Tag Archives: BPD cause

#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:

——————————-

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.

#20 – Splitting Explained and Thoughts on DBT

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

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

Example 1: The Mean Professor

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

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

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

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

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

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

Example 2 – A Date Turned Bad

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

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

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

Example 3 – The Savior Parent

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

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

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

Understanding Splitting as a Normal Developmental Process

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

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

Example 1 – The Constructively Critical Professor

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

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

Example 2 – Ambivalence Over A Young Woman on a Date

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

Example 3 – A More Independent Woman

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

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

Why Does Splitting Continue Into Adulthood?

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

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

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

How To Move Beyond Splitting

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

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

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

Types of Therapy for Overcoming Splitting

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

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

A Critique of CBT and DBT

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

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

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

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

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

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

Other Approaches to Overcoming Splitting

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

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

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

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

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

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

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

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

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

Understanding Splitting When One Is “Borderline”

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

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

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

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

#18 – Heroes of BPD: Jeffrey Seinfeld

A few months ago I discussed Gerald Adler, a clinician who treated BPD using a psychodynamic method. Today I’ll write about Jeffrey Seinfeld, the New York-based social worker who pioneered a Fairbairnian approach to Borderline Personality Disorder.

On this blog, it has been discussed several times how psychodynamic therapists have already “cured” BPD. Here is an example of a borderline patient’s recovery from Jeffrey Seinfeld’s book, The Bad Object.

seinfeld1

I thought the reader might be interested to hear in detail about one of the “successes” in BDP recovery that are often referenced on this blog. Her story shows how complex, challenging, and interesting the journey may sometimes be. Some of this account is paraphrased, while the parts in quotations come straight from the text:

A Case Study: Kim (from The Bad Object, pages 101-123)

At the start of her therapy with Jeffrey Seinfeld, “Kim” was a 22-year-old Irish-American young woman. From ages 17-22, she been in regular treatment with another therapist, but had made little progress. After dropping out of high school at age 16, Kim lived at home with her mother. She did not work or attend school; rather, much of her time was spent abusing alcohol and illegal drugs.

With her first therapist, Kim showed no motivation to change, and indeed would boast about antisocial and destructive behavior, including tempting friends trying to quit drugs into again using them. She would regularly miss therapy appointments without calling to cancel. Her therapist as the time described her attitude as, “Who can blame me for messing up with all I’ve been through?”

Eventually, Kim’s first therapist referred her to Jeffrey Seinfeld. He had not lost hope for her, but felt that they had reached an impasse and that a change of approach might help her. Seinfeld scheduled Kim for twice-weekly appointments at a social-work center. For the first year or so of their work, she continued to regularly miss appointments without cancelling ahead, and to abuse drugs and alcohol regularly.

Kim’s Early Childhood

Seinfeld describes Kim’s childhood in this way: “Kim was an only child in an intact family. Kim’s mother alternately neglected and overindulged her. During Kim’s first year of life, her mother often ran out of the house to escape a psychotic husband… The mother would promise to return later in the evening, but often stayed away for days at a time. Kim therefore had repeated experiences of awakening to find herself abandoned by her mother. She grew to hate falling asleep if her mother was present, and she had frequent tantrums, insisting that her mother sleep with her…”

“Kim’s psychotic father had delusions that he was Jesus Christ and that demons possessed him. He underwent psychiatric hospitalization, and his condition was finally stabilized with psychotropic medication. Kim’s mother went to work when Kim was 3 years old, leaving her at home with her father, who was on disability. He would ignore her as he read the Bible or sat in a catatonic-like stupor. If she disturbed him with her romping and playing, sometimes designed to get his attention, he would beat her…”

“Throughout childhood, Kim was on a merry-go-round in her relationships with her family members. First she would side with her mother against her father. When her mother upset her, she would go to her father and side against her mother. When her father upset her, she’d go to her grandfather and side against everyone. As an adolescent, Kim took no interest in learning at school but instead “hung out” with peers and smoked marijuana daily. She dropped out of high school at the age of 16.”

Kim’s Early Therapy – The Out of Contact Phase

Seinfeld described how Kim’s life had little structure outside of her regular abuse of alcohol and drugs. She had trouble sleeping at night, and often slept during the day instead. Kim could not bear to be alone, and would often call her drug-abusing friends from high school to chat at all hours of the day. However, these friends were becoming less interested in her as they grew older and got jobs or moved away.

Kim felt that people were always too busy for her and would eventually abandon her. Thus, according to Seinfeld, her internalized bad object was a “busy object” who did not make time for her. Kim projected this image onto outside people based partly on experience with her real mother, who often did not take time to care for her.

(If the reader is not familiar with projection of internal object relations onto present day relationships, based on past bad experience with parents, the following article may be useful – https://bpdtransformation.wordpress.com/2014/02/02/the-fairbairnian-object-relations-approach-to-bpd/ )

Seinfeld notes that his main experience in relation to Kim early on was that she was oblivious to him psychologically. Seinfeld felt that Kim was unaware of his separate presence, but simply “told him stories” about her adventures with drugs, friends, alcohol, and other adventures. She did not expect any help, understanding, or admiration from her therapist. Referencing the out-of-contact phase, Seinfeld stated, “My position as an object was that of a witness as opposed to an admirer.”

After several months, Kim showed the first sign of becoming aware of Seinfeld’s intent to help when she wrote about him in her diary. She felt concern that her life was “going nowhere,” and wished that she could work or attend school. Shortly after this awareness, Kim cut her wrist with a razor. Seinfeld describes how “the self-mutilation is an antidependent attack against the vulnerable, libidinal self’s expressed need for an internal holding object. The antidependent self thereby reestablishes a closed, internal, invulnerable position.” In other words, the patient identified with how people rejected her need for help and support in the past, and repeated the same behavior toward herself in the present, acting as the bad parent and punishing herself (the bad child) inside her own mind.

This early phase of Kim’s treatment was an “Out of Contact” emotional phase, as described here:

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

Dwelling on the Rejecting Object

Seinfeld acknowledged noted how Kim’s life was in reality extremely difficult. Her “friends” were self-absorbed and did not truly care about her, she had little support from her parents, and she had no structure in terms of a work or academic program, in addition to addictions to drugs and alcohol.

However, despite these severe difficulties, Kim did not respond by looking for positive ways out of her predicament. Rather, as Seinfeld describes,

“Kim was constantly preoccupied with how her friends and family exploited, rejected, and did not care about her. She would dwell on the rejecting object and rejected, unimportant self-image through the day and so would remain in a depressive, victimized position… Even when the external person did not in reality reject her, Kim would interpret the situation as rejection…. All of this is not to say that the external objects did not often treat Kim badly; on the contrary, they often did. But Kim had her own need to perpetually activate the all-bad self-and-object unit.”

Seinfeld noted that if one person in her life disappointed her, she would flee to a different person, but then find them equally disappointing. For example, Kim would go from her too-busy mother, to her drug-abusing and neglectful boyfriend, to her psychotic father, to friends who were moving on with their lives and did not care. Frustrated by each of these people, Kim comforted herself by using drugs, alcohol, and by stealing her mother’ car and “joyriding” despite not having a license.

