Tag Archives: borderline personality disorder treatment

#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

#26 – Why BPD Should Be Abolished, and What Should Replace It

Do we want people to believe that BPD is a real psychiatric illness that they must manage for the rest of their lives, or do we want to promote a message of hope which says, “You can become free of your emotional distress and live the life that you want”?

By presenting BPD as a severe mental illness which can be managed but not cured, the medical model of the BPD label utterly fails to promote hope. Additionally, the medicalized concept of BPD is scientifically broken: It does not describe a valid illness which is consistent across a population.

Why do we keep using BPD if there is so much wrong with it? Is it possible that we would be better off without BPD?

And if BPD is should be abolished, what should replace it?

This article addresses how to replace BPD.

To this question, my first answer is “Nothing” – that we should simply abolish BPD – and my second answer is “Emotional Dysregulation Susceptibility Syndrome”, which I will explore as a hopeful alternative. Let’s discuss these options.

Background: The Medical Model and My Opposition to NEA and “Make BPD Stigma Free”

My central conceptual argument is that Borderline Personality Disorder as defined in the DSM is an unreliable, invalid concept. Given its current popularity, it’s not easy to fight against the prevailing notion of BPD as a valid mental illness. But after speaking to many people who also experience BPD as a flawed, discouraging concept, I am more resolute in this view than ever. If you are unfamiliar with the argument against BPD, please see here, especially Myth #5:

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

While I prefer to understand people without labels, due to practical considerations I contend that BPD should be replaced by a more hopeful label. This new label should refute the myth of BPD as a life-long mental illness and emphasize vulnerability to stress along a continuum.

My position against BPD directly opposes the thinking of many in the psychiatric establishment, including large organizations like TARA BPD, the Treatment and Research Advancements Association for BPD, and NEA BPD, the National Education Alliance for BPD.

TARA and NEA assert that BPD is a “serious psychiatric illness”, one which they can reliably investigate and for which they will create improved treatments. In my opinion, these medicalized viewpoints represent poor research and outright misinformation.

Let me list and critique some of National Education Alliance BPD’s main positions. I hope the reader will sense how badly NEA’s claims on BPD, which often border on outright lies, fail to meet the criteria for good science and basic common sense.

My Response to NEA’s Misinformation about BPD

(Source – http://www.borderlinepersonalitydisorder.com/what-is-bpd/bpd-overview/)

1) BPD is an “illness”.
NEA’s position: BPD is a single illness which causes unstable mood and behavior.
Edward’s response: BPD is not one unitary entity that causes anything. BPD is not a single illness because the symptom-cluster that supposedly represents BPD cannot be reliably identified by any biomarkers (genes, brain scans, etc.) nor reliably identified by different psychiatrists across a population, as the NIMH recently admitted.
The way a person understands their world based on past experience leads to unstable mood and behavior.

2) Genes are involved in causing BPD.
NEA’s Position: Scientists generally agree that genetic and environmental influences are likely to be involved in causing BPD.
Edward’s response: This is misleading on so many levels it’s hard to know where to start. Again, BPD is not one reliable entity. And there is no evidence that genes “cause” any of the distress-experiences denoted by the BPD misnomer – such thinking involves the mistaken assumptions that genetic and environmental factors work as separable influences in a quantifiable manner. I have written about these distortions extensively in my article on twin studies (#4).

3) Brain scans provide evidence that biological factors cause BPD.
NEA’s position: There is evidence that biology is a factor in causing BPD, due to imaging studies in people with BPD showing abnormalities in brain structure and function.
Edward’s response: Does NEA think the public cannot understand basic cause and effect? Of course seriously distressed people have observably different brains than “normals”. That doesn’t mean biology or genes cause these differences; neglect, abuse, and lack of love, which are much more prevalent in those labeled “borderline”, inevitably lead to different brain functioning. But that doesn’t even mean those things cause BPD or that BPD is real. Never take a difference for an illness.

4) Biological factors make people more likely to develop BPD.
NEA’s position: The current theory is that some people are more likely to develop BPD due to their biology or genetics and harmful childhood experiences can further increase the risk.
Edward’s response: The current theory is a demonstrably false hypothesis. Constitutional vulnerability to stress may make it easier for some people to become overwhelmed by environmental stress, but that doesn’t mean that BPD is in any way a valid illness, nor that such people cannot become well. Plus biology and genetics do not act alone in the way implied in this reductionist model (see – http://www.madinamerica.com/2015/06/are-dsm-psychiatric-disorders-heritable/ )

5) The prevalance of BPD can be quantified.
NEA’s position: BPD affects 5.9% of adults at some time in their life
Edward’s response: Does anyone really believe that a subjective, descriptive label with no biomarkers can have its prevalence reliably identified to a tenth of a percentile?

