time I was five years old, until I was ten years old, I was ordered by my parents to come home from school immediately, without lingering with my friends, to babysit my grandmother because I left school at exactly 3:00 P.M. and the lady who took care of my elderly grandmother left at exactly 3:00 P.M. My grandmother was a very nice roly-poly lady who only spoke Polish and Yiddish, was blind except for being able to see shadows, and was able to walk from her chair to the bathroom to the bed by feeling along the wall. I, on the other hand, did not speak Polish or Yiddish.

My grandmother was alone for the five minutes it took me to get home and I would run all the way because I was told that if anything happened to her, it would be my fault, a rather heavy burden for a five year old. I would sit with her in a second floor apartment with very little communication and stop her from trying to cook. I would lead her to the bathroom and to the bed so that she didn’t fall, and sometimes would make her tea, watching that she didn’t spill it on herself. Either my aunt or my parents would come home between 5:00 P.M. and 6:00 P.M., but quite often, they went shopping first or had something else they had to do, and I would be stuck with my elderly grandmother for two to five hours. Also, since she couldn’t see, she kept all the lights off to save money so the apartment was usually dark.

When I turned ten years old, I was offered a part-time job and because work was so important to everyone in the family, when I got the job, my babysitting for my grandmother was over. What I remember most about the babysitting was that everything was always dark and boring. One day, I was very bored, and I could hear my friends playing ball in the street below. I opened the window and sat on the ledge, playing catch with a friend who was in the street. Someone called the police because they thought I was a jumper and they yelled and screamed at me.

After getting three advanced degrees, and spending a year in a horrific war, I came home and met my wife to be. I was always relaxed, mellow and calm, yet at the same time I could be cutting and sarcastic, all of which I admired in myself. After getting married, several days per week I would work late and come home when it was dark. When the lights were on in my house, there was never a problem, but if I came home to a dark house, I would feel enraged and walk in complaining, arguing, and finding fault with everything.

Since I was in my own training analysis at the time, I brought it up, thinking it had something to do with my time in Vietnam. I finally made the connection between the rage that I felt when forced to stay in a dark house watching my grandmother, and the rage I felt when I approached my house with the lights off. Having made that connection, I no longer became enraged when the lights were off, but I didn’t feel wonderful either. My wife and I discussed it and she kept the lights on for me, just like motel 6. Another point is that learning the connections don’t necessarily take away all the feelings but they do put you in much better control of those feelings.

That is a relatively minor cause of Post-Traumatic Stress Disorder. Who is a victim of it? Everyone, unless their childhood was just perfect, wonderful and magnificent, and so far, I haven’t met anyone who falls into that category, although I never met Donald Trump.

Understanding Borderline States Developmentally

I would like to discuss development at this point because most of the people seen by psychotherapists fall into this particular phase, including those with the arbitrary junk-science diagnosis of borderline personality. In normal development, when a child approaches the end of the first year or year-and-a-half of life, he/she begins to recognize that he is not one with his mother, but is really a separate person. This infantile recognition marks the beginning of the end of the “symbiotic” phase of human development and the very beginnings of the “practicing” sub-phase, sometimes better known as “the Terrible Twos.”

The practicing sub-phase is an early part of what we often refer to as the “separation-individuation” phase of development, which is so critical to our development that Margaret Mahler describes it as “the psychological birth of the human being.” In fact, she wrote a classic book just about that phase of human development. During the practicing sub-phase, the child’s mission in life is to prove that he is a separate, autonomous human being, while at the same time not losing his mother. He does this by exploring his world, by trying to do things independently from his mother, and by oppositional behavior, (saying “NO”.)

Sometimes, this phase of development can seem like a battle against parental figures, hence the name “terrible twos.” Problems that develop in the early parts of this phase of development which a child is unable to successfully negotiate often result in what they call “borderline issues” because they develop during the beginnings of the quest for reality on the part of the child, which occurs right on the border of these two stages. Let me go on with a description of the next part of the child’s emotional development.

The Identification Process, Splitting and Fusion in Childhood Development

While beginning the Separation-Individuation phase of development, the child begins to identify himself with others. This is also the beginnings of object-relationships. Since the primary object for all of us is mother (whoever mothers us, which could be the actual mother or a mother-substitute) a child will view his mother in very black and white terms as he begins the identification process. Mother in her nurturing role is seen as “good mother.” However, when mother says no to the child, restrains him in some way or frustrates him, mother is then seen as “bad mother.”

From a child’s point of view, “good mother” and “bad mother” are really two different people. This view occurs because of the absolute black and whiteness of the child’s thinking process at this age and is a normal age appropriate distortion of reality. The process is called “splitting.” When mother gives me what I want, she is “good mother” but when she doesn’t give me what I want, she is “bad mother.” These are totally two different people to the child.

Over the next year or two, depending upon intervening variables as well as the child’s developmental progress, the image of the “good mother” and “bad mother” slowly start to come together in a merging process. At a certain point, these objects “fuse” and we no longer see our mothers as a split object, one mother good and the other mother bad. When these objects fuse into one object, one mother, we begin to entertain a different, more sophisticated perception of mother. Now, mother is seen as basically “good mother” who sometimes is not so good. However, both the good and the bad are housed in the same person.

This is a much more benevolent view of mother and allows for imperfection. Since mother is the “primary object,” the first person that a child identifies with, his perception of mother is vital to his perception of himself. Once the good and bad objects are fused, the extreme view of the child is softened. He now also looks at himself and is able to perceive that: “I’m basically a good child, but sometimes I do bad things. Even so, I’m basically a good child.” This benevolent perception does two things. First, it brings us in closer contact with reality, and secondly, it softens out perfectionism both toward ourselves and toward others.

When Fusion Doesn’t Take Place, or What Causes BPD

The failure of all-good and all-bad perceptions to fuse is the genesis of all pathologically borderline states. Please be aware also that I am using the word pathology to simply indicate development gone awry or developmental stages that were not properly negotiated by the child for multiple reasons.

Sometimes, due to external issues that limit or skew a child’s development, or because of internal developmental issues, a child is unable to fuse the good and bad objects into one unified whole. In that case, the split object remains and the child continues to perceive dual mothers; one totally good and one totally bad. Under such conditions, when the child identifies with the primary object (the mother or mother substitute) and then looks in the mirror, he sees either a totally good person or a totally bad person with no redeemable good qualities, a rather harsh view of oneself. Under the above conditions, the child’s development makes him a potential candidate for suicidal thoughts, feelings, and actions as well as borderline personality issues.

In the so-called “borderline personality, the core issues precede the problematic object relations and there are also introjective insufficiency problems with good and bad objects. Most people dealing with this issue feel an “annihilation panic” based upon the relative absence of positive introjects that pretty much explain the “borderline” person’s feeling that he is existentially at risk.

In other words, in the so-called “borderline personality, it isn’t just the all-good, all-bad splitting that is a problem, but the paucity or insufficiency of positive introjects. Therefore, in people who are labeled borderline, the negative introjects predominate. Also, in come cases, they are able to solve the introject problem by, in a sense, becoming their own object or mother, thereby being able to comfort themselves without the need for anyone else. In the psychiatric establishment, these individuals are referred to as “psychopathic” or “sociopathic” personalities. They don’t need mothering because they can self-comfort.

Let’s go back for a moment to clarify what the mother-introject is. In normal development, the child internalizes a mental representation of the mother figure and the way in which she makes the child feel. Negative introjects always come from abuse that has taken place at around this time. (Sorry if I am blaming the mother figure but that is the way it goes.)

Gerald Adler, also a student of the ego-developmental model, extends this work further. He describes ideal treatment as an attempt to establish and maintain a dialectic therapeutic relationship in which the therapist can be used over time by the patient to develop insight into adequately holding onto positive introjects. In this manner, the arrested developmental process is set in motion to correct the original developmental failure. This is called the “Deficit Model” in that the focus is on what is missing in that person’s development. Therefore, the core of borderline issues precede the destructive internal object relations. The issues involve abuse, the absence of a positive introject, and an overwhelming constant feeling of being at risk, primarily due to the insufficiency of positive introjects.

Treatment for the Borderline, Suicidal or PTSD individual:

In this section, I would like to consider a number of treatments for these people and then the treatment of choice.

Electroconvulsive Shock; (ECT):

ECT, in short, involves placing two electrodes on the skull over the frontal area of the brain and then administering voltage that is comparable to being hit by lightening. This does several things. First, it causes a brain seizure which is not very pretty to observe. To avoid looking like a scene out of the movie “One Flew Over The Cuckoo’s Nest,” psychiatrists first administer sedative drugs to mute the external manifestations of the electric shock such as thrashing, broken bones, etc.

However, when they do this, to cosmetically improve the look of the treatment, they also have to increase the voltage, thereby creating greater cell damage and cell death in the brain, flatness of personality and affect, and slower thinking processes. This damage is similar to what occurs as a result of long-term heavy alcohol use, only more rapidly and in more focused areas, particularly the frontal lobes of the cortex or the cognitive and feeling areas of the brain. Keep in mind that ECT is similar to a motorcyclist head injury or explosion in that it is a “traumatic head injury,” only it is being caused by a physician. One of the side effects of killing off brain tissue in the frontal lobes is apathy, flatness of personality and affect, and slower thinking processes.

As a result of all this brain damage, suicidal thoughts (all other thoughts as well) are deferred and drastically slowed up. Therefore, ECT may temporarily defer suicide or soften the borderline issues, but it does not prevent it and when a person slowly and partially recovers from the shock, he may realize the lesser functioning he is left with permanently, an even greater motivation for suicide. ECT also significantly and drastically disrupts any psychotherapeutic process that is being carried on. Earnest Hemingway was “cured” of suicidal tendencies by ECT.