Seinfeld said that none of his interpretations of her self-destructiveness worked at first. He stated,

“Throughout the first of fourteen months of her treatment, she seemed relatively out of contact with mer. She would recount her adventures and seemed to expect nothing from me but my continued presence… There was no spontaneous, gradual shift in her relatedness. She continued to miss sessions at the same rate as characterized her previous (five year) therapy… She used my empathy to justify her “who can blame me” attitude.”

The Safety of the Bad Object

Seinfeld began to intervene with Kim by gradually making her more aware of how her feelings of rejection and worthlessness were caused not only by the actual behavior of other people, but by how she responded to and interpreted their actions. Seinfeld states, “When she described a bad experience in reality, I empathized with how she felt but then shifted the focus to what she was doing to herself in her mind with that experience. It was not difficult so show that all of the external people she discussed reflected one image – that of rejection in relation to her own image as rejected.”

Seinfeld notes how Kim eventually became aware that she continually maintained a negative pattern of thinking and expectation about others, even when nothing happened in the outside world to justify such thinking. Seinfeld commented to her that such dwelling on negativity might occur because it felt safer to Kim to feel rejected than to feel accepted.

Seinfeld also beautifully described how, “I listened to all that she said and commented from the vantage point of the activation of internal object relations units. I listened to this patient as one would follow the stream of consciousness in a novel by Joyce or Proust, in which reality is always brightened or shaded by the narrator’s internal vision and experience. Kohut (1984) has suggested that such novels reflect the fragmented sense of self in severe psychopathology. One does not ignore external reality from such a vantage point; rather, close attention is given to the subtle but constant interplay between internal and external worlds.” In other words, when listening to a borderline patient speak, the skilled therapist constantly tries to perceive how reality is distorted or “colored” in a positive or negative direction by the patient’s splitting defenses.

Ambivalent Symbiosis

Seinfeld notes that the foregoing work gradually move Kim toward an ambivalent symbiosis. She gradually became aware that Seinfeld cared about her and wanted her to get better. For the first time, Kim asked her therapist in subtle ways about whether he was interested in her viewpoint. She was no longer only telling stories or complaining about abuse. She would ask Seinfeld if he felt that her mother and boyfriend cared about her. She wanted to know if Seinfeld understood the desperation and uncertainty she felt. Seinfeld described how Kim displaced many of her wishes for closeness and support from him onto the mother and boyfriend, because it was initially too threatening to get close to Seinfeld and trust him directly.

The relationship now assumed a stormy, emotional, push-and-pull quality. Kim would want support from Seinfeld but then be angry that she only saw him occasionally for therapy. She wanted him to understand her feelings about her family, but then criticized him as overly intellectual and detached. She became jealous that Seinfeld’s own family own family got most of his time and love, while she only got the leftover scraps. Outside of sessions, she began to cut down on her drinking, but then would return to it when she felt that two hours a week with Seinfeld was inadequate. She would perceive Seinfeld, “sometimes as a saint and at other times as a psychotic with delusions of grandeur, like her father.”

Seinfeld therefore described how Kim tried to take in his support and acceptance, but would then reject it, both due to her familiarity and loyalty to the rejecting object and to her fear of vulnerability and openness toward the good object. For example, Kim asked Seinfeld for help with getting a referral to a doctor who worked in the same hospital as Seinfeld for a minor medical problem. When Seinfeld responded helpfully, she rejected the referral as inadequate by viewing the doctor negatively. This related to her being threatened by feeling that someone truly cared about her.

At this point, Kim began attending therapy regularly and never missed sessions, even becoming upset if she was forced to be late. Rather than being upset with her mother or friends as often, she became intensely upset with Seinfeld if he did not meet her demands for caring and empathy in a perfect way. Despite Seinfeld making extra time to talk to her on the phone outside of regular appointments, she would become angry when he eventually had to leave to go see his family. She viewed him as a “too busy” bad object just like her mother and friends had been the “busy bad objects” before. She again felt angry with Seinfeld for expecting her to depend on him for support, but having only a few hours a week to spend with her. She continued to alternately view him as a caring, supportive person whose help she desperately wanted, and then suddenly to transform him into a too-busy, uncaring, impersonal therapist.

Seinfeld comments on this ambivalent symbiosis in the following way:

“The patient activates the all-bad self-object unit to defend against internalization of the positive self and object unit. The insatiable need serves the antidependent defense. By making her need for contact with the external object insatiable, the patient can perceive of herself as rejected regardless of the external object’s behavior. Therefore, the patient is always able to think of her needs as being unmet, to think of herself as rejected and of the object as rejecting. The activation of the all-bad self and object unit results in depression and rage. Insatiable need, the oral self-exciting object relationships (e.g. use of alcohol while rejecting a truly supportive other), is then activated to counter the depression and rage. In this regard, the all-bad self-object relations unit becomes a vicious cycle constituting both the rejecting and exciting objects… Insatiable need serves to maintain the perception of the object as rejecting in antidependent defense. This patient succinctly stated the antidependent position, “If I don’t think you like me, why should I bother to like you?”

In other words, it’s necessary to understand how the patient is an active agent in perpetuating their view of the therapist and others as rejecting (creating an impossible-to-fulfill, or insatiable need) rather than potentially helpful and positive.

The Transition to Therapeutic Symbiosis

Seinfeld now constantly remarked upon the ways in which Kim focused on the ways in which he (Seinfeld) was not available because this felt safer and more familiar than focusing on the ways in which he was available. Kim came to recognize more and more how she herself played an active in viewing the external world negatively and keeping herself in a depressed state. She realized that if she were not provocative and looked for positive things in the outside world, they would appear there much more often than she expected. In this way, she could become an agent of positive change.

Gradually, Kim became aware of how unstructured and vulnerable her current life situation was. She realized how she was hurting herself by her continuing alcohol and drug use, and by ignoring opportunities to return to school or work.

Regarding the developing therapeutic symbiosis, Seinfeld stated,

“Kim’s vulnerable self became more connected to the internal holding object (the therapist as supporter of independent functioning and provider of love) through the transference, and she experienced severe separation anxiety. She faced the fact that her life was a mess and that she felt like a vulnerable child. She began to believe that I really was going to help her, that our relationship could affect the direction of the rest of her life.”

Seinfeld continued to explain that, at the same time as these positive feelings emerged, Kim feared that letting Seinfeld get too close to her would allow him to overpower and dominate her sense of self. She still feared trusting another person closely due to all the rejection from her past. So, she had to be very careful and gradual in the way she came to trust Seinfeld, lest he turn “bad”. Occasionally, she had dreams in which the “good” Seinfeld would turn into a psychotic madman like her father.

Gradually, Kim let herself get more and more attached to Seinfeld, and as this happened she began to feel self-empathy for the first time in her life. She remembered the alone, fearful child she had been and wanted to help herself.

Strengthening the Therapeutic Symbiosis

Kim bought a pet parrot that she would care for at home. She imagined herself as a good parent nurturing a good child most of the time. When the bird became difficult and squawky, she would briefly view herself as the bad mother and the bird as bad child. As her relationship with Seinfeld improved, she came to nurture her pet more and more and to be bothered less and less by its noisiness. As a projective container, it reinforced her positive internal self-and-object images via the fantasies of love she projected into it, supported by her relationship to Seinfeld.