6) BPD is a life-long mental illness.
NEA’s position: People with BPD have BPD for life. (NEA stops short of saying this outright, but they imply it. Their website talks over and over about managing and reducing symptoms in “borderlines” of different ages, never once mentioning the possibility of becoming free of “the illness” or discussing the possibility of full recovery)
Edward’s response: This is one of the most damaging myths being promoted about BPD. Problems that are mislabeled BPD can be fully recovered from; people who once approximated borderline criteria can eventually live a satisfying, emotionally normal life. Many thousands of people have already done so. Getting better is hard work, but people do not have to cope with and manage BPD for life. People need real hope, not the discouraging prospect of a life-long illness.

My Manifesto Against National Education Alliance for BPD

As can be seen, NEA BPD set themselves up as the experts on how to define and treat the BPD “illness”, an illness label they obviously intend to keep. But they may not have considered that former “borderlines” can see through their propaganda.

My position on NEA’s “BPD as a serious psychiatric illness” notion is this:

  • Severely distressed people do not have accept the label BPD as an identity nor as an explanation for their problems.
  • Emotional problems are not reducible to “psychiatric illnesses”, nor are they the exclusive province of psychiatry.
  • Effective help which often leads to full recovery from problems mislabeled BPD already exists. Recovering does not require the assistance of “experts on BPD”, nor does it require DBT and medications, although these can help. Also, people can have their own definition of recovery and a meaningful life.
  • Emotional problems mislabeled BPD can be completely healed and do not have to be managed for life.

It’s time to say goodbye to National Education Alliance’s harmful theories about BPD as a life-long psychiatric illness, to end the borrowed time these theories have been living on.

Why Reducing BPD’s Stigma is Doomed to Failure

I also oppose the message of blogs that attempt to put a positive spin on BPD, like “Make BPD Stigma Free”. In my opinion, reducing BPD’s stigma and building “BPD Pride” is doomed to failure. To me, these efforts resemble shifting deck chairs around on the Titanic. Similar attempts to reduce depression’s and schizophrenia’s stigma have foundered miserably; the problem is that reducing complex emotional issues to medical labels explains nothing and fails to empower people.

Two examples of such programs are instructive:

  • “Defeat Depression”, a large scale British campaign to reduce the stigma of Major Depressive Disorder, failed to reduce stigma and did not improve outcomes according multiple follow-up studies.
  • “Beyond Blue”, an Australian attempt to reduce the stigma of so-called mental illnesses, also backfired. Studies investigating its effect found that those who knew less about mental illness diagnoses, or who were given a diagnosis but rejected it, had better outcomes than similar people who believed they “had a mental illness.” This unsettling finding has been confirmed in John Read’s research (e.g. Models of Madness).

The disturbing conclusion of this research is that accepting that you have a “mental illness” – as opposed to rejecting the medical model of emotional distress – actually decreases the chances of recovery. This shocking Youtube presentation by critical psychiatrist Sami Timimi covers this and other eye-opening facts about “mental illness”:

If Defeat Depression and Beyond Blue failed to destigmatize depression, why should a destigmatization program for BPD succeed? Alongside “schizophrenia”, BPD is the most unreliable, invalid, confusing, harmful, stigmatized, and useless label. Even if BPD were to lose its stigma, it would remain an unreliable term that explains nothing about an individual’s problems.

Abolishing BPD – The Ultimate Goal

Borderline Personality Disorder can and should be entirely abolished. BPD should be consigned to history as a tragically misguided way of
concretizing emotional distress.

Here is how a world without BPD would look:

1) No More BPD Diagnoses: Distressed people would no longer receive the BPD label during hospitalizations or psychiatric consultations. They would be understood as individuals using the Formulation approach to distress (see article #19 here – https://bpdtransformation.wordpress.com/2014/12/04/19-hope-meaning-and-the-elimination-of-borderline-personality-disorder/).

2) Label-Free Treatment: Psychotherapists and treatment programs would help distressed people without viewing them as borderline, no matter how much the client “fit” that outdated term.

3) Label-Free Family Understanding: Families would be helped to support their distressed members without being fed the fiction that their loved one “has BPD.” Parents, siblings, partners, and children would find that their loved ones’s problems can be understood without calling them borderline.

4) A New Research Paradigm: into severe emotional problems would cease to be focused around BPD. It would instead use the emotional dysregulation spectrum concept that I’m going to discuss. There would be more qualitative, experience-focused research, and less quantitative label-focused research.

5) Abolition of BPD and the DSM: BPD would be abolished from the DSM, as it has already been removed from ICD (Europe’s version of the DSM, from which BPD was recently voted to be dropped). Furthermore, as an unscientific fraud full of fictional illnesses, the entire DSM would be eviscerated.

In time, BPD would be viewed as an outdated relic, a sad symbol of an age where psychiatrists constructed bizarrely misguided labels for emotional distress. People in the year 2200 would look back on “BPD” in disbelief, much as people today look back at centuries-old conceptions of physical illnesses. BPD would be mocked alongside notions of evil spirits released by bloodletting and plagues caused by divine curses.

A BPD-free world is possible. People often underestimate what can be done over long periods of time with sustained, gradual effort. Perhaps BPD’s life is already growing short.

How Would We Understand People Without BPD?