Bio-psychiatric Treatments:

The medication approach (anti-depressants and/or anti-psychotics) is useless in people with borderline, suicidal, and PTSD symptoms. In fact, anti-depressants are probably one of the major causes of iatrogenic (doctor induced) suicide in this country in the past 15 years, especially with individuals labeled borderline. Also, feeding a patient cocktails of neuroleptic (anti-psychotic) drugs acts simply as a temporary chemical restraint, often called a “chemical lobotomy.” In that sense, these drugs mimic ECT. I do not consider either real help for any individual and they make insight oriented therapy almost impossible.

Insight Oriented Psychotherapy:

According to Bertram Karon, Ph.D., one of the world’s most prolific researchers on effective psychotherapy with patients labeled schizophrenic, suicidal, and borderline, “The best suicide prevention is effective psychotherapy.” He goes on to say: “Of course the most effective way to prevent a suicide or a homicide is to understand the psychodynamics and deal appropriately in therapy with these issues.”

There are also a number of things that need to be confronted in any psychotherapeutic situation with a suicidal, borderline, or homicidal patient. Among them are his anger and rage, his and the therapist’s loss of control, and in a child, the significant parental issues, the patient’s developmental history, the ways in which the patient transfers his feelings (mostly bad and angry feelings) to the therapist, as well as other issues.

From the therapist’s perspective, he must be able to handle the transferential rage and aggression as well as his own feelings of lost control and counter-transferential issues. Finally, the therapist needs to deal with his own fears of the patient’s potential for suicide. Untrained,

fearful therapists, when they hear that a person has suicidal issues, get frightened and immediately refer to a psychiatrist, as though a psychiatrist has some magical powers to treat this problem. Unfortunately, when a therapist does this, the message to the suicidal person is “I am afraid of you and am not equipped to deal with your issues. The therapist is then immediately written off by the suicidal person.

Many therapists also do not want to work with people diagnosed as borderline for two reasons. The first is the rage that gets directed at the therapist. Borderline development results in a huge need to get rid of the aloneness they feel which results in rage that makes the therapist cease to exist. The counter-transference from an untrained therapist is a feeling of “I’m wasting my time here.” The second is that the amount of support needed is greater than with other kinds of development. You cannot resolve splitting until a strong positive relationship exists between the person and the therapist. In treatment, the unrealistic idealization of the therapist that the borderline person feels must be slowly worked through and discussed before it is relinquished and replaced by a more realistic view. The therapist’s goal is to slowly build up the earlier foundations of the ego structure through the relationship so that what is established is a not-so-harsh superego and thereby, less black and white pain in the face of imperfections and losses.

It should be understood that using this model, the therapist works toward a stronger continuum of emotional development so that a person can function in a more whole way. It is not a disease or medical issue and therefore, nobody is “cured.” People just learn to handle various issues in their lives in a smoother, more comfortable manner for them.

A Brief Word on Narcissism

Narcissism is often a component of borderline development. Narcissists are particularly hard to treat. They find it difficult to form the warm bond with a therapist that naturally evolves with most other patients. Instead, they often become cold or even enraged when a therapist fails to play along with their inflated sense of themselves. A narcissistic patient is likely at some point to attack or devalue the therapist, and it is hard to have to sit with such people in your office unless you are ready to accept that.

But narcissism is not limited to the most extreme cases who make their way to the therapists’ office. A healthy adjustment and successful life is based to some degree on narcissism. Healthy narcissists feel good about themselves without needing constant reassurance about their worth. They may be a bit exhibitionistic, but do not need to play down the accomplishments of others to put themselves in a good light. And although they may like adulation, they do not crave it.

Normal narcissism is vital for satisfaction and survival. It is the capacity to identify what you need and want. Pathological narcissists, on the other hand, need continual reassurance about their value. Without it they feel worthless. Though they have a grandiose sense of themselves, they crave adulation because they are so unsure of themselves that they do not know they have done well or are worthwhile without hearing it from someone else, over and over. The deeply narcissistic person feels incomplete, and uses other people to feel whole. Normally, people feel complete on their own.

”Narcissistic vulnerabilities,” as psychoanalysts refer to them, make people particularly sensitive to how other people regard them. You see it in marriage, in friendships, at work. If

your boss fails to smile when you greet him it may create a withdrawn, anxious feeling. If so, your self-esteem has been hurt. A sturdy self absorbs that so it’s not unbalanced. But if you’re vulnerable, then these seemingly small slights are like a large trauma. On the surface, extreme narcissists are often brash and self-assured, surrounded by an aura of success. Indeed, they are often successful in their careers and relationships. But beneath that success, feelings of inadequacy create the constant need to keep inflating their sense of themselves.

If they do not get the praise they need, narcissistic people can lapse into depression and rage. Thus, many workaholics put in their long hours out of the narcissist’s need to be applauded. And, of course, the same need makes many narcissists gravitate to careers such as acting, modeling, or politics, where the applause is explicit. Many difficulties in intimate relations are due to narcissism. Marriage brings to the fore all one’s childhood yearnings for unconditional acceptance. A successful marriage includes the freedom to regress, to enjoy a childlike dependency. But in marriage, a couple also tend to re-enact early relationships with parents who failed to give them enough love. This is particularly hard on those with the emotional vulnerabilities of the narcissist. All narcissists fall within the borderline spectrum of development, but not everyone in the borderline range of development is narcissistic.

In summary, a therapist who is not trained well will usually not want to work with a borderline person for all the reasons mentioned above. To avoid their own discomfort, they describe them as untreatable. Well trained therapists do not have that opinion. It is not a “mental illness,” (disease.) Rather, it is a breakdown of a developmental phase that we all go through and involves issues such as splitting, negative introjects, probably early abuse, suicidal issues, and narcissistic issues.

Well trained therapists have done well with these individuals, provided the therapist knows both what to expect and what he is doing. Because it is not a disease, no one is cured. However, with proper insight oriented therapy, people labeled as borderline do go out in the world and function quite well in relationships, employment, etc. Like the rest of us, the goal is not to be cured from some non-existent disease, but to simply resolve the issues in our development that stop us from functioning in a relatively comfortable manner.

Finally, the term “borderline,” when used as a medical or psychiatric diagnosis, is both useless and harmful in that it is suggestive of some evasive disease. To use the term from a developmental point of view is very different and can be helpful in understanding what in a person’s development, was not negotiated properly or fully successfully. Using the term “borderline developmental issues” enables us to go back in time and try to help the individual to undo, modify, and soften development that did not go smoothly the first time around. This is something that is being done all the time by private-practice therapists, but not by what I call “the mental health industry.” However, that is a topic for some other time.

Below, I have listed a few books that should be helpful in understanding the treatment issues with individuals who are dealing with borderline issues. I have also included several books that support my opposition to the medical model approach.

Bibliography

Adler, G. (1977). Borderline Psychopathology and Its Treatment. Northvale, N.J.:Jason Aronson.

Breggin, P.R. (1994). Toxic Psychiatry. New York: St. Martin’s Press.

Jackson, G. E. (2005). Rethinking Psychiatric Drugs. Bloomington, Indiana: Author House.

Jackson, G.E. (2009). Drug Induced Dementia: A Perfect Crime. Bloomington, Indiana: Author House.

Blanck, G., & Blanck, R. (1972). Ego Psychology: Theory & Practice. New York: Columbia U. Press.

Colbert, T.C. (1996). Broken Brains Or Wounded Hearts. Santa Ana, California: Kevco Publishing.

Ferenczi, S. (1950). “Introjection and Transference.” In Sex In Psychoanalysis: Selected Papers. 35-93. New York: Brunner/Mazel.

Freud, A. (1936). The Ego and The Mechanisms of Defense. London: Hogarth Press.

Freud, A. (1965). The Writings of Anna Freud, Vol. VI: Normality and Pathology in Childhood Assessments of Development. New York: International Universities Press.

(Hartmann, H., Kris, E., & Loewenstein, R. (1949). “Notes on the theory of aggression.” The Psychoanalytic Study of the Child, ¾, 9-36.

Jacobson, E. (1954). “The self and the object world: Vicissitudes of their infantile cathexes and their influence on ideational and affective development.” The Paychoanalytic Study of the Child, 9, 75-127.

Jacobson, E. (1964). The Self and the Object World. New York: International Universities Press.

Karon, B.P., & VanderBos, G. R. (1994). Psychotherapy of Schizophrenia: The Treatment of Choice. Northvale, New Jersey: Jason Aronson, Inc.

Kohut, H. (1972). “Thoughts on narcissism and narcissistic rage.” The Psychoanalytic Study of the Child, 27, 360-401.

Mahler, M. (1960) “Symposium on psychotic object-relationships: III. Perceptual differentiation and ‘psychotic object-relationship’.” International Journal of psychoanalysis, 41: 548-553.

(51) Mahler, , M. & LaPerriere, K. (1965). “Mother-child interactions during separation-individuation.” Psychoanalytic Quarterly, 34: 483-498.

(52) Mahler, M. Pine, F., & Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books.

(55) Masterson, J. (1973). “The mother’s contribution to the psychic structure of the borderline personality.” Paper read at The Margaret Mahler symposium on Child Development, Philadelphia, May, 1973. Unpublished.

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

ParallelPsychModels1

A diagram showing some common psychodynamic approaches to understanding BPD. Read more to understand how this continuum works!

In earlier articles, I discussed the following ways of conceptualizing borderline mental states:

  1. Fairbairn’s Object Relations Approach, including the bad object, the internal saboteur and the moral defense.
  2. Harold Searles’ Four-Phase Model, including the out-of-contact phase, ambivalent symbiosis, therapeutic symbiosis, and individuation.
  3. Gerald Adler’s Deficit Model, which discusses the quantitative predominance of all-negative memories and the deficits of soothing-holding experience.
  4. Donald Rinsley’s Borderline-Narcissistic Continuum, which illustrates how BPD and NPD represent states of psychological developmental arrest that flow into one another.