Over the next year, Seinfeld described Kim’s progress as follows,

“As Kim became less depressed and angry , her vulnerability and strivings for autonomy emerged. Having decided that she must do something to change her life, she managed to earn a high school diploma. She then pursued college courses and part-time work… She brought to me her ambitions and interests for mirroring admiration. Her ambitions, which were originally grandiose, gradually became realistic. She informed her drug-addicted boyfriend that he had to stop using cocaine if he wanted to continue to see her. She saw him less as a rejecting object and more as a person with problems that interefered with his capacity for intimac. His family eventually arranged to have him go for detoxification. Kim remained in contact with him but also started to see other men.”

Seinfeld then described how Kim gradually focused more and more on her own goals and independence, and became less dependent and close to Seinfeld as she had been at the height of the therapeutic symbiotic phase. Thus she transferred into a more “resolution of symbiosis”-like phase, as described in Article #10.

———————-

Comments on Seinfeld’s Case of Kim

In this case study, one can see how in the early phases of treatment, Kim was at first oblivious to Seinfeld as a potential helper, due to the extreme neglect and abuse she experienced as a child which left her with a structural deficit of positive internal self and object images. She literally could not recognize help and love when she saw them.

As she gradually became aware of Seinfeld as a potentially helpful therapist, her fear that he might reject her like her parents had done, as well as her general unfamiliarity with and distrust of genuinely kind people, caused her to distance herself from him as a potential good object. It required painstaking work to become aware of how she herself continually viewed others (and later Seinfeld) as “all-bad” while rejecting the good aspects of the outside world in order to overcome this phase.

Eventually, the therapeutic symbiosis took over, and Kim was able to trust Seinfeld and take in his love and support. At this point, she was no longer “borderline”, and began to feel well and stable much of the time. She resumed school and work, developed new positive relationships with other men, and gained a healthy capacity to view people like her mother and abusive boyfriend as troubled people rather than persecutory rejectors.

In reading this article, I learned how important it is to identify the subtle ways in which we distort others into “all-bad” and “all-good”, when we are borderline. We can apply these case examples our own lives, since we all distort external reality to a greater or lesser degree. Since they are often based unrealistic projections from past negative relationships, learning to “distrust” or question our initial negative perceptions can be a positive, corrective process. It allows us to realize how the world outside is much more positive than it sometimes appears when we are viewing things through the lenses of “bad objects.”

Seinfeld As An Author

Seinfeld is one of those authors I read about a certain topic and say, “Wow, this guy is brilliant! That really is how things are!” I remember being struck right away by his penetrating descriptions of borderline problems and what was necessary to transform them. The reader is again recommended to his book, “The Bad Object”, which is available used on Amazon. Its case studies of successfully treated borderlines are some of the best of any book I’ve read, especially the cases of “Kim” described here, along with similar-length successful cases of “Justine”, “Diane”, “William”, and “Peggy.”

To understand Seinfeld’s concepts, it may again be useful for the reader who is unfamiliar with the psychodynamic explanation of BPD to skim through the following articles:

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

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

Seinfeld adapted an object relations theory of trauma, building on theories developed by Ronald Fairbairn working with abused children in the early 20th century. Seinfeld understood how parental neglect and abuse became internalized by the (future borderline) child, and then was constantly replayed in their adult life, causing the borderline symptoms. He adapted the four phases that Harold Searles pioneered with schizophrenic patients, and modified them for use with less-disturbed borderlines. These phases – Out-of-Contact, Ambivalent Symbiosis, Therapeutic Symbiosis, and Individuation – involved “reparenting” the borderline individual so that they learned to love themselves and eventually became able to love other people.

It’s hard to summarize everything else from Seinfeld’s book on how to treat Borderline Personality Disorder (The Bad Object). So, as with the post on Gerald Adler, I will focus on a few key points.

#1: The Concepts of Structural Deficit and Bad-Object Conflict

One of Seinfeld’s foundations for understanding BPD was seeing a borderline individual as having both “a structural deficit of positive self-and-object images” and “bad object conflict.”

What the structural deficit means is that, compared to a healthier or “normal” individual, a borderline has not taken in sufficient positive experiences with the outside world to feel secure psychologically. This results in an inner emptiness or psychic void that makes it harder for the borderline to take in new positive experiences in the present, since they have trouble recognizing them as positive. This is the same concept as Adler’s notion of introjective insufficiency:

https://bpdtransformation.wordpress.com/2014/04/30/15-heroes-of-bpd-gerald-adler/

In healthier people, who have had much nurturing, love and security in childhood, the high number of past positive memories serve as “receptors” that help them recognize, seek out, and take in new positive experiences. By contrast, the borderline-to-be child usually receives very poor responses to their need for nurturance. Instead of internalizing a sense of love, security, and blessing, the future borderline child is left with an emptiness or longing for love which then becomes repressed. That is the structural deficit as described by Seinfeld and Adler – the quantitative insufficiency of internal positive memories based on a lack of past external positive experiences.

It is the structural deficit that results in the borderline’s being relatively unreceptive to new positive experience. For the adult borderline, positive experience – for example, being offered friendship, acceptance, and interest by other people – will seem unfamiliar, strange, alien, and even threatening when they are encountered. This is why, early on in the therapeutic process, Seinfeld found that severely borderline patients often didn’t know how to relate to him in a positive way. Rather, they experienced him in his helping role as, “an alien creature from another psychic planet.”

#2: Bad Object Conflict

As for “bad object conflict”, Seinfeld understood this to mean that not only is there a lack of positive memories, but there is a predominance of powerful negative memories (or images of oneself and other people) in the borderline’s mind. These scary, traumatic negative memories don’t just sit there – they act to reject the internalization of new positive memories. They are like metaphorical demons or monsters that scare the patient away from trusting others.

The child who becomes borderline internalizes many memories of being unloved, rejected, and even hated by inadequate parents. These memories collectively form the unconscious “internal bad object” or “rejecting object.” Despite its painful nature, relating to a rejecting other as an adult often feels safer and more familiar than trusting someone new who might prove disappointing. Also, the borderline tends to feel a perverse loyalty toward the people who abused him in the past, and to feel he is “bad” and therefore unworthy of help from good people.

For both these reasons – fear of being vulnerable toward good people, and loyalty toward the bad people from the past – the borderline individual tends to reject potential help and remains attached to the image of themselves as a worthless, undeserving, bad person. This can be acted out in many ways – via remaining alone and isolated, via abusive or neglectful relationships with present-day partners, via staying attached to the original abusive parents in the present day, via self-injurious acting-out behaviors, and so on.

Therefore, Seinfeld described how the borderline acts in subtle and overt ways to actively maintain an internal negative view of themselves and others. I would call this, “Perpetuating the past in the present.” The bad-object conflict thereby works in a vicious cycle to maintain the “structural deficit” because as long as the activities focused around bad perceptions of oneself and others predominate, quantitatively speaking, then new positive experiences are not being taken in in sufficient amounts to “tip the balance” and effect lasting psychic change.

Seinfeld likened the negative and positive relationships of a borderline patient (as long as they remain borderline) to a mathematical equation. In his formula, negative relationships to external others are activated more frequently than positive relationships, maintaining the attachment to the internal bad object and preventing the internalization of a good set of self-and-object images strong enough to displace the bad object.