What a scary idea! How could we ever understand people showing “borderline” symptoms without labeling them with BPD?!

How do we understand the problems of anyone we care about?

1) Listen to their story. Learn about what past and present experiences are causing their distress. Develop a shared understanding of their problems based on their history.
2) Learn about what they want to change in the future. Develop a shared understanding of their needs and dreame.
3) Understand fundamental human needs for security, dependence, respect, and independence.

These are the fundamental steps in the Formulation approach to emotional distress, as described here in the story of Emma:

https://bpdtransformation.wordpress.com/2014/12/04/19-hope-meaning-and-the-elimination-of-borderline-personality-disorder/

People labeled “borderline” can be effectively helped without labeling them as BPD. But because of the reductionist ideology that has crippled the minds of too many mental health “professionals”, abolishing BPD without a replacement label may be a bridge too far. The Big Pharma profit incentives which maintain the need for medicalization of emotional distress present another obstacle.

The First Step Toward Abolishing BPD – A New Name

Supported by the public’s ignorance about what a precariously perched house of cards “BPD” really is, the profit motives of psychiatrists and Big Pharma will likely block a total abolition of BPD, even though BPD paradoxically never existed and does not exist today. Therefore, I suggest the intermediate step of renaming BPD, something which has already begun to happen for other pseudo-illnesses such as “schizophrenia”.

If done well, renaming BPD would accomplish multiple goals:

1) Undermine the false conceptualization of emotional distress as an illness that is consistent from person to person.
2) Emphasize that emotional distress varies along a continuum and that people labeled “X” are not always “X” (i.e. are not always distressed, but are vulnerable to stress).
3) Reduce stigma by introducing a fresh name without negative connotations.

Despite these hopeful goals, one might argue that replacing BPD with another name would lead to just as much stigma and misunderstanding.

But could a new name truly aspire to be as miserably uninformative as Borderline Personality Disorder?

Would BPD by any other name smell just as bad?

I doubt it.

Japan, Jim Van Os and the Abolition of Schizophrenia

I’ve gone through some brainstorms about what BPD could be renamed, drawing on the campaign against “schizophrenia” for ideas. Many people are calling for schizophrenia to be abolished, and Japan legally abolished schizophrenia about 10 years ago

(Yes, there really are no more “schizophrenics” in Japan. They have a new, less-stigmatizing name for psychotic distress, meaning “integration syndrome” in Japanese, and people undergoing psychotic episodes are no longer called schizophrenic. The entire Japanese government-recording and psychiatric-labeling system for psychosis has been changed. See here – http://www.schres-journal.com/article/S0920-9964(09)00140-6/abstract ).

Jim Van Os, a Dutch psychiatrist, created a website labeled “Schizophrenia Does Not Exist” here: https://www.schizofreniebestaatniet.nl/english/

Van Os renames schizophrenia, “Psychosis Susceptibility Syndrome” , or PSS. The name implies that psychotic experience occurs along a spectrum of severity, involves vulnerability to environmental stress, and that people who have been psychotic in the past are not always psychotic today. In this model, “schizophrenia” as a discrete illness is meaningless and false.

Taking Van Os’s lead, I suggest replacing Borderline Personality Disorder with “Emotional Dysregulation Susceptibility Syndrome”, or EDSS.

The Emotional Dysregulation Susceptibility Syndrome

If BPD were renamed Emotional Dysregulation Susceptibility Syndrome, what would that mean? The EDSS concept would contrast with BPD as follows:

1) Spectrum, Not Illness: EDSS represents a spectrum or continuum of increasing vulnerability to emotional distress. Despite similar appearances, people vary along this spectrum both in degree and kind of distress experienced. People would have more or less “EDSS” in relation to others and themselves at different times. EDSS is therefore not one illness, but a spectrum of related conditions – it refutes the misrepresentation of BPD as an internally reliable illness.

2) Vulnerability, Not Illness: EDSS represents a heightened susceptibility or proneness to emotional distress, usually correlated with neglect and abuse in childhood. EDSS itself does not cause distressing symptoms; rather, it represents the heightened likelihood of environmental stress causing these distress experiences. Compared to BPD, EDSS gives more weight to what happens around a person, rather than to isolated non-contextual internal experiences. EDSS is a syndrome – again meaning it represents similar-appearing experiences which do not necessarily reflect a consistent underlying illness.

3) Recovery and Freedom, Not Management: EDSS represents a psychological state that someone can be in at a certain time of their life, but can grow out of and be free from at a later time. It is in no way a lifelong condition. With effective help, people have a good chance of moving out of the EDSS spectrum for good. This refutes one of the most damaging lies about BPD: That BPD is a life-long illness.

(If you could rename BPD, what would you call it and why? Or would you keep BPD? Let me know in the comments.)