If you are looking for explanations of why borderline mental states develop, what keeps people stuck in them, and how to become free from BPD, please check out the pages above. In my opinion these object-relational approaches explain BPD’s etiology and how to become non-borderline better than CBT or DBT approaches. The latter approaches typically focus on short-term symptom management rather than transformation and cure of BPD.

Today’s post will add another approach, the Kleinian Approach to Borderline States. Kleinian theory focuses on the Paranoid-Schizoid Position and the Depressive Position.

What do these words mean, and why are they useful in understanding borderline conditions?

Melanie Klein: An Early Psychoanalytic Pioneer

To start with, why is this approach called Kleinian?

The Kleinian Approach to BPD is based on theories developed by Melanie Klein, an early 20th century psychoanalytic theorist. Klein grew up in Austria and received psychotherapy as a young woman from Sandor Ferenczi, a Hungarian psychoanalyst who was himself an innovator in understanding schizophrenic and borderline individuals.

Klein studied psychoanalysis in Berlin and London, eventually becoming a renowned therapist of emotionally troubled children. Working with children enabled her to see processes of all-good and all-bad splitting occurring live in the therapy sessions. Having often been severely neglected or abused, the children misperceived Klein as all-good or bad based on their past experience with “bad” parents and their need for a “good” parent-substitute.

Melanie Klein noticed that the more abuse and neglect the child had experienced, and the worse the relationship between child and parents, the more severe the splits in the child’s perception of the therapist tended to become. This meant that, despite the fact Klein tried to treat them well, children with worse parents tended to more unrealistically perceive Klein as an “all bad” mother figure. This transference (transfer of feelings from past people onto present people) is related to how borderline adults tend to misperceive potential friends or lovers as uninterested and rejecting.

Klein also noticed that as they improved in therapy, children who had initially utilized all-bad splitting became attached to her as a good parent figure, growing emotionally to the point where they could trust her and feel concern for her wellbeing (reparation). Children from healthier families often started therapy at this more advanced position, allowing Klein to observe a more positive mode of relating from the beginning.

From these two different ways in which the children related, Klein posited two primary orientations toward perceiving the world as seen from the child’s perspective. She called the first, developmentally earlier, more dangerous and isolated way of experiencing the world the Paranoid-Schizoid Position. She called the second, later, more secure and dependent orientation the Depressive Position.

These two positions can be understood as regions along a continuum of increasingly healthy and integrated personality development, the early, paranoid-schizoid part of which anyone can get stuck in given enough trauma and deprivation, and the later, depressive part of which anyone can reach given sufficient positive resources.

The Paranoid-Schizoid Position

The paranoid-schizoid position is the way of experiencing one’s emotional life that corresponds with what are commonly labeled “borderline” mental states or “schizophrenic” mental states. In my understanding, borderline and schizophrenic states of mind are not different in kind, but only in degree; schizophrenia represents a more severe version of the splitting, self-fragmentation, and primitive defenses seen in borderline states. As discussed in the many psychodynamic books linked to in earlier posts, both borderline and schizophrenic states are fully reversible and curable with sufficient help over a long period.

Back to the topic at hand. Why is the “paranoid-schizoid” position called that and what does it mean? The “paranoid” part refers to misperceiving external others who are neutral or mainly good as “all-bad”, as paranoid people tend to do, and the “schizoid” part refers to the tendency to withdraw and isolate oneself from meaningful emotional interaction with others, as people who feel threatened and unsafe tend to do. When a person’s entire personality is centered around misperceptions of others as “bad”, and when a person isolates themselves interpersonally in a way that tends to perpetuate these misperceptions by not allowing in good corrective influences, they are operating in a “paranoid-schizoid” mode.

The term paranoid-schizoid is not meant to be pejorative, only descriptive. I think a better, more empathic term for the paranoid-schizoid position in adulthood would be something like, “The Adult Worldview of the Traumatized Child”, so please keep that in mind when reading these labels.

To Klein, the paranoid-schizoid position represented the earliest way of experiencing the world for a young child who is trying to test whether or not the external environment is safe and supportive. If parents and other important relationships mainly nurture and protect the child, then the child’s mind will develop a feeling of basic trust in others and of basic security in the world. This security will help them gradually move from the paranoid-schizoid to the depressive position. If neglect, abuse, trauma, and excessive stress predominate during childhood and early adulthood, if bad experiences tend to outweigh good experiences, then the person will get stuck in or regress back to the paranoid-schizoid position. In experiential terms, such a person will continue to feel unsafe and to distrust others relatively indefinitely, and may not even know what they are missing.

Core Features of the Paranoid-Schizoid Position

The paranoid-schizoid position features:

  • Lack of basic trust in others’ good intentions (“the basic fault” as discussed by Michael Balint).
  • Predominance of all-bad splitting, i.e. viewing others as rejecting and oneself as unworthy.
  • Predominance of feelings of aggression and envy over love and gratitude.
  • High levels of anxiety, a constant feeling of insecurity at the core of one’s being (“ontological insecurity” as discussed by R.D. Laing).
  • Frequent acting out – drinking, drugs, sex, food, etc – to defend against overwhelming negative emotions and lack of self-soothing ability.
  • Tendency to isolate oneself and withdraw emotionally and physically. Related lack of awareness of others as psychologically separate from oneself.
  • Lack of subjective sense of self.
  • Use of primitive defenses to block awareness of what a precarious emotional state one is really in, including denial, avoidance, splitting, projection, and projective identification.

My Emotional Experience of the Paranoid-Schizoid Position

These descriptions are highly technical and removed from real experience. So here is how I experienced the paranoid- position, i.e. the out-of-contact and ambivalent symbiotic phases, emotionally:

  • As my being a tragic, pointless character from Dante’s Inferno, The Myth of Sisyphus, or Kafka’s Metamorphosis, doomed to endlessly repeat the same self-defeating behaviors.
  • As being alive and dead at the same time – alive physically, but dead emotionally and dead because no one knew the real me.
  • As being unable to trust or confide in anyone, because nobody cared and nobody had time.
  • As waging a constant battle to keep my terror and rage controlled enough to survive.
  • As having no idea how normal people handled relationships and problems so easily, resulting in intense envy.
  • As continuing to live emotionally in “the house in horrors” (my name for my childhood home with its physical abuse).
  • As being a cork on a stormy ocean on which you could never tell where the next rogue wave was coming from.
  • As being very aware of negative inner thoughts and very unaware of what was going on around me. These bad thoughts felt to me like persecutory demons.
  • As having to preserve as much energy as possible to defend against potential threats and dangers. I often thought of myself as an emotional warrior, spy, antihero, or survivor.
  • As being willing to do almost anything addictive or distracting rather than feel the bad feelings and the lack of love.
  • As a vengeful, hateful, evil person who wanted to take revenge on those who hurt me and strike back at the world to feel some power and self-control (It is, I think, this type of paranoid-schizoid experience in young men that leads to many mass shootings).

These experiences are correlates of periods when the all-bad self and object images were mostly or fully dominant over the all-good self and object images. For many years this paranoid-schizoid nightmare was my predominant way of experiencing myself and the world.

Kleinian Theory Compared to Other BPD Models

The paranoid-schizoid position correlates with the following elements of other psychodynamic approaches to borderline states:

The Four Phases, the Structural Deficit, the Borderline-Narcissistic Continuum, and the Paranoid-Schizoid and Depressive Positions are all analogous ways of describing a continuum of early emotional development. They can be diagrammed as follows:

PSPvsSearlesPhases3

These “primitive” (meaning developmentally early) mental states are consequences of the quantitative predominance of bad self/object images along with a structural deficit or quantitative lack of positive, loving memories. In other words, they result when someone has many more bad than good experiences with other people, and/or when the absolute quantity of good experiences is severely lacking.

The lack of love in the past, combined with present fears that keep a person from getting help, can keep an adult frozen in the paranoid-schizoid position for long periods. In this situation, partly out of a fear of being totally alone or objectless, the person will maintain a closed psychic system of all-bad internal relationships which feel like tormenting inner demons, monsters, and ghosts. The paranoid-schizoid state can feel like an inner hell or prison.

How All-Bad Splitting Perpetuates the Past in the Present

The psychoanalytic writer James Grotstein discussed the persecutory inner representations of the paranoid-schizoid individual as acting like a “band of merciless thieves” or “gang of brutal thugs”. These internalized relationships attack the vulnerable part of the person that wants help by “warning” or convincing them that other people are untrustworthy, uninterested, dangerous, and rejecting, even though this may no longer be true in the present.

These all-bad identifications are seen when borderline people tell themselves, “I am worthless”, “Nobody wants to help me”, “Other people are always too busy”, “Things never work out for me,” and so on. There is sometimes a large grain of truth to the negative perceptions about others, but the individual also colors what they perceive and how they “self-talk” to make things seem worse than they are. In other words, they only perceive the all-bad aspects and spit out the all-good aspects of external reality. In this way they treat themselves as did people in the past who rejected or neglected them. This is what I call “perpetuating the past in the present.”

These paranoid-schizoid inner objects or memories can be understood as schemas, i.e. models of representing past experience in relational terms. These models actively (and often negatively) influence the ability to perceive reality accurately and to take action in the present.

Examples of Paranoid-Schizoid Experiences in the movies Psycho, Memento, and Beauty and the Beast

Several dramatic films illustrate how past attachments to “bad people” (and more importantly the internal memories and self-images based on them) block potential relationships to new good people and serve to keep a person in the paranoid-schizoid position.

1 – Psycho: Norman Bates, the main character in Alfred Hitchcock’s horror movie Psycho, exemplifies the paranoid-schizoid position. Because he fears his mother will be jealous, Norman is unable to tolerate the presence of Marion, the lovely young woman who comes to visit his motel. In reality Norman’s mother is long dead, her rotting body sitting in a rocking chair in the manor house. But her remembered voice is alive and well in Norman’s mind, guiding his actions and ordering him to kill off the threatening “good” Marion. Norman constantly experiences the paranoid-schizoid position, always feeling in danger and unable to trust outsiders.