According to Seinfeld, unawareness of the good object (“object” meaning person or people) tends to occur more in the out-of-contact phase, and active rejection tends to occur more in the ambivalently symbiotic phase, as described in post #10 on the Four Phases. Active rejection is necessary in the ambivalent symbiotic phase, because the good-object images are strong enough in that phase to pose a threat to the internalized bad object, which the patient unconsciously fears losing (since it is what he is familiar with).

#3: The Exciting Object

Another key concept from Seinfeld’s writing is the nonhuman exciting object. The exciting object is any addictive, stimulating, non-human object that serves to fill the void created by the lack of the good object. Food, drugs, sex, alcohol, medications, excessive use of TV or internet, and other nonhuman “things” can provide an addictive fix to compensate for the lack of love that a borderline feels.

The exciting object is part of Seinfeld’s mathematical equation of how BPD works. Because of the structural deficit and the bad object conflict, the all-negative split self and object units are mostly dominant in the borderline’s mind. These all-negative images reject the taking in of new positive experience which could be soothing, and therefore the borderline feels mostly empty, unhappy, and unstable emotionally.

To try to assuage these bad feelings, the borderline turns to nonhuman exciting objects as described above. These exciting objects plug the “hole” or emptiness created by the lack of truly satisfying positive relationships to good people in the outside world. However, exciting objects can only do so temporarily, since they are not truly satisfying long-term. Once their effect wears off, frustration will set in, and the borderline will usually return to involvement with the bad self and object images. This will then lead to more psychic pain around bad objects, resulting in the need for more exciting objects to assuage it, and so on.

#4: Interrupting the Rejecting-Exciting Object Cycle – Therapeutic Symbiosis

The main focus of Seinfeld’s book was not on the negative aspects of how a borderline functions, but on how to heal them. Seinfeld believed this could be done by interrupting the constant oscillation between rejecting and exciting objects via the internalization of a new good object relationship.

In normal language, the borderline needs to overcome their fear of trust and dependence, allowing themselves to develop a satisfying, loving relationship with the therapist. Seinfeld emphasized that successful therapy must move beyond a detached, professional relationship, and should explicitly involve love and closeness between patient and therapist. This does not mean that the pair are friends outside the sessions; rather, it means that a parental-like relationship of vulnerability, tenderness, and support is nurtured within the frame of the sessions.

This is the phase of therapeutic symbiosis. Seinfeld described how, “In this phase, there is a full reemergence of the vulnerable, regressive true self, in the care and protection of the idealized holding-therapist… At first, the patient’s vulnerable self is increasingly related to the therapist as holding object. The Internal positive self and object representation unit is increasingly dominant over the negative self and object representation unit, as long as the external therapist is highly available to reinforce the strengthening of the positive unit… As one patient said, “So long as everything is all right between you and me, I feel that all is well with the world. The good internal object serves to neutralize the bad, persecutory, rejecting object….

“In the later part of therapeutic symbiosis, the patient internalizes and identifies with the therapist to the point at which he is no longer so dependent upon the external therapist… The patient can now increasingly comfort, soothe, and mirror himself, regulating his own affect, mood, and self-esteem. In unconscious fantasy, he is now the comforter, sympathizer, and holder, as well as the comforted, empathized with, and held… All goodness is taken into the self; all badness is projected into the external object world…. In this way, the patient can establish a psychic foundation (of primarily positive self and object images) to eventually integrate the good and bad self and object units into whole, or ambivalently experienced, self and object images.” (pages 73-74)

Seinfeld’s Model of BPD – The Inversion of the Normative Developmental Psychic Process

Seinfeld continues, “The healthy child tries to take in or internalize the good object and reject or externalize the bad object. In the model I’m developing, the borderline patient manifests an inversion of the normative developmental process. Instead of taking in the positive object relations unit and rejecting the negative object relations unit, he takes in the negative object relations unit and rejects the positive object relations unit. In Fairbairn’s terms, he is attached to the internal bad object. The out-of-contact phase and ambivalent symbiosis are manifestations of the pathological inverted symbiosis in terms of the attachment to the bad object and rejection of the good object. Symbiosis becomes therapeutic when the patient adopts the normative but primitive developmental position of taking in all that is good and rejecting all that is bad. In this way, the patient can establish a psychic foundation to eventually integrate the good and bad object relations unit.” (page 75)

To me, this is a beautifully clear model of what causes BPD – bad relationships are taken in during development and reenacted continuously during adulthood, whereas good relationships are not taken in and are rejected later on. Successful recovery from BPD involves an reversal of this process.

Through the phase of therapeutic symbiosis, the patient can gradually gain confidence and make progress in three main areas in their outside life: 1) Leaving behind negative relationships (for example, to abusive partners, friends, or parents), 2) Developing new positive friendships and relationships to replace the bad ones, and 3) Developing enhanced autonomous functioning, work and interests.

In this way, the formerly borderline patient reverses the mathematical equation that had predominated when they were “borderline.” Instead of remaining attached to the all-negative images of themselves and others, the patient engages in new relationships and activities that are good, encouraging and self-supporting. In this way they take in a quantitative predominance of positive self-and-object images, and “spit out” the bad self and object images.

How To Interrupt the Rejecting-Exciting Object Cycle – Insight

The reader is probably interested as to how a borderline may start to break out of the negative-exciting object attachments. What Seinfeld worked on in therapy (and what one can work on with oneself) is developing the insight into how one sabotages oneself, which allows one to start making more constructive and adaptive choices instead.

Attachments to bad objects from the past are like schemas or relationship-templates that one replays over and over in the present “perpetuating the past in the present”), even though one doesn’t have to keep doing so. A person needs to identify how they are replaying bad relationships in the present, and treating themselves in the way that their parents did, to begin realizing how their behavior could change. As they become aware of the structural deficit (of positive self and other representations, resulting in unreceptivity toward good experience), and of the bad object conflict (which actively rejects and causes a person to fear good relationships), the borderline can start to actively seek out better experiences.

A great way to illustrate how this process works is via a case example. Hopefully, in the case of Kim above, the reader should be able to identify the structural deficit, bad object-conflict, use of exciting objects, and the ways in which Seinfeld interrupted these activities and nurtured insight in the patient, to encourage internalization of the therapist as a good object.

Recovery as a Mythic Journey

Lastly, I loved Seinfeld’s view of the therapy process as a mythic or epic journey. Seinfeld states (page ix), “This volume shows how to help the patient overcome what has been decribed as the most serious obstacle to psychotherapy: the negative therapeutic reaction. It is the bad object that is predominantly responsible for this reaction. The patient and therapist enduring the travails of the therapeutic journey often resemble Odysseus and his crew forced to outwit the demons, sirens, witches, and Cyclops threatening to thwart the long voyage. In fact, those mythological demons personify the manifold masks of the bad object often described as exciting (but not satisfying), enticing, bewitching, addicting, engulfing, rejecting , punishing, and persecuting…

“The bad object is comprised of the actual negative attributes of the parental figures – often a composite of both mother and father along with later figures resembling them – and the child’s fantasies and distortions about these figures. In this regard, the unsatisfactory experiences with the parental figures give rise to frustration and anger, which color the child’s perception of the object… The designation “bad” regarding the other person does not refer to a moral valuation but rather to the child’s subjective unsatisfactory experience with it… Therapeutic progress threatens the patient and therapist with the terrible wrath of the bad object. The patient is conflicted between his loyalty and fear of the bad object and the longing to enter into a good object relationship that will promote separation from the bad object… Fairbairn believed that the term “salvation” was a more apt designation than that of “cure” for the patient’s subjective experience of his need to be rescued from the bad object.” (preface page x)

This article is getting long enough already! I hope the reader, whether having borderline traits themselves, or wanting to help or understand someone with BPD, has found some interesting insights in Seinfeld’s approach to treating Borderline Personality Disorder.