A Psychodynamic Model of the EDSS Continuum

Drawing on my psychodynamic background, I conceptualize Emotional Dysregulation Susceptibility Syndrome as a continuum marked by a relative deficit of positive self/object images, combined with a predominance of all-bad images of self/other within a person’s mind. The deficit of good internalized experience and the predominance of all-bad self/other images would usually correlate with neglect, lack of love, abuse, or trauma caused by parents and peers in childhood and young adulthood. I developed this model fully here, drawing on the “master theorist” of borderline-spectrum conditions, Ronald Fairbairn:

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

The deficit of all-good images leads to the inability to comfort oneself when under stress (i.e. emotional dysregulation), and to the increased susceptibility to stress relative to most emotionally-healthy people who had more consistent past and present support. All the other distress experiences commonly labeled “borderline” – e.g. destructive acting out, lack of identity, rapidly shifting moods, extreme rage, splitting, etc. – would be understandable results of having to cope with the missing self-comforting functions that can only be provided by a predominance of good self/other images over bad self/other images, i.e. enough good experiences in one’s past to reassure oneself when under present-day stress.

These distress experiences would also be understood as present-day replayings of past trauma; i.e. as the projection of the all-bad self-object images internalized in childhood onto others in the present, which make the person experiencing EDSS feel that they are “bad” and others are rejecting or unavailable.

EDSS might also be conceptualized as the spectrum encompassing the “Out of Contact” through “Ambivalent Symbiotic” Phases in this 4-phase model:

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

These descriptions do not represent an illness, but rather a dynamic state of relating to oneself and others at a certain time. One can function at any point along the spectrum from almost Non-EDSS to very severe EDSS – i.e. from approaching a normal range of being able to comfort oneself and function well, with only occasional regressions into serious distress – down all the way to very severe EDSS, in which the distress experiences are constant and severe to the point that normal functioning is not possible. Hopefully that the paradigmatic differences between BPD and EDSS are clear.

You Don’t Have to Accept the BPD Label

I hope these ideas will be encouraging and provoke thought about whether BPD really is valid and useful. Replacing BPD might seem unthinkable now, but there were times when women voting seemed impossible, when black people being free seemed impossible, and when tobacco causing health problems seemed impossible. Radical change can happen. Often, the process leading to a dramatic change is gradual and unseen, like when decades-long pressure building under the Earth’s crust goes unnoticed before an earthquake.

If a small but growing number of people reject the BPD label, this process can build momentum toward renaming and/or abolishing BPD. I encourage everyone reading this who has ever been labeled “borderline” to consider that you no longer have to identify with or accept BPD, period.

If a psychiatrist labels or has labeled you as BPD, or if the voice of people calling you borderline is stuck in your mind, I encourage you to tell them something like this:

“The BPD label you’ve called me is a simplistic checklist of distress factors, factors which anyone under stress for long enough can experience to different degrees. There are no reliable genes, brain-scans, or other biomarkers which can identify so-called BPD. In fact, BPD is in no way a reliable classification; it is an “illness” fabricated out of thin air without a basis in real science.
There is therefore no proof that I have an illness like you say, or that there is anything innately wrong with my brain; most likely, I am reacting in a perfectly logical way to the stresses I’ve gone through. There are other, better ways to understand my problems, and I do not accept the false label of BPD that you are putting onto me. If I get enough help, I can fully recover and live the life that I want.”

Psychiatrists and therapists need to hear this from more of the people they call “borderline”!

#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

#10 – Four Phases of BPD Treatment and Recovery

In their treatment of Borderline Personality Disorder, certain psychodynamic therapists developed a four-phase object-relations approach. The four phases included:

1)      The Out-of-Contact Phase

2)      Ambivalent Symbiosis

3)      Therapeutic Symbiosis

4)      Resolution of the Symbiosis (Individuation)

The Washington, DC-based psychoanalyst Harold Searles originated this approach in his work with hospitalized psychotic patients in the 1960s and ‘70s. He later adapted it to use with less disturbed borderline-spectrum patients. In the 1990s, New York social worker Jeffrey Seinfeld updated Searles’ four-phase model in his book The Bad Object.

Over the last 10 years, as I worked to transform my borderline illness in therapy, I passed through these four phases sequentially. They describe a severely troubled person’s emotional experience at different stages of treatment, while providing an object-relations model which delineates the relative strength of positive and negative self-and-object units. For me, they are the most accurate way of conceptualizing the progress of a borderline individual in recovery.

None of this is meant to minimize the great differences which exist among individual people diagnosed with BPD. These phases are not meant to be exact descriptions of what each borderline in recovery experiences. Rather, they are a rough map of the recovery journey.

This model’s four phases of therapy for BPD can be subjectively described as follows:

1)      Out-of-Contact Phase – In this earliest phase, the borderline individual is emotionally cut off from the outside world, existing in a “closed psychic system” where little to nothing from the outside world influences them in a positive way. Searles described the patient and therapist in this phase as being “isolated in their own psychic territories”. Out-of-contact patients experience themselves passing through life like automatons, with little to no subjective emotional experience. They experience profound depersonalization and derealization (not feeling real).