While Norman is actively psychotic, a parallel process plays out in less disturbed borderline mental states. Norman’s acting out of the way he imagines his mother would reject his wish for a positive relationships is disturbingly similar to how some older borderline adults keep sabotaging potentially good relationships even after their abusive parents are gone.

Memories of disappointing interactions with parents and peers therefore “warn”, discourage, and forbid the borderline person not to trust and enjoy relationships with friends and lovers in the present, because if they do they would be betraying their past bonds to “bad” parents (for which they often blame themselves) along with risking rejection by the potentially good new person. These unconscious identifications with all-bad memories of others explain the repeated frustrations that many people labeled BPD have with keeping friends and sustaining romantic relationships.

Check out the Psycho Trailer.

2 – Memento: In the Christopher Nolan movie Memento, Guy Pearce plays a man, Leonard, suffering from an unusual problem:  He cannot form any new memories. This disability occurs after he is beaten by thugs who killed his wife. Therefore, Leonard is unable to remember or trust anyone new he meets. He becomes at the mercy of others who take advantage of his limited memory. The constant sense of paranoia that Leonard exhibits, along with his great difficulty in discerning what is real and what is a deception, brings to mind the paranoid-schizoid mental experience.

People in severe borderline states experience similar difficulty in trusting others, usually not because they are amnesiac, but because they are terrified that being dependent and close will result in rejection or abandonment. In other words, they believe that the present will repeat the past, i.e. that new potentially good people will turn bad, just as parents and peers rejected them before. These inner identifications with bad objects (objects meaning memories of past experiences with others), combined with a lack of past good object experience to rely on, results in the extreme sensitivity to imagined rejections that borderline people experience.

I remember watching the Alien movies starring Sigourney Weaver as a boy and being terrified by the scenes where a human suddenly turned into a monstrous alien and devoured a fellow colonist. I think these scenes unconsciously reminded me of my father’s sudden transformations into a violent “monster” who physically beat me, which fed my expectation that other adults would turn on me if I trusted them.

Check out the Memento Trailer.

3 – Beauty and the Beast – This classic Disney children’s movie features another example of the paranoid-schizoid position. Due to his selfish and unkind nature, the Beast has been condemned to live alone in his castle. He can only be redeemed if he learns to love, and earn another’s love in return, by the time the last petal falls from a magic rose. Rather than seeking someone to love him, the Beast becomes hopeless, withdrawing and isolating himself inside his castle. When beautiful Belle tries to penetrate his “closed psychic system” of all-bad expectations, the Beast is at first aggressive and untrusting, not believing that anyone could love his true self.

Gradually, the Beast is able to permit himself to be vulnerable and experience closeness with Belle. This move toward dependence, attachment, reparation of past harms done to Belle, and realization of the love he has been missing out on, represent the Beast’s movement from the paranoid-schizoid to the depressive position. Gaston and his henchman represent the all-bad objects that serve to impede reunion with the hoped-for good object, and the Beast must courageously fight them off to defend his loving relationship with Belle (i.e. to securely reach the depressive position).

Check out the Beauty and the Beast Trailer.

The Reunion Adventure – The Transition from Paranoid-Schizoid to Depressive Positions

The timeless theme of reuniting with a lost good person by fighting past inner demons and their external representatives repeats in many classic stories, including Homer’s Odyssey, the Star Wars movies, the epic films Gladiator and Braveheart, Disney’s Aladdin and the Lion King, The Crow starring Brandon Lee, and the novel Ulysses by James Joyce.

To see the repeating narrative, the reader need only think of how the heroes in these stories are separated from those they love by evil forces (“bad objects”) before having to fight for reunion with the lost beloved person. Joseph Campbell provides many additional examples in his book The Hero with a Thousand Faces. This epic battle comes alive in long-term psychotherapy of borderline states, when the battle is to overcome all-bad projections onto the therapist in order to trust and depend on the therapist as a new good person who can help the client move from the paranoid-schizoid to the depressive position.

The Paranoid-Schizoid Position and DSM Diagnoses

Different degrees and permutations of the paranoid-schizoid way of relating are commonly (mis)labeled as: Borderline Personality Disorder, Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder, Bipolar Disorder, Schizoaffective Disorder, Schizophrenia.

I don’t believe in the validity of these labels as distinct illnesses; rather, people should be viewed as individuals with strengths and deficits along a continuum of ego functioning. If they are used at all, labels like “borderline” should be viewed as a cross-sectional working hypothesis which loosely describes the problems a person has at a given time. Labels like borderline emphatically do not represent a life-long incurable illness. In my view, DSM labels should be abolished since psychiatrists are unable to use them as descriptions of pathological ways of relating with which people can work creatively and from which healing is possible.

Instead of something descriptive and hopeful, the labels become perversely distorted into “lifelong mental illnesses” which may have a genetic or biological cause. This is ridiculous since no evidence exists that these diagnostic labels are reliably discrete from each other, nor that biology or genes cause the behavioral, thinking, and feeling problems to which they refer. It’s offensive, harmful, and arrogant for psychiatrists to misrepresent problems of thinking, feeling, and behaving to vulnerable people in this reductionistic, pessimistic way.

Therefore I again encourage readers to consider dismissing labels like Borderline Personality Disorder from your mind. Instead, consider thinking of individuals as experiencing different degrees of borderline mental states at different points in time and of borderline states as being reversible and curable.

The Depressive Position and Healthy Personality Organization

Since much of psychology is focused on what is wrong, pathological, symptomatic, or immature, I now want to focus on maturity, wellbeing, and psychological health, using these questions:

How do many people become emotionally healthy, i.e. able to regulate their feelings and self-esteem, to work productively, to form families, become loving parents, have intimate friendships, etc.?

Are emotionally healthy people just born that way, or does childhood experience matter, and if so how much?

Why are healthy people not borderline?

How can borderline people become healthy?

These are complicated, contentious issues. In most cases the answer to the first three questions is that emotionally healthy people have had many more good than bad interpersonal experiences during childhood and early adulthood. Compared to people who are labeled “borderline”, healthy people usually had more opportunities for trusting, secure, long-term relationships with family, mentors, and/or friends.

These good relationships helped them to overcome the paranoid-schizoid position and the splitting defense – which when not prolonged are normal parts of every child’s development – and to develop the capacities for ambivalence, self-soothing, and intimacy. In one sense, emotionally healthy people were simply lucky – lucky as helpless children to be born into families where love and security were readily available.

I believe that that healthy adults usually had parents who, while they were not perfect, were good enough most of the time. They were “good parents” in the sense of empathically responding to the child’s needs, comforting the child when vulnerable, and supporting the child’s independent activities. These parents themselves usually had a considerable degree of healthy personality development; i.e. the parents themselves did not make heavy use of splitting, and were able to accurately perceive their children as mostly good and only slightly “bad”.

In other words, non-borderline parents tend to raise non-borderline children, and borderline parents are more likely to raise future borderline children. NAMI won’t like to hear that parents can cause BPD, but sometimes the truth hurts! As suggested by the ACE Study below, poor  parents do more frequently raise “borderline” and “schizophrenic” children. That doesn’t mean poor parents are “bad people” or that they should be blamed for their children’s problems. Of course they shouldn’t.

Rather, the passing of abuse and neglect from generation to generation is a tragedy for which no one should be blamed, and the maximum amount of support should be given to such parents to help understand and change destructive patterns.

The ACE Study – How Adverse Childhood Events Increase Risk of Psychiatric Diagnoses

What evidence is there that childhood neglect and abuse correlate with increased mental illness diagnoses? The recent Adverse Childhood Events (ACE) Study of 17,000 people has explored the connection between childhood trauma and psychological disorder diagnoses. This study polled a large sample of people seen in hospital and medical settings to examine how frequently different childhood experiences co-occurred with physical illnesses and mental health diagnoses. The ACE study shows that childhood emotional, physical, and sexual abuse are directly linked to likelihood of both physical illnesses and psychiatric disorder diagnoses in a dose-response fashion.

In other words, the more abuse and neglect a person reports in childhood (a higher “dose amount”), the more likely a person is to be labeled depressed or schizophrenic in adulthood. In my way of thinking, more childhood abuse and neglect increases the chances that a child will become developmentally frozen in the paranoid-schizoid position and experience borderline or psychotic mental states as an adult.

Here are details on The ACE Study.

Drawing from the ACE Study, one can deduce that the less frequent and severe are a person’s experience of childhood abuse or neglect, then the less likely the person is to experience “borderline” or “psychotic” mental states as an adult. Although the survey didn’t cover it, I’d bet that a strong group-level relationship exists between having had reliable, loving parents (as the child experienced and perceived them) and an absence of adulthood mental health diagnoses. It makes sense because families with less abuse and neglect also tend to have more love, safety, closeness, and support (I could be wrong about this, but I doubt it. Let me know what you think in the comments).

Further Sources on Healthy Childhood Emotional Development

I’ve now digressed again from the topic of healthy personality development. The point I’m trying to make is the obvious one that loving, secure human relationships are crucial to healthy personality development. Rather than discuss this in further detail, I wish to refer the reader to sources with more knowledge than I.

Some good writers on healthy emotional development, i.e. on what helps young people become navigate past the paranoid-schizoid position (avoiding borderline mental states) and enter the depressive position (and reach psychological maturity) are:

1) Donald Winnicott (e.g. Maturational Processes and the Facilitating Environment). Drawing on his experience as a English pediatrician-therapist, Winnicott wrote beautifully about the healthy emotional development of children. Winnicott viewed psychotic states, including severe borderline conditions, as the “negative” or mirror image of healthy emotional development. They illustrated for him what happens when healthy parenting and secure childhood emotional development break down or never become firmly established.

Winnicott’s book is available for free as a PDF on this page.