Lastly, here is an interview and memoriam for Jeffrey Seinfeld, who sadly passed away a few years ago.

http://www.orinyc.org/JeffSeinfeld_InMemoriam.htm

Please share any comments you have below!

——————————–

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

#12 – Cracking the Borderline Code

In this post, I’ll explain the concept of Borderline Personality Disorder as an emotional programming language. While recovering, I developed emotional strength and insight which allowed me to consciously redirect destructive thought patterns. This formed part of a long-term plan by which I reversed the early course of the disorder.

Here I’ll explain how my plan worked, and provide some suggestions for current borderlines and their families to consider.

I’ll begin with the idea of BPD as a destructive code and the sufferer as a spy who must break and reprogram that code. While struggling to recover from BPD years ago, I often imagined myself in metaphorical roles. The most prominent was as spy or code-breaker.

Today, having more of a neurotic personality organization, I can mentally play with such roles without taking them seriously. However, when I was severely borderline, they felt real – I almost believed myself to be a real-life espionage agent or warrior, trying to outwit and defeat the sinister forces arrayed against me. My lack of a strong observing ego caused me to have difficulty distinguishing fantasy from reality.

Recently, memories ran through my mind about these difficult days. I remember the keenness of the desperation, how getting through each day presented a titanic struggle. I was deathly afraid of never “making it,” meaning not succeeding in work and relationships as an adult. And I did not know how I was ever going to fully trust another human being.

The Bourne Identity

I loved watching movies about characters who played soldiers or spies. Doing so gave me a powerful feeling of motivation, of being alive and active. One of my favorite spies was Jason Bourne. In the clip below, Matt Damon demonstrates the intensity and coolness under pressure which define Bourne. He uses expert planning and deception to outmaneuver the Central Intelligence Agency, which is attempting to kill a witness who knows too much:

http://www.youtube.com/watch?v=DUd5RPVDjPY

I related to this scene because I too felt persecuted and pursued by a heartless, inscrutable adversary. In my case, it was the past memories and present-day projections of my abusive father that haunted me. Since I did not know love as a child, I could not perceive the goodness in other people as an adult. I always expected people to ignore and abuse me like my father had done. For years, it did not dawn on me how unrealistic these (mis)perceptions were. Right before my eyes, people were far kinder than I could ever have imagined.

Fighting through the maze of persecutory misperceptions to reach human help was, for me, emotionally equivalent to the desperate escape from murderous persecutors shown in this Jason Bourne scene. For my college-age self that watched it years ago, Jason Bourne represented my evolved, adult-self, and the victim represented my vulnerable child-like self, which the adult self sought to protect from persecution. Today, I watch this clip with a tremendous sense of pathos toward my past self.

Jason Bourne also personified a determination, focus, and ruthlessness that I admired. Since I was entering the adult world without the necessary emotional equipment to navigate it, I felt that I had to be absolutely committed to finding help at all costs. There was an element of ruthlessness to my personality at that time, and I did use people.

Today, I am much kinder and gentler, but there is still a lingering dark aspect to my personality. When I occasionally feel threatened in some real-life situation, my “protector” side, the inner Jason Bourne, will come rushing back. But it doesn’t dominate my mind like before, since I now know that I’m re-experiencing the past in the present.

I always had some sense of the great challenge facing me after enduring repeated physical abuse and an unloving childhood home. It would take every bit of ingenuity, cunning, courage and endurance I possessed to create a good adult life. And that is why I identified so strongly with creative, fearless characters like Jason Bourne.

Taken

Bryan Mills, the father played by Liam Neeson who seeks to free his daughter from ruthless kidnappers in Taken, became another of my favorites.

I always identified with fearless, intimidating male protagonists who endeavored to save a weaker, vulnerable character from a heartless persecutor. This, of course, represented what I had been unable to do for myself in the face of my father’s abuse. It also signified my failure, at that time, to work through the feelings created by my father’s abuse or to forgive him. Here is an example of Liam Neeson playing the father-spy-protector in Taken:

http://www.youtube.com/watch?v=wcjY-VN8_l4

It may be disturbing, but my old self loved the confidence in Liam Neeson’s voice as he talked about tracking the criminal down. He exhibited such absolute certainty that he would punish the bad guys and recover his kidnapped daughter. It represented the strength and freedom to take action that I wished I had when my father abused me. Although I did have murderous thoughts toward my father sometimes, I never would have followed through with them as Liam Neeson’s character does in this movie.

How Splitting and Projective Identification Recreate Past Experience in the Present

My identifications with Matt Damon and Liam Neeson in their spy-soldier roles demonstrate important aspects about how splitting and projection in Borderline Personality Disorder.

In earlier essays, I discussed Fairbairn’s object-relations model, and four phases of BPD recovery derived from that model:

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

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

The reader is referred to these essays for more detail on these topics, which will form the foundation of the current discussion.

In my life at the time, I was constantly reliving my past abusive experience in the present. I always feared that other people would reject or abuse me like my parents had, and so I could never feel safe or comfortable in relationships. Even after leaving the family home to go to college, I felt unsafe, alone, and threatened.

Intra-psychically, I was constantly projecting “all-bad” (negatively split) images onto other people. This occurred regardless of whether the people were nice or not-nice in reality. In fact, if they were kind, the all-bad splitting happened even more, because I was afraid of intimacy and therefore wanted to create distance. In this way, I unconsciously prevented myself from perceiving their actual kindness and good intentions. The strong observing ego that is writing this post was not there then, so I was truly emotionally blind to my own self-sabotage.

Therefore, I was “transforming” any new person (in my mind, as I saw it at the time) into uncaring, mean people like my parents. The defenses that did this were splitting – or viewing people unrealistically as all-bad, based on my internalized parents – and projection / projective identification – meaning putting these images onto new people in the outside world, and relating to them in provocative ways which made them respond negatively. These defenses serve to distort the external world and to confuse the emotional past and present.

My identification with Jason Bourne and Bryan Mills occurred in a roundabout way. In my own life, I was continually recreating threatening, all-negative scenarios with new people. For this self-perpetuated reason, I continued to feel alone, unsafe, and unloved. This gave rise to the need to save myself by finding someone to help me. Therefore, I identified with strong movie characters, like these spies, who personified the strong male savior that I wanted to be. If I had not been borderline, I would not have identified with them in the first place.

BPD Deconstructed

For me, the essence of Borderline Personality Disorder is that it involves, 1) An inversion of the normative developmental process, and 2) A constant, nightmarish reliving of the past in the present. What does this mean?

1)      An inversion of the normative developmental process: This means that the borderline individual pursues unsatisfying relationships and rejects satisfying ones. Borderlines are continually focused on, is sensitive toward, and addicted to bad, frustrating, persecutory interpersonal relationships. By contrast, they reject or are relatively unaware of loving, good, supportive relationships. This represents the “attachment to the internal bad object” that Fairbairn discussed, with the concomitant “rejection of the internal good object.”