These people bring to mind tragic characters from Franz Kafka’s novels, individuals who experience life as meaningless and the outside world as full of capricious, heartless persecutors. They are symbolized in T.S. Eliot’s The Wasteland as “men who have lost their bones”. The wasteland represents the internal psychic world of people who, because of overwhelmingly severe neglect and/or abuse, have lost all hope of forgiveness, love or redemption. Instead of hope, there is the view of the outside world as cold, empty, unforgiving, and punishing.

The out-of-contact phase represents the most severely emotionally ill borderline individuals. These individuals usually have chaotic lives in which they are unable to commit themselves consistently to jobs, living places, or relationships. In therapy, they experience the therapist in his empathic helping role as being like “an alien creature from another psychic planet” (Seinfeld). They do not tend to develop a positive relationship to the therapist, or to understand what therapist is about.

2)      Ambivalent Symbiosis – This second phase represents those borderlines who have had enough positive emotional experience to hope that recovery is possible. They believe in the possibility of reclaiming a good relationship with the outside world. They form an ambivalent relationship in which they want to trust the therapist, but at the same time fear being retraumatized and thus maintain distance.

Searles described this phase as “the therapist and patient driving each other crazy.” There is a constant struggle between accepting versus rejecting the therapist’s help. The feeling tone between patient and therapist is primarily one of aggression, wariness, and provocation. In this phase, the patient will find complex, often subtle ways to maintain distance from the therapist and prevent the development of a therapeutic symbiosis.

The struggle of an ambivalent symbiotic patient to trust their therapist, and accept loving support from the world in general, brings to mind Joseph Campbell’s classic conception of the hero (from The Hero with a Thousand Faces). The archetypal hero must struggle against demons, ghosts, monsters, or human enemies to reunite with good people with whom they have lost contact.

A famous example is Homer’s Odyssey, in which Odysseus must prevail against monsters, sirens, and traitorous suitors to reunite with his beloved wife and son. Analogously, the ambivalent borderline patient must overcome the metaphorical demons of past neglect and abuse, fighting through their distrust and fear of closeness to become able to love other people again.

My favorite example of this transformation occurs in the Disney movie, Beauty and the Beast. The Beast must overcome his distrust and anger toward the outside world, and learn to love another, or be forever cursed to live in non-human form. His castle metaphorically represents the type of “closed emotional system” that many borderline individuals live in.

Compared to out-of-contact patients, ambivalent borderlines tend to commit themselves much more consistently to regular jobs, living places, and relationships. They have more real, positive emotional investment in the outside world, and thus more basis for hope that things can improve further. However, because they are afraid of intimacy and of really trusting others, their overall personality structure remains fragile, and they are vulnerable to separation stress.

3)      Therapeutic Symbiosis – If the borderline patient can come to deeply trust the therapist, the phase of therapeutic symbiosis gradually emerges.

Searles described the feeling tone of therapeutic symbiosis as characterized by “maternal care and love.” In this phase, the vulnerable, childlike aspect of the borderline reemerges and is nurtured by the therapist, who is idealized as a perfect parent.

For the borderline patient, who has struggled his whole life to achieve psychological wholeness, it is difficult to overstate the benefit of a prolonged therapeutic symbiosis. A genuine therapeutic symbiosis is a psychic rebirth or redemption, a transformation in which the person comes to feel truly alive for the first time. It marks the beginning of the subjective sense of self, and the first true awareness of psychological separateness from other people.

During this phase, the borderline’s independent functioning is enhanced. They become more assertive in achieving goals in work, study, or other interests. They begin to be able to tolerate separation from other people better, without always feeling lonely or abandoned. And their self-esteem improves dramatically.

Because of the awareness of separation and the gain in self-esteem, the (former) borderline in therapeutic symbiosis usually develops healthier, rewarding relationships with new people in the outside world. They become increasingly aware of how many positive experiences they have missed out on during their earlier years as a borderline personality.

4)      Resolution of the Symbiosis / Individuation – In this final phase, the (now former) borderline comes to function increasingly independently, and to need the therapist less and less. Gradually, the patient becomes disillusioned with the therapist, realizing that the therapist is not their parent, cannot solve all their problems, and will not be there forever.

In this phase, the patient increasingly develops an individuated sense of themselves as a unique and valuable person. In a parallel fashion, they become more and more aware of other people’s separateness and of the individuality of others. In a successful treatment, the patient gradually tapers down the frequency of meetings with the therapist, coming increasingly to manage life’s challenges using their own inner resources.

Comments on the Separability of The Four Phases

In reality, these four phases are not strictly separate. For example, a given patient could have periods of being out-of-contact, alongside periods of being ambivalent toward the therapist. Often, one phase at a time will predominate. But sometimes, the patient will show aspects of multiple phases at once.

Searles described how patients may oscillate between phases, progressing in a two-steps forward, one-step back fashion. This is particularly the case when a patient is transitioning from one phase (e.g. from being mainly ambivalent and doubtful toward the therapist) into another phase (e.g. to trusting and accepting the therapist’s support).