2) James Masterson (e.g. The Seach for the Real Self). The American psychiatrist Masterson wrote mainly about borderline and narcissistic personality problems but always discussed what happens in healthy development contrasted with borderline/narcsisistic development. Masterson explained how the borderline/narcissistic personality could become healthy via internalizing self-parenting functions that they had missed out on in childhood.

Check out Masterson’s book on the search for the real self.

View a Youtube interview with Masterson.

3. Heinz Kohut (e.g. How Does Analysis Cure?). German psychoanalytic pioneer Kohut developed the field of self-psychology, which emphasizes how crucial empathic parental responses are to the young child’s healthy emotional development. He developed the ideas of idealizing relationships (referring to how children need a strong, safe figure to protect them) and mirroring relationships (how children need a supporter for their independent functioning).

It is instructive to understand how these relationships fail to occur between parents and future-borderline children, and why such relationships do not immediately develop when borderline adults go to psychotherapy. From Kohut’s work one can see that if most borderline adults had received adequate mirroring and idealizing responses earlier in life, they would likely be normal, healthy people today.

Here is an Overview of Self-Psychology.

4. Lawrence Hedges (e.g. Working the Organizing Experience; Interpreting the Countertransference). Hedges is a California-based psychogist who recasts schizophrenic and borderline disorders as “organizing” and “symbiotic” ways of relating. He has a beautiful way of writing about how certain “potentials” for relateness never get activated and become frozen in borderline and psychotic mental states.

In the link below, which is a free e-book download, the sections “Borderline Personality Organization” (pg. 98) and “A Brief History of Psychiatric Diagnoses” (pg. 175) may be of interest. Hedges’ writing is not about healthy personality development per se, but he constantly discusses what positive elements are missing in the relational development of psychotic and borderline individuals.

Access a free e-book copy of Hedges’ Relational Interventions.

5. Allan Schore (e.g. Affect Regulation and the Repair of the Self, The Science of the Art of Psychotherapy). Schore is an American neuroscientist who writes about how reliable, secure attachments to caregivers are crucial to the developing child’s brain, and how attachments to parents directly modify how genes express or do not express themselves. Schore does fascinating brain scans showing how the child’s brain reacts to good and bad relational influences. He also shows why nature and nurture cannot be separated and quantified in such myths as, “BPD is 50% genetic.”

Here is an Interview with Allan Schore on Youtube summarizing Attachment Theory.

6. Ed Diener (e.g. Happiness: Unlocking the Mysteries of Psychological Wealth). Diener is a sociologist who researches how social conditions on a national level promote psychological wellbeing. Good parents and mentors are extremely important for psychological wellbeing, but factors beyond family relationships a lot too, like poverty, educational opportunities, diet and exercise, safety at a national level, freedom of speech, economic inequality, etc. Diener shows how these factors correlate with psychological wellbeing for national populations.

As you might guess, people in Iraq, North Korea, and Zimbabwe really are far less happy than people in Sweden, Australia, and South Korea. While advanced nations have their own problems, Diener shows how some poor countries suffer such severe instability that they are almost “paranoid-schizoid” worlds, in which people constantly feel threatened and are unable to actualize their potential for wellbeing.

Here is Diener’s Book on Wellbeing.

Compared to the simplistic, symptom-focused descriptions of Borderline Personality Disorder in the DSM , I believe so much more can be understood from these etiological depth approaches to borderline conditions and healthy emotional development.

Returning to the Kleinian theory, how does the Depressive Position fit into healthy emotional development?

Key Characteristics of the Depressive Position

The Depressive Position, although it might sound negative (like “depression”) actually refers to increasing psychological attachment, closeness, and maturation. It was called “Depressive” because Melanie Klein focused on how the young child experienced guilt, depression, loss, and increased concern for their parents’ wellbeing as they emerged from the paranoid-schizoid position. These “depressive” feelings emerged as the child became more aware of the mother as a separate person and realized how their actions could negatively affect her.

But the real thrust of the depressive position lies in these characteristics:

  • Increasing security in positive emotional attachments to other people (development of basic trust).
  • Predominance of all-good splitting followed by capacity for ambivalence.
  • A richer, nuanced, three-dimensional view of oneself and others.
  • Predominance of love, gratitude, reparative urges, and guilt over aggression, envy, hatred, and vindictiveness.
  • Increasing ability to self-soothe, tolerate frustration, and maintain self-esteem.
  • Repression replaces splitting, denial, and projection as primary defense.
  • Increasing awareness of others as psychologically separate from oneself.

This link from the Melanie Klein Trust explains the depressive position in more detail.

My Experience of the Depressive Position and Therapeutic Symbiosis

As stated before, a lot of these descriptions are technical and removed from real experience. So here is how I experienced the early part of depressive position, i.e. therapeutic symbiosis, emotionally:

  • As the end of a war in which I was a survivor emerging from the ruins, realizing that the whole battle had been going on in my mind, not the outside world.
  • As an incredible realization that I was not in danger, people could be trusted, the world was safe.
  • As emerging into real life after years in emotional hibernation.
  • As seeing the world and other people in color for the first time.
  • As “the halcyon (blessed) days”, my term for this period in my diaries.
  • As the sense that everything was right between me and my therapist, that I was like a blessed child and she was like a loving mother.
  • As a regression to being the playful, carefree child that I had never been able to be in my actual childhood.
  • As an overpowering sense of loss about how many years had been lost to misery and fear because of my parents’ abuse.
  • As feeling like a savior because I had saved myself by finding good people, just like the Beast found Belle to free himself from the curse.
  • As a feeling that I had become a self, a real spontaneous person for the first time.
  • As being able to enjoy other people and experiences, finally.

These feelings are correlates of the period when all-good self and object images begin to outweigh all-bad self and object images, i.e. the phase of therapeutic symbiosis as described by Harold Searles. In this stage the formerly borderline person achieves a healthy narcissistic level of object relations and reaches the depressive position.

Why Don’t Some People Reach the Depressive Position?

In severe borderline mental states, a person remains fixated psychologically in the paranoid-schizoid position as described above. Viewed from various vantage points, the borderline person tries to become healthy, functional, securely attached, and able to regulate their feelings but may fail because:

  • They have a quantitative deficit of internal positive memories that healthy people use to soothe themselves (Adler’s structural deficit), but don’t yet have the resources in their daily life (friends, family, therapist, etc) needed to repair this deficit.
  • They are simply unaware of the positive relationships they are missing (Searles’ out-of-contact state).
  • They are scared of trusting and depending on others due to past trauma which they fear new people may repeat, and thus choose to remain attached to their internal all-bad relatoinships (Fairbairn’s object-relations model of the attachment to the bad object, Searles’ phase of ambivalent symbiosis).
  • Their use of primitive defenses like denial, avoidance, acting out, projection, projective identification, leads them to unconsciously repeat self-destructive patterns.

This is only a brief attempt to answer the question about why some borderline individuals remain in the paranoid-schizoid position. I am still optimistic that healing and progress out of the paranoid-schizoid position is possible with appropriate insight and help.

Final Thoughts On Recovery From Borderline States and Progress to the Depressive Position

My own experience and research suggests that the single most crucial thing for recovering from borderline states in a long-term, dependent, loving relationship with somebody. It could be a therapist, a friend, a family member, or some combination of these. Feeling safe and loved by others for years is what enables children to become healthy adults, and it is also what enables once-borderline adults to become healthy adults. There is no substitute for internalizing the self-soothing and self-organizing functions of a loving, mature outside person. As I described in an earlier article, I experienced these healthy relationships for the first time with my therapist and a few key friends.

In normal childhood development, there is a “healthy” or normative paranoid-schizoid experience called the practicing phase, in which the child jubilantly explores the world and is relatively unaware of mother’s separateness. For most children, the parents and environment are supportive enough that the children don’t get stuck in a pathological paranoid-schizoid position that later becomes a borderline adult mental state.

Rather, most healthy children progress out of the normative paranoid-schizoid position into the depressive position at a relatively young age. These children are unlikely to regress and become borderline unless they encounter some overwhelming prolonged stress in later life. For children who are constantly neglected and abused, the risk is much greater that they will psychologically retreat and stay in the pathological paranoid-schizoid position, which leads to experiencing a chronic borderline or psychotic mental state in adulthood.

Again, it should be remembered that “normal”, healthy people would often have become borderline adults if they had experienced sufficiently severe abuse and neglect in earlier life. In Kleinian terminology, anyone can get stuck in the paranoid-schizoid mode of functioning when subjected to enough prolonged stress. People opearting in borderline mental states are not fundamentally different than the rest of us – they are just as human, but more unlucky in some ways.

With sufficient insight and resources, borderline people can become weller than well, i.e. become free from borderline symptoms, study and work productively, have intimate friendships and relationships, and experience joy and meaning. After they have become psychologically mature, life challenges still present themselves, but former borderlines can handle them with confidence as the capacities for ambivalence, regulating feelings, and maintaining self-esteem are developed in the depressive position.

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I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

– Edward Dantes

#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!

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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

#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

#7 – Addiction Recovery , 12-Step Groups and BPD

A common symptom associated with Borderline Personality Disorder is the presence of addictive, self-destructive behaviors.

This can include drug abuse, alcohol abuse, and overeating. Other compulsions include sexual promiscuity, gambling, and eating disorders, which are related to overeating but can be more damaging and complicated.

It is useful to consider why these addictions develop. Many authors view them as methods of coping with and numbing severe emotional pain. When one is tormented by chronic anxiety, anger, and uncertainty, blocking out the feelings with an addictive behavior makes sense in the short term. A deeper view is that addictions are a compensation for some “lack” – that is, if one has low self-esteem and few good personal relationships, addictions can serve to compensate for this void.

In the long term addictions are destructive and do not make the underlying problems disappear. But in the absence of better ways of coping, it is not surprising that so many people turn to addictions to make their problems temporarily “go away”. Since powerful negative emotions and a lack of healthy interpersonal relationships are both frequently associated with Borderline Personality Disorder, it makes sense that many borderlines develop destructive addictive behaviors.