2)      Reliving the past in the present – Most people diagnosed with BPD have severely traumatic histories filled with neglect, inattention, and abuse from inadequate parents. The borderline adult recreates this childhood experience in their present-day life. They do so by continuing to view the external world, no matter how different it really is in the present, as filled with mainly bad, frustrating, and persecutory people. And they do it by rejecting and remaining oblivious to those who try to help. In other words, the inversion of the normative developmental process, described above, represents a continuation and present-day reliving of past traumatic experience in the present day.

In my case, as a teenager and college-age boy, I constantly preoccupied myself with the ways in which other people ignored me, disliked me, thought I was weird, and/or directly rejected me. Emotionally, I kept reliving the feeling of being ignored and rejected that I felt at home. I repeat this point again because it is so important for understanding common borderline processes.

It is important to see that people in the outside world did not usually set out to treat me this way. Rather, I unconsciously looked for only the bad aspects of the outside world and rejected the good aspects.

In this way, I “created” what became my felt reality – that I was rejected and worthless, and other people were uncaring and mean. Healthier people would have experienced their peers at my high school and college very differently. But, since I had had very little loving, emotionally close experience growing up, I lacked “receptors” – or positive memories – which would have helped me to recognize good things when I saw them. In that sense, I was emotionally blind.

This is something I find that non-borderline individuals often misunderstand about BPD. They think the borderline’s lack of receptivity to positive gestures and their inability to trust is intentional. Hopefully, my experience demonstrates that the issue is far more complex. For the most part, borderlines would like to trust and take in more help, but they simply don’t know how to.

The Paranoid Position

This constant negative psychic activity – of clinging to bad perceptions and people and rejecting good ones – creates the emotional ground where the outside world seems dangerous and threatening. It generates the nine symptoms of Borderline Personality Disorder that are listed in the DSM, and it is the very heart of what perpetuates the disorder.

Technically termed the “paranoid-schizoid” position, this is the earliest period of emotional development in psychoanalytic theory. It describes the position of the young child’s ego or self when they have just come into the world. It represents the young child’s emotional position before they become able to trust outside people and to view them ambivalently as mixtures of good and bad.

Cracking the Code of BPD

In both Taken and the Bourne series of movies, the leading characters must penetrate an initially-mysterious and threatening network of criminals. Jason Bourne turns the tables on his pursuers and discovers the truth about his identity from a time before the CIA brainwashed him. Bryan Mills penetrates a shadowy network of criminals to recover his beloved daughter.

In both cases, I learned from the way in which the main character defeated their adversaries. Both Bourne and Mills already knew or learned everything they could about their enemies before turning the tables on them. In Machiavellian fashion, they did whatever was necessary to overcome the obstacles, without concern for anything outside themselves and their loved ones.

In my case, the past “enemy” was the emotional abuse from childhood that I internalized and kept re-inflicting on myself in the present. My present-day opponents were splitting, denial, projection, and projective identification. These defenses distorted the external world, and caused me to constantly repeat bad relationships while rejecting good people who wanted to help me.

How I Used My Understanding of BPD to Recover

My weapons were my intelligence and my unwavering motivation to improve. I realized that I would have to learn everything I could about Borderline Personality Disorder, understanding it in much greater depth beyond DSM descriptions.

In fact, the DSM-allied psychiatrists who said that BPD was untreatable (or treatable but not cure-able) became a new enemy. Their pessimistic, medicalized views, which advocated symptom management and medication, represented capitulation and defeat. I wanted to understand WHY borderline symptoms happened, and I wanted to recover fully and live a great life as a non-borderline. And that is why I taught myself the “code” of object-relations theory, which for me best explains why borderline symptoms occur.

Once I understood how my mind had been “hacked” by my past abuse, implanted with relational “code” that made me to endlessly repeat bad relationships, I realized that I could change the pattern. I needed to specifically address my inability to trust other people, and to devote time and energy to cultivating new positive relationships.

That process began with my therapists, who were able to confront the many ways in which I distorted them into “bad” people so as not to trust them. I am extremely grateful to my therapists for their help in confronting my projection and splitting. I learned from that process and continued the work of perceiving others more realistically with new friends and family members.

After several years, my positive images (memories) of myself and others became strong enough that I could fully trust other people and develop deeper, intimate relationships. As this happened, the borderline symptoms all gradually lessened and faded away. I developed the abilities to control previously destructive behaviors, to regulate my own feelings, to distinguish past from present, and to tolerate frustration. I came to feel alive, real, and happy most of the time.

Today, when I watch movies like Taken or the Bourne Supremacy, I no longer identify with the main characters personally. But, I wistfully remember how attached I was to them years ago.

Borderlines Starting in Recovery

Many recently diagnosed borderlines who share their story on web forums have, understandably, not yet come to deeply understand the genesis and causes of their problems. These borderlines and their families are the primary people that I hope will take something away from this site.

In my view, our society’s approach to Borderline Personality Disorder is shallow, symptom-focused, and often unreasonably pessimistic. How many therapists truly understand the causes of BPD in the ways I describe on this site? That may be a bit arrogant of me, but there are many poorly trained and incompetent therapists out there.

I recommend that sufferers and families do not simply trust one therapist or psychiatrist, but instead do their own research and reading about the disorder. Self-help, self-education, and self-therapy can make a huge difference. If I hadn’t taught myself about what BPD really is and what causes it, I would probably still be on three medications, not working full-time, not in good relationships, and not happy.

Looking Beneath Symptoms

The key point that I would like borderlines and their families to take away from this article is to look beneath symptoms. There is so much more to gain from looking at the object-relational causes and patterns that drive BPD symptoms.

Focusing on BPD symptoms alone, i.e. how to reduce or control them, can only be palliative. This means it will reduce symptoms but not treat the underlying causes. Medication used for years on end and superficial therapy focused on symptom management are examples of these approaches. It is because of unthinking treatments like these that many borderlines continue to suffer, year after year after year, with no real long-term improvement in their emotional wellbeing. It’s time for that to change.

If borderlines do not understand and take action to change their attachment to internal bad objects, then their self-abusive cycle, the pattern of recreating bad relationships and rejecting good ones, repeats endlessly.

A Dramatic Example of Repeated Self-Abuse

I recently watched a horror movie that illustrates this phenomenon, Triangle. Its trailer is here –

http://www.youtube.com/watch?v=SQk2NpfQm7k

In this movie, a woman gets stuck in a time-loop where she must survive a nightmarish situation on board a cruise liner. The nature of the time loop is such that her past self always confronts her present self and kills it just as it is about to break free. Her job is to realize, as the trailer states, “It’s starting over again, that’s what going on…. Everything that happens to you, happened to you before!” The solution is “to change the pattern… if we change the pattern, we’re not trapped!”

As the reader should see, this movie’s plot is reminiscent of the way in which borderlines can endlessly repeat negative pas experiences. It is only by understanding what one is doing to oneself, and by taking responsibility for change, that it can get better. Near the end of this movie, the woman gains insight into how she is contributing to her own repeating problem, and this leads to hope about changing the outcome.

An Optimistic View of BPD Recovery

I would like to repeat that I am very optimistic about full recovery from BPD being achievable, as stated in earlier articles on this site. To be more exact, it’s not whether or not BPD recovery is achievable. I know that it is. It’s that I’m optimistic that the resources needed to recover are reachable, and the work doable, for motivated people who are diagnosed with BPD.