Like the diagnosis of Borderline Personality Disorder itself, these phases are not scientifically validated or based. They are based purely on the observation of therapists working with borderline patients. For that reason, they should be viewed with caution, since they may not be useful or a fit for everyone diagnosed with BPD. However, in my experience, these phases and the underlying object-relations they are based on (to be discussed below) form a remarkably accurate and useful way to conceptualize BPD recovery.

 An Object-Relations Analysis of the Four Phases

To better understand them, it is helpful to describe the four phases using object-relations terminology. For an overview of object-relations, please see my last article below, on the theories of Ronald Fairbairn, one of the founders of object-relations theory.

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

Writers like Searles and Seinfeld thought about early psychological development in terms of the “good” and “bad” object relations units theorized by Fairbairn. They then integrated these units into the sequential four-phase theory of treatment for borderlines which I am outlining here.

Here are the four phases again, this time considered in terms of the relative strength of positive and emotional self and object images within the mind of the borderline patient:

Out-of-contact Phase’s Object Relations – This phase features a strong dominance of all-negative mental images of self and other. These self-and-object units actively reject internalization of anything positive from the outside world. The patient continuously maintains a “closed system” in which he is “attached to the bad object” (Fairbairn). There is no symbiotic interaction with the therapist, no recognition that a positive relationship is even possible, and no projection of a hoped-for good object into the transference relationship.

Ambivalent Symbiotic Phase’s Object Relations – The all-negative images of self and other are still stronger, but there is a larger (minority) proportion of positive images compared to the out-of-contact phase. This relatively greater quantity of positive images result in the patient becoming aware that a positive, nurturing relationship with the therapist is possible. In other words, the patient possesses an internal “hoped-for good object.”

However, the dominance of the all-negative images during ambivalent symbiosis result in the patient distrusting the therapist and using projective identification to reject them. The patient distorts the therapist, turning him “all bad” in their mind in order to block the development of a positive relationship. In other words, the patient sabotages himself by actively attacking his potential positive relationship to the therapist.

The patient turns the therapist into someone disappointing and rejecting, even when the therapist’s actions in reality do not warrant this view. As long as it continues, this projective activity maintains the dominance of the negative self-and-object units by rejecting the internalization of the therapist as a good object.

As an ambivalently symbiotic relationship evolves, the patient will gradually reveal more of themselves to the therapist, coming to feel more trust and support. This process happens gradually, in a two steps forward, one step back fashion. Like a slow drip, like grains of sand in an hourglass, each positive experience makes the patient’s positive self-and-object images slightly stronger. This gradually tips the internal balance away from the negative images toward the positive self-and-object images.

Therapeutic Symbiotic Phase’s Object Relations – This phase begins to predominate when the all-positive images of self and other become stronger than the all-negative images. Once this internal balance shifts, the patient comes to fully trust the therapist and to strongly internalize the therapist’s positive attitudes. Of course, the therapist must be a truly “good” person in reality for this to happen.

Therapeutic symbiosis is still based on splitting, in that the patient unrealistically sees the therapist as all-good, disavowing and splitting off any less-than-perfect aspects of the relationship. Emotionally, the patient feels the therapist to be an all-good parent figure relating to the patient as a perfect child.

This stance is maintained via extensive projective identification by the patient, who now maneuvers the therapist into the role of good parent, expecting to be treated well (a contrast to the earlier phase of ambivalent symbiosis, in which the patient unrealistically rejects the therapist as untrustworthy, projecting past bad objects into the present transference relationship).

As therapeutic symbiosis proceeds, the dominance of the positive images of self and other grows. The patient feels gradually less vulnerable to the now-unconscious, persecutory, all-bad self-and-object images. Over time, the patient internalizes the psychological functions that can only come from an extended good-object relationship. These include the ability to comfort themselves, regulate negative emotions, maintain self-esteem, and delay gratification.

Resolution of Symbiosis / Individuation Phase’s Object Relations – In this phase, the patient begins to integrate the all-good and all-bad sets of images (resolving splitting). They will gradually realize that the therapist is not a perfect parent. Like in the ambivalently symbiotic phase, but in a less distorted way, the patient will again perceive the therapist’s imperfections. However, this time, with a stronger positive set of self-and-object images as a foundation, he will arrive at a “whole object” integrated view of the therapist as a mostly good, but slightly “bad” person.

In a parallel way, the patient will “update” their view of themselves. They will see themselves as mostly good and worthy, but possessing some shortcomings and weaknesses. They will finally see themselves as a whole person.

The therapist now becomes a repository for the patient’s remaining all-bad object images. By practicing his independent functioning while objectifying the therapist as an imperfect, disillusioning, sometimes needy parent, the patient feels increasingly separate intrapsychically from the “bad objects” of his past. Over time, he individuates, coming to develop his own unique interests, preferences, identity, and sense of self.

#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

#3 – The Tragic Borderline Experience

This post is a reflection on the experience of being borderline, and all the losses it entails. In addition, it discusses one of the core causes of borderline psychopathology – traumatic early experience usually focused around inadequate parenting.