My Addiction

Between about ages 16 and 24, I developed the addictive behavior of eating massive amounts of junk food. My favorite items were a giant 500-gram family-sized bag of Utz potato chips, along with a big bag of Hershey milk chocolate candies. I would ravenously eat these snacks – often totaling 3,000-4,000 calories or more – and then feel very bad about myself afterward (but, while it lasted, eating chips and chocolate together did feel awesome!).

I overate most often when feeling hopeless, alone, and angry. At the time, I wouldn’t really reflect on why it was happening, but the behavior also related to my negative beliefs about myself. Namely, that people didn’t care about me, that I had no future, was unattractive physically, was worthless and so might as well do it, and so on.

Usually, my overeating would be followed by efforts to restrict my eating to “even things out”. The idea was to punish myself and to prevent myself from becoming overweight (and miraculously, I did not ever become obese). Obviously, this whole cycle was terrible for me emotionally and only made my self-esteem worse.

Early Efforts to Deal With My Addiction

At first, I viewed my eating habits in and of themselves as a primary problem, i.e. as a cause of my other problems. Later, I would realize this was mistaken. However, as a teenager I focused a lot of energy on forcing myself to stop overeating. As the reader might guess, such efforts of willpower normally failed. I would frequently call myself bad names, berating myself for my lack of self-control. A vicious cycle developed where the more I overate, the more such self-attacks would occur, the longer the subsequent “starvation” periods would become, the worse the next round of overeating would become, and so on.

Visits to 12-Step Groups

Eventually, I discovered that 12-step groups existed that specifically addressed overeating. I visited these Overeaters Anonymous groups starting at age 19 and attended regularly for give years. Many people will know something about these programs even if they have not attended. Such programs usually involve an addicted person getting together with other addicts in a church, hospital clinic, or other accommodation for for at least one hour a week. At meetings, one gets to verbally share one’s experience recovering from addiction with the group, while also learning and gaining encouragement from the “shares” of others.

In 12-step groups, people also “work the steps,” the steps being positive, spiritual guidelines that  encourage reliance on the help of fellow addicts and on God rather than on one’s own willpower. Often, a new person will get a “sponsor,” a more experienced member that mentors them in their recovery journey.

To oversimplify it, 12-Step groups involve a group of “addicts” sitting around a table and performing what outsiders might view as “mutual therapeutic sharing,” although 12-step leaders would not call it that.

Positive Aspects of 12-Step Groups

I benefited greatly from attending 12-step groups. Given that I had experienced very little honest sharing of feelings in my family, the openness of people in the 12-step groups represented both a new emotional world and a massive source of support. People would share their most intimate feelings about their personal and family problems, knowing that they were protected by the “anonymity” of a program in which everyone starts on a first-name basis.

Seeing that other people were conquering their cravings for food encouraged me that I was not doomed to suffer with this compulsion forever. Having to drive to the meetings bolstered my self-esteem, because it meant I was taking action to help myself. The general tone of the meetings was one of acceptance and tolerance, which became incredibly therapeutic for me.

Over time, I came to see that most of the people in 12-step meetings were genuinely kind, good people. I lost the image of addicts being twisted, innately disturbed freaks. Many of the better-adjusted men and women that I met functioned well in the outside world. They had real friends, spouses, children, and jobs that contributed to the community. But they struggled with an often-hidden compulsion that caused them great anxiety and lowered their self-esteem.

There were also some more disturbed people who attended meetings. Often these addicts did not have a regular job, were involved in abusive relationships, and had trouble trusting or sharing feelings with others in the group. They seemed to have had more severe abusive and neglectful family histories. Nevertheless, many of them were eventually able to share their experience meaningfully and to begin to make friends. I learned from meeting them that even the most severely disturbed people can still want help and love. Near the end of my time in 12-step groups, I made it a point to reach out to them and make them feel welcome.

Nevertheless, during the first 2-3 years that I attended 12-step meetings, I failed to make significant progress in reducing my destructive acting-out behavior. While I made friends in the program, I never developed a trusting relationship with a sponsor. This partly related to my fear of authority figures which came from my physically abusive father.

More importantly, I was having trouble trusting my therapist outside of the program. The lack of a good relationship there, which also related to my historical lack of trust in my parents, led me to continue to feel alone and uncertain. This lack of a good core relationship in turn drove me to continue the addictive behaviors that masked the bad feelings.

Why I Left 12-Step Groups – The Christian Focus

Eventually, I decided to leave 12-step groups. There were several reasons why I did this. At around age 23-24, I had begun to work full-time and found it difficult to consistently attend meetings in the evenings. Looking back, I was overworking but did not know it then.

More importantly I disagreed with some of the core viewpoints of the 12-step program. The 12-step program is a Christian program, and I am not a Christian. I never liked being forced to say the Lord’s Prayer, having to admit out loud that I was “powerless” over my addiction, and needing to submit my problems to God.

My personal belief is that the Christian God is a fabrication invented by primitive, tribal, pre-scientific people. For early humans, Christianity many important functions, among which two stand out for me: 1) To give an illusion of knowledge about the origin and structure of the universe, and 2) To protect them from the fear of death, via the illusion that they could transcend death by going to heaven.

To admit that we have no idea why the universe started can be unsettling. And to face the fact that we may die and nothing comes afterwards may be similarly disturbing and depressing. However, I do not find these things depressing – they are simply mysterious, fascinating, and perhaps tragic, although not in a bad way. I would rather face these uncertainties than blindly place my faith in something that is unproven.

I realize these last two paragraphs may sound arrogant to Christian readers, but in fact I am only agnostic, not atheist. I admit that I could be wrong and that the Christian God could exist. I just find it extremely unlikely, since I believe in evidence, not faith, and no evidence has thus far convinced me that a Christian God exists. I do believe that some non-human “god-like” force could exist which initiated the big bang and thus the universe. But what that might be is a mystery.

To conclude, I understand that others feel differently and I do not begrudge them that; everyone is entitled to their own religious beliefs.For the purposes of this article, what matters is that human relationships and human love “works” in terms of promoting recovery from addiction and BPD. I have gotten better with the help of humans alone. If other people need both their fellow humans and faith in God to recover,  that is fine!

To return to the 12-step group, my viewpoints about religion differed too fundamentally from the group’s. This contributed to my eventual decision to leave.

Addiction As a Disease

People within the 12-Step group also referred to addiction as a “disease”. This is ridiculous, since it ignores everything we know about diseases. Actual physical diseases are caused by a preexisting physical agent or genetic condition.

To start with, like BPD itself, addiction is not a discrete entity or syndrome like a physical disease. At what exact scientific point does overeating become an “addiction”? Doesn’t everyone eat more than they should at some point? So is everyone addicted? Etc. The brains of the severely addicted do look different, but these differences can plausibly and entirely be explained by environmental factors.

Second, even if someone does have a relative genetic weakness (vulnerability to stress), that would not be the cause of their addiction. In most cases, addiction could again plausibly be explained almost entirely by environmental stress, such as abuse, neglect, low self-esteem, and poor personal relationships.

Addiction cannot be reduced to the level of a physical disease; to do so is reductionist and dehumanizing to the addict. However, we should not be surprised that psychiatrists and drug companies are currently trying to label addiction as a disease, given that they stand to make billions of dollars in additional profit from doing so.

“Cui bono?” (meaning who benefits, financially or otherwise) should always be asked whenever Big Pharma and research psychiatrists are involved in making some pronouncement about addiction or BPD. More often than not, their self-serving conclusions should be rejected outright.

To return again to 12-step groups, their blind acceptance of the disease model of addiction caused them to lose credibility with me. Many overeaters in the group unthinkingly accepted this idea and referred to themselves as having a “disease.” They conceptualized it as some physical process that they could not control. This fit with the idea about needing to admit “powerlessness” over addiction, discussed below.

Powerful or Powerless over Addiction

One other aspect of the 12-step groups bothered me – their insistence on admitting one’s “powerlessness over addiction”. This never made sense to me. I wanted to build capacities and a sense of personal strength that would let me overcome my addiction. Why should feeling powerful be a bad thing? Today, I am probably burdened with an over-abundance of confidence, as the reader may see in this writing, but I am not ashamed of it. The 12-step program viewed “pride” as a sin, but in moderation I view personal pride as a virtue.

Neither the disease model of addiction nor the admittance of powerlessness over addiction are ideas that I am accept. Rather, I am proud to reject them wholesale. I never had an addictive “disease”, and I was never personally powerless to start recovering from my addiction.

In any case, the Puritanical, God-fearing, self-effacing aspect of 12-step groups were what finally led me to leave them. For a while, I continued to attend while trying to take the good things out of the group and ignore the “bad” things. However, this did not work, since as I developed more of an identity, the focus on “God” and “powerlessness” made me feel out of place there.

I searched for a similar but non-religious addiction recovery group, but did not find one. So, today I am without such a group. I feel the better for it, since I am being true to what I believe, and because I have found other ways of overcoming my addiction.

What Helped Me Overcome My Addiction

In reality, many complex interrelated factors helped me to overcome my addictive acting-out with food. Three of them stand out:

1) My work in therapy on not attacking myself for overeating, but instead compassionately understanding my acting-out behavior.

2) A focus on reducing the underlying need for the addiction, rather than on stopping the addiction itself.

3) A focus on building a positive,trusting relationship with my therapist, and later on with friends and family that replaced her.

I’ll discuss each of these in more detail.

1) Replacing self-blame with compassion

The psychotherapist Theodore Rubin wrote a great book called Compassion and Self-Hate: An Alternative To Despair. This book inspired me to start changing my attitude toward myself. Rubin describes dozens of ways in which people perpetuate destructive cycles by attacking themselves themselves rather than choosing self-compassion. He devoted a chapter to addiction in which he described it as one of the most insidious forms of self-hate.