 “Cracking” the borderline code is not impossibly difficult; but it takes a significant amount of time and work. I encourage those with BPD to look beyond shallow, limiting, symptom-focused descriptions of BPD. Instead, focus on learning how the disorder works in depth in order to break the destructive cycles that cause the symptoms. In this way, transformation and full recovery are real possibilities.

———————-

I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or would like to more effectively help someone who is borderline, 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

#5 – What to do if you are diagnosed with BPD

If you have recently been diagnosed with Borderline Personality Disorder, you are probably wondering what to do to start getting better. Or perhaps you’re wondering if it’s possible to recover at all.

Deep, lasting recovery from BPD takes a significant amount of time – in my opinion, at least 3-5 years to move far along the road to being emotionally well. However, it is possible to begin going in the right direction immediately. The early years of recovery for a borderline individual, while sometimes very challenging, can be rewarding and meaningful in the long run.

Step 1 – Educate Yourself about BPD

One of the most important things for someone diagnosed with Borderline Personality Disorder to do is to become informed about the disorder. In my opinion, three interrelated areas are useful to learn about:

1) What BPD is and how it “works” from different viewpoints.
2) Different treatment options.
3) Case studies of former borderlines who have now recovered.

For step one, the most basic, but limited way of understanding BPD is reading its definition in the DSM. After that, basic books like The Borderline Personality Disorder Survival Guide (Chapman), Stop Walking on Eggshells (Mason), and I Hate You, Don’t Leave Me (Kreisman) can give a basic overview of BPD’s characteristics.

While they can be useful initially, I no longer give much credence to these books, since they are superficial and give little guidance about how to recover. They tend to cater to friends and family, rather than to the individual diagnosed with BPD. Also, some of them hold the viewpoint that BPD is a disease to be struggled with for life, rather than a condition that can be fully recovered from. That is something that my experience has disproven.

Books that Helped Me Understand BPD And Have Optimism About It

To address steps one and three – how BPD works, and stories of people who recovered – I learned the most from two sources. First, from reading therapists’ case studies of borderlines who they successfully treated. These case studies usually  illustrate important facets of the disorder, including its developmental genesis, the use of splitting and projective identification, typical phases of treatment, how the attachment to bad relationships works, the fear of trust and dependence, and so on.  Second, I learned from reading material on the internet and in print by borderlines in recovery. These first-hand accounts of recovery written by former borderlines can be more powerful and direct than second-hand accounts of recovery seen through the eyes of a therapist. All of these books provide hope that lasting recovery from BPD is real and possible.

Realistic hope for BPD recovery is critical – hope that committed, hard work over a lengthy period will lead to a better life free from borderline symptoms. One of the lessons I’ve learned is that how one thinks and fantasizes about oneself in relation to Borderline Personality Disorder makes a big difference. At first, via my research and through therapy I worked on convincing myself that BPD could be deeply recovered from. Replacing my former pessimism and fear about BPD being a hopeless, life-long disorder with optimism about recovery helped me immeasurably. Later on, I came to question whether BPD was a valid diagnosis at all, which I no longer believe it is. But that is not so important initially as nurturing the simple belief that no matter what one’s problems are, they can get better.

At the bottom of this article, you can find listings of books by therapists about their successful treatment of BPD patients. They are mostly psychodynamic or psychoanalytic, since that is the viewpoint that was most useful in my own journey. I bought all these books used for low prices off Amazon. Also, some good online and print sources written by recovered borderlines are described.

Treatment Options – Psychotherapy

If one is diagnosed with BPD and can afford it, therapy can be one of the most important drivers of recovery. As a teenager, I was fortunate to have my therapy funded by my parents. Later on, I lived frugally while paying for treatment myself. Therapy can be expensive, but many therapists use a sliding scale of reduced fees correlating to ability to pay. If you want therapy but feel you cannot afford it, do not give up. Make sure you search around your area for different reduced rate or pro bono options. In large cities, there are hospital-based nonprofit clinics which offer low-rate or even free group and individual therapy.

What type of therapy is the best? Obviously, that is a question that cannot be answered objectively. In my view, the more important factors are the motivation of the person suffering with BPD, and the personal qualities of the therapist regardless of their orientation. However, with that caveat I believe that that the two best kinds of therapy for BPD are psychodynamic/psychoanalytic therapy and Dialectical Behavior Therapy (DBT). I am biased toward psychoanalytic treatment for BPD because it worked for me. I have no direct experience of DBT. However, it has worked for many others suffering from borderline symptoms, so I recommend it also.

Many uninformed therapists are pessimistic about BPD or do not know how to treat it. However, there are also many therapists out there who are skilled at treating BPD. They know from experience that lasting recovery from BPD is possible. If you seek treatment, it is obviously important to find the latter kind of provider.

How To Find A Therapist

My favorite source for finding therapists is the Psychology Today’s Therapist Finder. It can be accessed at:  http://therapists.psychologytoday.com/rms/

This site has the largest and most up-to-date listing of therapists currently available in the United States and Canada. Once you click on a region, you can search for therapist by orientation (psychodynamic, dialectical, etc.), by specialty (borderline personality disorder, eating disorders, anxiety, etc.), and so on. For example, I just searched in the large American city nearest me, and found over 70 therapists who specialize in treating Borderline Personality Disorder. You can also find therapists that are covered by different insurance providers, which is important because insurance can often cover a significant part of the cost of therapy. And you can directly email or call the therapists directly from the site.

My Therapist Interview Process

I used Psychology Today’s site to find a good therapist several years ago. What I did was to email and call all the therapists I was interested in, asking them a few brief questions. I introduced myself in a friendly way and asked them some version of the following:

– Do you have a lot of experience treating personality disorders, in particular Borderline Personality Disorder?
– Do you believe that individuals with Borderline Personality Disorder can be successfully treated? In particular, do you believe that a sufferer of BPD can become free of the disorder over the long term, i.e. come to live a healthy life free largely free of borderline symptoms?
– Are you willing to meet with me for a 15 minute free in-person consultation to see if we might be a good fit?

If the therapist answered no to any of these questions, I rejected them. For me, a therapist who won’t volunteer 15 minute of their time for a brief consultation is not worth your time. If the therapist had little past experience treating personality disorders, I discounted them. That might be arbitrary, but it made sense to me that I wanted someone with a lot of experience treating a difficult condition. And most important, if they were at all pessimistic or doubtful about recovery from BPD being possible, I moved on. I met two therapists in person who thought that BPD was a lifelong “disorder”, the symptoms of which could be managed but would always remain with the sufferer. These “therapists” were poorly educated charlatans who shouldn’t be given the time of day. I was happy to walk out of their offices and go on to find someone much better.

Alongside these kinds of questions, one might also ask if the therapist offers a sliding scale of fees based on income. Good therapists often do this, but they will not always advertise it up front, since of course they have to treat many patients at full price to make a good living.

For me, finding a good therapist for BPD was like shopping for a car or a house. It’s a big decision that requires careful consideration and research. In some cases, the buyer should beware.

Much more could be written about different types of therapy. Those will not be explored here, mainly because I am not an authority on different types of therapy for BPD (I only know a significant amount about psychodynamic-psychoanalytic approaches). However, I encourage you, if you are diagnosed with BPD, to research other types of therapy and come to the best understanding possible of your options.