Although I am grateful to feel well today, I still feel sadness at the thought of the childhood I did not have, and at the emotional suffering forced upon me at a young age in my chaotic family environment. I simply did not have the emotional capacity to handle severe abuse and neglect as a young child. Because of this, my teenage self unavoidably responded by developing the symptoms and defenses of Borderline Personality Disorder.

What is Missing in the Family Environment of the To-Be-Borderline Child

To begin with, I’d like to consider what is missing in the psychological development of someone who becomes borderline as a young adult. Psychodynamic theorists universally emphasize the importance of a secure, attuned, loving relationship between parent and child.  A healthy adult personality is based upon a long-term positive relationship between the child and his caretaker including, 1) Warm encouragement from the parent for increasingly independent activities (mirroring), 2) Protection from the parent during periods of vulnerability (idealizing dependence), and 3) The child’s eventually coming to feel fully separate psychologically, and to be accepted as such by his parents (individuation). Some of my favorite psychodynamic and psychoanalytic theorists that write about this process are Donald Winnicott, Margaret Mahler, Ronald Fairbairn, and Heinz Kohut. Their books are cited below.

The borderline experience in childhood is that the parent is unable to consistently provide security and love. Instead, the child’s legitimate need for acceptance and support is consistently rejected or ignored. Because the healthy psychological development of human children requires parental support for a long period after birth, the lack of it creates a desperate struggle for the borderline child-to-be. When his protests fail to extract the support he needs, the child will eventually come to feel overwhelming fear, rage, and grief.

How the Future Borderline Adult Defends Against His Conflicts

These powerful emotions will shape the child’s future life, and defending against them will become his priority. The child will be forced to use denial, avoidance, splitting, acting out, projection, and projective identification in order to control the terrible feelings. For me, these defenses are all variations of denial. In essence, the child must deny what is really happening, because at a young age it is too threatening to face the fact that he is helpless, has inadequate parents, and does not know who to turn to for help.

Instead, the child and young adult will avoid facing his core problem – that he has never had a safe, dependent, loving relationship that would allow him to develop into a mature adult – via many self-defeating strategies. He may avoid facing the problem by misusing sex, drugs, food and alcohol. As a child, he may act out his anger in school and at home via oppositional, defiant behavior. As a young adult, he may become involved in abusive, neglectful “romantic” relationships with present-day people who repeat the traumas of his past, unaware that they resemble his own parents. He may cling to his original parents in adulthood, since having a bad attachment feels better than having nobody. Alternately, he may run away from responsibility and the demands of mature adulthood by not working or going to school, breaking the law, or working under an authority figure who resembles his abusive parent.

There are countless ways in which the traumatized person can live out the past in the present, maintaining his attachment to “bad objects” from the past by recreating them in the way he lives and relates to others in present day life. It is important to recognize that these “self-defeating” strategies, while extremely damaging in adulthood, are also “self-preserving” because they allow the individual to function and survive when faced with overwhelming emotional conflict.

Missing Out on Life – Friendships

The great tragedy in this is at some level, deep down, the borderline individual knows that he is missing out on what could make life worth living. He is not able to create friendships with people that are truly rewarding and meaningful – friendships where you truly know and appreciate another person for themselves. Usually, the severely borderline individual is so insecure, and lacks identity to so great a degree (having never had a good model from the relationship with his parents), that he cannot relate in meaningful depth to other people and thus does not make real friends.

Throughout my teen years and early 20s, I avoided making real friends, although I hardly knew what I was missing at the time. I tried to pretend that I had friends, but looking back, most of them were superficial, meaningless relationships. Good people who might have been my friend did not want to spend time with me, because I did not have a positive, alive sense of myself as a person that I could share with them. Instead, they sensed my uncertainty, fear, and low self-esteem and were pushed away. The result was overwhelming loneliness on my part.

Missing Out On Life – Love Relationships

Further, the borderline individual will face great challenges in romantic relationships. A successful romantic relationship demands the greatest degree of self-expression, self-revelation, and ability to be intimate with another person. These are all capabilities that the severely traumatized person does not have, and so they will usually be forced into one of several undesirable paths: 1) Avoid dating and love relationships altogether, 2) Enter repeated short-term relationships, often for only a few weeks or months at a time, before “bailing” out of them when the closeness becomes too threatening, 3) Enter long-term detached and/or abusive relationships which contain no intimacy or love; instead, these relationships recapitulate the abusive and/or neglectful treatment by their parents. This last type of abusive relationship can perversely feel safer and more familiar to the borderline than having a new, healthy, loving adult relationship.

Until about four years ago, I was stuck in this cycle of brief, short-term relationships lasting only a few weeks and months. I had no idea how to relate to a young woman in a way that she would like, and was extremely afraid of intimacy. I expected women to dislike my personality and appearance, even though several had told me I did look attractive. Usually, after several dates, I would not know how to go on with the relationship and would invent a reason to get out of it. I had no concept of why my relationships weren’t working, of what I was missing. Important aspects of romantic relationships that I can handle today seemed impossible – things like being genuinely interested in a woman’s interests and activities, caring for her wellbeing outside of what she could do for me, developing trust and dependability over time, discussing plans for the future, and having a satisfying physical relationship. These things were as alien to me as airplanes, cars, and internet would be for a Stone Age caveman brought to the present day.