Developing compassion for myself became a primary tool that allowed me to escape the metaphorical labyrinth of addictive behavior. I started by often repeating to myself the cliche that everyone is a person who deserves love and understanding, especially from themselves.

In various ways I would tell myself that I deserved better than to attack myself as worthless and horrible. I would particularly try to be gentle with myself right after I had relapsed and acted out, that being the time at which I most needed self-compassion. This eventually helped me to stop starving myself after the overeating episodes.

Eventually, it dawned on me how much energy I wasted calling myself names. My therapists often told me how “harsh” I was on myself, and their defense of my true self against the “false self” and its attacks proved a valuable model.

2) Focusing on what drives the need for the addiction, not the addiction itself

Early on in my addictive struggle, I obsessed over “stopping” the addiction. I would try to will myself to stop going and eating. Of course, this did not work, because underneath I still felt alone, unhappy, afraid, and hopeless. Even if I did will myself to stop overeating for a while, I would inevitably restart a few days or weeks later.

For long term recovery, my real need was to build an entirely new, healthy personality for the first time. This initially daunting task took years. Food did not drive my addiction. Rather, my entire borderline personality structure created and then drove the addiction.

My severe ego-splitting, low-self-esteem, inability to regulate feelings, and lack of identity created the fertile ground on which addiction grew. Some kind of addictive behavior was almost bound to develop, since the emptiness, hurt, and fear were so great that they could not be tolerated without an addictive distraction. If it were not food, it would have been something else.

Viewed in a more positive light, my lack of being nurtured in childhood created the personality problems that led to my addiction. I needed to find a good way to fill the emotional void created by my abusive childhood, and to begin to tame the swirling cauldron of fear, rage, and despair that accompanied it.

If I could come to trust other people, take in their love and comfort, and raise my self-esteem, I would have less need for the addiction and it would naturally diminish.

3 – Developing long-term good relationships

It is obvious, but it bears reminding ourselves that good, supportive human relationships are as crucial for a healthy personality as oxygen is for a healthy body. Without good relationships to real, external people, we do not develop adequate security, self-esteem, or the ability to regulate our feelings.

By around age 20, I had read extensively about Borderline Personality Disorder. From a psychodynamic standpoint, I understood that BPD reflected a faulty personality structure stemming from extremely poor relationships in childhood. It was hardly coincidental that so many borderlines reported abuse and neglect growing up.

To use Gerald Adler’s terms (from his book, Borderline Psychopathology and Its Treatment), the core of borderline psychopathology was a failure in the formation of soothing, comforting images (or functional introjects) of other people. This in turn resulted from a lack of sufficient good, comforting relationships in early life.

Since the ability to self-soothe never developed, the future borderline could not resolve splitting (which requires a predominance of positive over negative introjects) and continued to see themselves and others as all-good or all-bad into adulthood. All the other borderline symptoms like addictive behaviors, low self-esteem, suicidal ideation, etc. flowed from this central failure of nurturance and love in childhood development.

Given this research, I understood that I absolutely had to develop a trusting, dependent relationship with another person, or I would not get better in the long term.

This is what I worked so hard on with a series of therapists for several years. At the outset, it can be very difficult to trust someone when you have been let down and rejected countless times in the past. I often distrusted my therapists, telling myself that they cared about my money and not me, and that I was innately not worth caring about. However, over the years it gradually dawned on me that they were genuinely interested in helping me and that I did deserve help.

So much changed during the years that I pain-stakingly became able to trust my therapists and feel their support. It is impossible to describe it all here. But gradually, the external world became “real” and “in color” to me. For the first time, I became able to form real, loving relationships with people outside therapy as well as with my therapist. I developed real friends that I liked and that liked me. My relationship to my parents improved. I gained the courage to date women, and believed that a woman could love me for myself.

All of this internal and interpersonal progress helped my addiction. I felt less and less need – less desire – to overeat. I was not even thinking about it as much, because my focus shifted away from my inner world and toward the real, external world of human relationships. The previously exciting, addictive “thing” relationship to food held progressively less allure.

In this way I gradually conquered my addiction, replacing the inner emptiness and lack of love that drove it with real positive relationships and healthy self-esteem.

A Metaphor for Recovery from BPD and Addiction

This whole process of recovery makes me think of a long, slow version of the famous movie scene in which the Beast transforms into the Prince in Disney’s Beauty and the Beast. The curse on the Beast and his friends is lifted, the whole castle transforms into vibrant color, and the returned Prince can finally take in Belle’s love as a human being. It is a dream come true.

Although the Beast in the movie did not have an addiction (probably because Disney did not want kids to see a drug-addicted Beast!), he easily could have, given his isolation and despair in the castle for most of the story. The lesson that human love and taking the risk of opening up to another person transformed the the Beast is a timeless one and something I often remember.

That scene can be viewed here – http://www.youtube.com/watch?v=eM3j3S465oo

Or by searching for “Beauty and the Beast final scene” on Youtube.

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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

#6 – Life After Borderline Personality Disorder – My Vacation

Spending the last two weeks visiting my extended family in England provided a great opportunity to reflect on my journey over the past few years.

I had not returned from America to my homeland for six years. In 2007, the symptoms of BPD had a powerful hold over me. Extended travel away from home was so stressful that I could barely appreciate the positive aspects of a holiday trip to visit loved ones.

In the past, overwhelming feelings of being alone, abandoned, and afraid would prevent me from relating meaningfully to my extended family. Being healthier emotionally than my own parents, my uncles, aunts, and cousins would make genuine efforts to reach me and make me feel accepted.

However, these efforts barely reached me, because my emotional suffering canceled out everything else, and because I had no idea how to love or be loved by others. In fact, I experienced my relatives’ efforts to show me love as a threat. Emotional closeness had barely existed in my immediate family, and so its sudden appearance in them seemed alien, strange, and frightening.

In the Lord of the Rings trilogy of movies, there is a scene where King Theoden of Rohan is possessed by the evil spirit, Lord Sauron. Theoden looks aged beyond his years, and is unnaturally cold, with his coat and beard covered in ice. He barely recognizes his loving daughter and son. When the heroes of the story visit him, he unfeelingly asks why he should welcome them.

As those who have seen the movie may remember, Theoden is freed after the wizard Gandalf exorcises Sauron’s spirit from him. With the curse lifted, Theoden appears immediately younger, warmer, and is shocked at how coldly he acted previously. He returns to life and becomes able to love his family again.

When I saw this scene, I immediately associated it metaphorically with the way in which traumatic, neglectful experiences “possesses” people who are later said to have Borderline Personality Disorder. Abuse and neglect can warp people’s personalities and transform them into shadows of who they otherwise would have been. In technical terms, they are possessed by “bad objects”, or negative experience from the past, which prevents them from becoming the loving person they could be in the present.

Back to my trip to visit extended family – I had a fantastic experience! For the first time, I could deeply feel the love they had for me. I was nervous about how my family might react, since I had not visited for many years. However, they went out of their way to make me feel welcome. They provided a warm place to stay, included me in family meals, helped me get around London, and showed real interest in how my life in America was going.

When I was swamped with borderline symptoms, it had never dawned on me that these people had their own work, relationships, and interests. But now, I could perceive my relatives as separate, distinct people and really come to know them in the meaningful sense of that word. Previously, I would use them, but have no interest in them beyond their ability to satisfy my immediate needs. This year, I discovered my uncles, aunt, and cousins as real people for the first time.

While exploring London, I was fascinated to discover how people in London, UK live so differently than in my American suburb – for example, they use public transport all the time, walk great distances, have few big cars, shop at tiny grocery stores, etc. Christmastime was fantastic – there were crafts markets full of international artisans, outdoor ice skating rinks everywhere, magicians and acrobats peforming in public parks.

These varied sights were meaningful in that when I was severely borderline, I would not have noticed them, or at least would not have delighted in them. I would have been like King Theoden, “possessed” by my negative emotions and prevented from taking in good things from the outside world. However, in 2013, a childlike sense of wonder and discovery dawned on me.

In his great writing on borderline conditions, the psychoanalyst Harold Searles described how the successfully treated borderline patient would eventually experience a psychic “rebirth”. The person would belatedly experience a sense of wonder and discovery, of being the child that joyfully explores the world for the first time.

It is important that such a regression not go on too long, because it is also critical to mourn the real losses in a childhood marked by severe abuse, and to develop mature adult emotional capacities in general.

However, every borderline deserves to one day feel this childlike joy – the delight of knowing that you are better, that you are alive, and that the world is there for you to discover.

Another primary emotion in me right now is vindication. This recent vacation is yet another, among hundreds of positive experiences in the last few years, by which I have disproven those who say that BPD is incurable and hopeless. I know that one can recover fully from Borderline Personality Disorder – and not even have the disorder at all anymore – because I am living that recovery.

If I’m to become more fully mature, I’ll need to fully relinquish the desire to get back at those who kept me down in the past. However, proving people wrong remains one of my favorite things, and so it won’t be too damaging to delight a little bit in my ongoing victory over the “false prophets of Borderline Personality Disorder.”

Among the “false prophets of BPD”, I include:

– Those therapists and laypeople who say that Borderline Personality Disorder is life-long, i.e. that once you have BPD it cannot ever fully go away, the implication being that it can only be managed while living a life periodically afflicted by its symptoms.
– Psychiatrists who believe BPD is biologically- or genetically-caused and needs to be treated primarily with medication.
– Anyone who says that borderlines are bad or evil, that they are not motivated to get better, and that they have a bad prognosis or are hopeless.

To all such pessimists, I am delighted to prove you wrong on a daily basis. There is a reason this post is titled, “Life After Borderline Personality Disorder.” Whether or not you believe what I write doesn’t matter one iota, because my feelings and experiences are 100% real to me. I am your reckoning.