Missing Out on Life – Work

Due to the constant conflicts over dependence, i.e. the lack of ever having a dependent relationship to a loving parent-figure for an appreciable period, the borderline adult is unable to develop consistently meaningful work and hobbies. Successfully developing a career and a professional identity usually requires encouragement by others of the child’s exploring their environment and independently trying new things. This process is severely interrupted in the childhood of a borderline individual. That is one reason why many adults who are severely borderline work at jobs below their capacity, are on welfare,  or do not know what they want to do in life.

The borderline is fixated on conflicts surrounding the original mistreatment they suffered, and there is not enough positive energy left for other meaningful pursuits. Many such individuals’ “hobbies” are actually shallow ways of distracting themselves from bad feelings and avoiding responsibility, rather than genuine interests. Overuse of videogames, computers, and other electronic media is one example. That is not to say that such pursuits cannot be healthy – they can, if they are part of a life which also contains healthy interpersonal relationships and meaningful work or other activities.

As mature adults reading this article will recognize, the borderline individual is forced to miss the best of what life has to offer, through no fault of his own. Having true friends, meaningful love relationships, and rewarding work and hobbies are priceless experiences that make living life worthwhile.

The Importance of Having Sympathy for the Borderline Individual

The reason for writing this article is to inspire sympathy and understanding in the reader toward the plight of traumatized borderline individuals. It is impossible to convey in words the depth of frustration inherent in severe trauma. Due to grossly inadequate and/or abusive parenting, much of what one’s life could have been is stolen away. The chance to enjoy life and love other people is replaced with a nightmarish daily struggle filled with rage, terror, grief, and the constant feeling of being thwarted. There are many millions of people right now in America and throughout the world who are trapped in this living hell. Most of them have no clear idea of why they have the problems they do, or the way out. Their sometimes manipulative, aggravating, and even abusive behavior is the inevitable result of a desperate emotional struggle in which they are willing to do almost anything to survive. They need our support and understanding if they are to have a better chance of recovering.

If there are people diagnosed with Borderline Personality Disorder reading this, this article might sound pessimistic and gloomy. As a younger man, I would often project pessimism into such authors and become afraid that they thought BPD was hopeless. That perception does not apply here. I am strongly optimistic about Borderline Personality Disorder being treatable and able to be recovered from. This is both because I have recovered from it myself, and because I know of many other people who have done so. There is no reason why any borderline individual cannot recover and find fulfillment in relationships and work.  In that light, this article simply describes realistically  the tragic losses involved when one is deeply traumatized in childhood.

Further reading – Earlier some books by developmental psychodynamic theorists were mentioned. Those books are:

Maturational Processes and the Facilitating Environment – by Donald Winnicott. Winnicott is one of the most respected psychodynamic writers of the 20th century. He was a pioneer in studying infants and young children to discover what formed the elements of a healthy parent-child relationships. He created the concepts of “true self” and “false self” which can be useful in thinking about Borderline Personality Disorder. In this book he beautifully describes the ways in which the good-enough environment meets the child’s needs for emotional support.

The Psychological Birth of the Human Infant: Symbiosis and Individuation – by Margaret Mahler. Mahler was another pioneering writer on early human development. By directing studying infants with their mothers, she identified phases of psychological development including differentiation, practicing, rapprochement, and object constancy. Many psychotherapists in the 1960s, 70s, and 80s viewed BPD as involving a developmental arrest in the rapprochement or sometimes practicing subphase.

Psychoanalytic Studies of the Personality – by W.R.D. Fairbairn. In this volume, Scottish psychiatrist Fairbairn outlined his new psychological model focusing on the innate human need for relationships. His pioneering views on splitting and internal object relations (with his concepts of the good object, exciting object, and rejecting object) anticipated later models used to explain Borderline Personality Disorder.

The Analysis of the Self – by Heinz Kohut. This book is actually much more about Narcissistic Personality Disorder than BPD.  Interestingly, Kohut was initially quite pessimistic about treating borderlines, mainly because of his lack of understanding about how to work with bad internal objects and trauma. In this well-known book, he discusses the processes of mirroring and idealization, which are critical ways that the young child receives support from the parent in healthy development. They are also critical ways that the adult borderline patient receives support from therapists and/or friends and family as they recover.

I am fully aware that psychoanalytic views are not the only way of conceptualizing Borderline Personality Disorder. I’ve read about cognitive-behavioral, Dialectical Behavioral, genetic/biologically-focused, and other models of BPD. However, everyone has a bias and preference for how they view things, and the psychodynamic-psychoanalytic model is mine. It is the model that has helped me the most to understand BPD. Its concepts about healthy psychological development in young children and how those processes can be restarted in adult borderlines were extremely useful in my recovery 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