I only hope that other borderlines will take heart from people like me who have recovered. Borderlines have enough challenges with which to deal on the road to recovery, without being burdened by the discouraging opinions of those who stigmatize them.

My message to borderlines reading this is – Don’t pay one bit of attention to the pessimists and liars that say you can’t get better. Borderline Personality Disorder can be fully recovered from, and life can be far better than you imagined. Let yourself dream of a better tomorrow for yourself and those you love.

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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

#2 – How Did I Recover from Borderline Personality Disorder?

People reading this page are probably searching for hope and encouragement, either because they have problems related to Borderline Personality Disorder or they care about someone who does. Or, perhaps they are simply curious and wonder whether BPD can be recovered from.

On this page, I will describe what allowed me to move from being an emotionally immature young person, suffering from many painful borderline symptoms, to being the relatively mature, functional, and symptom-free adult that I am today.

When I Was “Severely Borderline” – Teenage and Young Adult Years

From approximately ages 13-23, I was severely emotionally ill. I had the following symptoms, most of which are in the DSM-IV definition of BPD:

– Severe anxiety and depression most of the time, with little ability to comfort myself.
– Constant feelings of emptiness and low self-esteem.
– Acting out in various ways, especially overeating.
– Viewing other people and myself as all good or all bad, accompanied by childlike clinging toward the “good” people and extreme rage against the “bad” people.

– Very poor personal relationships in terms of their emotional depth – I had no real friends and tended to use people for my needs and then quickly lose interest in them.
– No clear identity or long-term goals – I usually only planned a few days or weeks ahead.
– A tendency to be paranoid and fear that other people were “out to get me”.
– Intense fear of losing important family members (fear of abandonment).
– Suicidal thinking when I became very depressed.

These symptoms persisted relatively constantly for 10 years starting in middle school. It is difficult to describe in words how painful or frustrating they were. Externally, I tried to appear normal and to function in school and work, but internally it was a constant emotional nightmare. I felt myself to be cursed, a walking example of Murphy’s Law, existing in a personal hell on earth. When first working on recovery, I had no idea where to go. Emotionally, I felt like a cork caught in the waves of a stormy sea.

My Progress Toward Being a Mature Adult Today

However, here is how I would describe myself today, at age 28:

– Able to regulate my feelings– I can comfort myself and rarely become anxious or depressed.
– Able to think in an ambivalent way, and to see others and myself as good and bad at once.
– Have confidence in myself, possessing a clear sense of what I want to do in work and relationships. I think long-term, able to plan months and years ahead.
– Able to feel genuine concern and interest in others, rather than only using them to satisfy my needs.

– Have had a good romantic relationship and several meaningful long-term friendships.
– No paranoid thinking, suicidal ideation, or fear of abandonment.
– Able to function independently in a job I enjoy; no need to cling to other people to function well.
– Have a strong core identity which persists through difficult times.
– Much reduced acting out – I still do occasionally overeat when under unusual stress at work, but it’s much less of a problem than before.

I am pretty happy with how my life is going today, and proud of myself for the work I did. How did I make these changes to develop a good life, and to lose almost all of my borderline symptoms?

What Helped Me Become Healthy and Non-Borderline

1) Long-term psychotherapy

Starting in my late teens, I was fortunate to be able to attend psychodynamic, psychoanalytically-informed psychotherapy. At first, I went once a week, and then for several years I went an average of twice a week, sometimes going three times a week during difficult periods. It was extremely expensive, and I was fortunate to have parental financial support to go to therapy (I later financed myself, sacrificing in other areas of my life so that I could go to therapy). Essentially, I used psychotherapy as a reparenting process in which I worked to be able to deeply trust someone else for the first time. My various therapists – I had four significant ones – provided me with crucial emotional support that allowed me to become independent in my job and to develop better interpersonal relationships. They were the substitute mothers for my emerging true self.

In other articles, I will discuss more extensively how and why therapy helped me, my views on therapy vs. medication, as well as options one has if one does not have the money to go to therapy initially (therapy is certainly not the only path to getting better, although it can be very valuable).

2) True friends

Starting in my late teens, I was fortunate to develop a close friendship with a man, Gareth, who knew about my history of physical abuse (my father beat me throughout my childhood). He was an older, middle-aged family man who I met via the shared interest we had in tennis. I took the risk of opening up to Gareth about my problems, and we developed a friendship that has endured to this day. We spent hundreds of hours talking through my past and present problems. There were many times I cried with him, as well as some periods when I became angry or paranoid and misunderstood his kind intentions. However, most of the time his support was extremely helpful, coming during a period of my life when I desperately needed love and understanding. I will be eternally grateful to Gareth for his decision to help me.

From about age 15 until the present day, I developed three other close friendships, with two men and one woman, all of whom helped me tremendously and gave me hope that life could get better. My relationships with Julian, Andrew, and Helena were similar in quality to the first one described above, in that I took the risk of opening up to these people, telling them my life story, and asking for help. However, they were not as deep or intense as the first one.

Today, I also have a number of other important friendships, but they are more “normal friends” that I enjoy for themselves and can share my present-day sense of self with. These friends do not know my history of being borderline in nearly as much depth as the four people I opened up to in my teens.

I will write more in another article about how genuinely opening up to another person for help is one of the most important risks a borderline person can take.

3) Family – My mother

Despite her faults, my mother supported me financially to go to psychotherapy, and she did genuinely care about me although it was difficult for me to feel that fact early on. She had a very difficult relationship with my father, and her decision when I was 18 to divorce him and live alone provided me with a stable, safe place to live for several years. As I became a young adult, I came to trust my mother more and risked talking to her openly about some of my problems. This occurred in parallel with my trusting and opening up to the friends noted above. To my mother’s credit, she matured along with me, becoming a supportive listener and a cheerleader for my developing independence. I owe much of what I am today to her heartfelt efforts to help me.

4) My passion – tennis

The one thing I always liked as a young child was the sport of tennis. I took group classes at the local club and viewed the coaches as substitute father-figures. The process of hitting the ball and running around with other children became addictive, and I developed an obsession with the pro game and players like Roger Federer. Perhaps surprisingly, this interest endured during my teens and early twenties even when I was struggling with all the horrible emotional symptoms associated with Borderline Personality Disorder.

Tennis had great value as something that distracted me from my emotional suffering during the most difficult periods, and had meaning for me in its own right. It also led me to work with children as an assistant coach in college, which eventually led to my present day job, in which I work with kids.

5) My own study of Borderline Personality Disorder

When I first learned about BPD, and later was diagnosed with it, I was terrified because of all the pessimistic descriptions about how difficult it was to help people with the diagnosis and how many therapists did not want to treat them. Online web forums were filled with horror stories about manipulative, evil, hopeless borderlines.

Over time, I researched BPD extensively and came to a more nuanced understanding of it. I understood it from a developmental perspective, meaning how traumatic childhood experience shapes later adult problems, as well as from an object-relations perspective, referring to how the traumatized individual uses psychological defenses and modes of relating that distort the external environment based on pathological internal views of themselves and others. More on that in later posts.

I studied the writing of many therapists who had successfully treated individuals with BPD, including Harold Searles, Vamik Volkan, Otto Kernberg, Heinz Kohut, Gerald Adler, James Masterson, Peter Giovacchini, Jeffrey Seinfeld, and others. I met Gerald Adler and James Masterson in person and interviewed them about their views on the treatability of BPD. From this research I developed an overall picture of what was necessary in the “big picture” for borderline individuals to become non-borderline. In essence, the traumatized person needed to learn to trust and accept support from another person, and to be helped via a therapeutic alliance to develop healthy adult ego functions that they never developed as a child. By around age 20-21, I understood BPD in more depth than many therapists do. Understanding it taught me what was necessary for a successful recovery process.

I will write much more about these issues in later articles, but for now, the point is that having a map of where to go when struggling with BPD helped immeasurably.

6) Eventually abandoning the concept of BPD

Paradoxically, I now no longer believe that Borderline Personality Disorder is a valid diagnosis. This is despite the fact that I was diagnosed with it, and have recovered from having almost all of its symptoms.

As I improved, I continued to be periodically worried or depressed by the idea that I was still a borderline. I would often fear that maybe the writers who said borderlines were untreatable and hopeless were right, that I would always be a borderline, and that if I did improve I would inevitably relapse.

Today, I view BPD as an archaic, outdated term, one fabricated by psychiatrists to (mis)label a wide range of severely abused and neglected people. To me, a more realistic view is that “borderline” symptoms exist on a continuum of severity, i.e. that there is no firm line that divides borderline from non-borderline. Looking back, it is obvious that as I recovered there was no past time at which I suddenly no longer “had” BPD, if I ever had it at all. Of course, I did have (and gradually stopped having) all of its symptoms, which were real and extremely painful.

Once I realized this, I experienced a paradigm shift in which I was no longer worried by the diagnosis of BPD, since I regarded it as invalid.

7) My curiosity, resilience, and aggression

By my nature, I have always been curious. This helped me when dealing with BPD, since it spurred me to extensively investigate the disorder and how it could be treated, as well as to eventually question its validity as a useful diagnosis.

Even more important, I am one tough cookie (I was going to use another word, but want to keep this blog’s language clean!). Starting in my early teens, I promised myself that I would get better or die trying. After reading about how borderlines often failed to improve, I defiantly predicted that I would recover. I weathered the long, slow storm of many years of depression, anxiety, rage, and uncertainty, never giving up despite times when things seemed hopeless.

Lastly, I can be a pretty direct and blunt person. Aggression is often regarded as a “bad” thing in our society, but aggressively seeking out the truth or defending oneself when under attack can be good things. My aggressive rejection of those who are pessimistic about BPD was important in my recovery. I’m not afraid to say what I really think, as you will see on this site!

These qualities are partly genetic. They certainly helped me with my challenges. Each person has their own strengths, and there are other ways in which I’m not as gifted as others. For other people working to recover from past trauma, it may be these or other strengths that are most useful on their journey.

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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