Medication

I hesitate to include this part, because it is controversial. However, it is best to be honest about one’s views. For most people, I do not believe that psychiatric medication is a major long-term contributor to recovery from BPD.

Medication can play a role in the early phases of treatment. It can be useful because it controls symptoms in the short term, usually for a period of months. If a borderline individual is struggling with overwhelming suicidal impulses, or with terrible, unamanageable anxiety, medication can be useful to stabilize them. It can bring down the temperature and stop a person from “overheating” emotionally. I was prescribed anti-depressant medication for this reason myself in my late teens and early 20s. However, I then decided to taper off of it, and I have not used medication at all for the last six years.

However, beyond stabilizing short-term symptoms, I believe that medication is a waste of money and potentially dangerous. I recently read the books Anatomy of an Epidemic, by Robert Whitaker, and The Myth of the Chemical Cure, by Johanna Moncrief. These and many other books on the subject make clear that psychiatric medication carries with it the risk of severe long-term side effects that are currently poorly understood. In particular, there is the scary and very real possibility of tardive dyskinesia (uncontrollable, often irreversible movements of the mouth and other body parts) in those who take psychiatric medication long term.

For me, there are several problematic emotional aspects to using medication long-term in the treatment of BPD. Using medication long-term promotes the myth that taking a pill can magically solve one’s emotional problems. It implies that one does not have the ability to deal with long-standing issues interpersonally. And it suggests that the primary source of one’s problems is biochemical or genetic, which for me is pessimistic and false. As referenced in Whitaker’s book, disturbing long-term studies are now showing that if they take medication long term, patients with several types of psychiatric disorders do worse on most measures of recovery than those who never take them. Big Pharma companies are denying these results. But of course, they have billions of reasons to do so.

I recommend that people do their own research and come to their own conclusions about medication. My position is that therapy, self-help, and support from family and friends are the main drivers of recovery. If I were to start over with recovery, I would remain open to taking medication in the short term to provide relief from overwhelming symptoms. However, I am so glad to be off medication for the past six years. It gives me the empowering feeling that my own actions are responsible for my recovery, that I am a free agent.

Other Sources of Support Early In Recovery – Family and Friends

On my recovery journey, learning about how the borderline disorder works, reading stories about how former borderlines recovered, and finding an effective therapist were key early steps.

Support from family and friends is also very important. If one’s family can come to understand BPD in a compassionate way and be supportive of one’s recovery, that can obviously be tremendously helpful. My mother never actually knew that I had BPD, but she nevertheless supported me  to go to therapy, gave me a place to live, and was available to talk for several years after I graduated from college. Without her financial and emotional support, I would not be where I am today.

Opening up to friends about BPD can also be valuable, although it can feel risky. Over the course of five years (between ages 17-22), I told four people I met about my history of physical abuse and the problems between my parents, who divorced when I was 18. Although they never knew that I had BPD, Gareth, Julian, Andrew and Helena did discover that I was severely depressed, occasionally sometimes suicidal, and that I had great difficulty trusting and opening up to other people. They became invaluable sources of support and helped me to feel less alone during the early period of my recovery.

I was very hesitant initially to confide in these people, since I had no real friends at the time and feared that they would reject me. The antidependent side of me did not want to risk asking anyone else for help. However, the healthier, dependent part of me correctly sensed that they were kind, mature people, and it eventually won out. Gareth was an older family man in his 40s that I met through tennis, Julian was a fellow high school student in the class above me, and Andrew and Helena were young people in their mid 20s who worked at a spiritual retreat center that my family went to every summer.

Where to Find Friends Who Support Your Recovery

If you don’t have friends like this yet, there are many people out there willing to help. Online web boards and forums can be useful places to find support, but nothing replaces meeting people in real life and talking face-to-face. For that reason, I believe that group therapy and 12-step groups are extremely valuable. I attended both in my late teens and in my 20s.

Many therapists listed on the Psychology Today site above run or make referrals to group therapy. To find such groups it is usually necessary to get referrals from therapists or local hospitals and social work clinics. I went to a group for emotionally troubled young people at the state college that I attended. The university hospital ran this group, and it was free.

Regarding 12-step groups, I met several great people at these meetings that became friends whom I could call or meet in person during difficult periods. Twelve-step groups exist for almost every possible emotional problem, including eating disorders, sex addiction, drug and alcohol addiction, gambling, self-harm, and many more.  Here is a list of 30 different 12-step groups, along with their websites:
http://www.12step.org/12-Step-Groups/

Also, Meetup (www.meetup.com) is a great way to make new friends in your local community. This worldwide online platform creates groups for specific interests that meet in real life. I met several of my current friends through Meetup groups in my area. This might not be the very first step to take in BPD recovery, but once the borderline individual is more confident and ready to leave behind past abusive relationships, Meetup provides access to a whole new world of people.

I hope this article has provided some useful ideas for those wondering where to start looking for help with BPD recovery (and please also see the books below). The central, overriding goal throughout my recovery from BPD was to learn to trust and develop satisfying relationships with other people. Good long-term psychotherapy can help a borderline individual come to trust and truly depend on another person for the first time. Therapy groups, 12 step programs, friends, and family can be invaluable sources of support, with or without individual therapy. Lastly, the individual’s own self-advocacy and motivation to get better are perhaps the most critical drivers of their recovery.

————————————

Therapists’ Books About Borderlines Who Recovered

The Bad Object – By Jeffrey Seinfeld. Seinfeld’s successful cases of Kim, William, Justine, Diane, and Peggy are detailed 20-30 page “stories” of these borderline patients’ lives. Seinfeld tells how they went from severely borderline to learning to trust him and becoming increasingly functional and independent. Seinfeld, a New York-based social worker who recently passed away, is one of my heroes for how optimistically he writes about BPD.

Six Steps in the Treatment of Borderline Personality Organization – by Vamik Volkan. This internationally renowned psychoanalyst was a master at conceptualizing and treating BPD. In this book he illustrates his conceptual understanding of BPD, and outlines six phases of successful treatment that he used. His account of his treatment of Patti, the borderline patient whose history fills half this book, is a touching and ultimately triumphant story of how Patti became a mature adult over a period of several years.

Borderline Psychopathology and its Treatment – by Gerald Adler. In this book, Adler defined specific phases in the successful treatment of BPD and reviews the treatment course for several borderlines with whom he worked. Adler, a Boston-based psychiatrist, uses a deficit model of BPD which is different from some other psychodynamic writers. He focuses on the relative absence of positive introjections and the inability to regulate emotions, rather than on the attachment to bad objects. I met Adler in Boston in 2008 to discuss BPD, and he is still very optimistic about treating the disorder, while not being unrealistic about the major challenges involved. Adler is such a kind man, and he is another one of my “idols of BPD” 🙂

Psychotherapy of the Borderline Adult – by James Masterson. Masterson describes his theory of BPD treatment, which is focused on working through negative feelings and encouraging independence in the patient. He tells the stories of several young and middle-age adult patients who had strong outcomes, becoming able to love and work. I’m not a big fan of Masterson’s theories, since for me they overemphasize autonomy at the expense of dependence and closeness, but I respect his success in treating BPD. Until he recently passed away, Masterson practiced therapy in New York where he developed an institute which trained other therapists in how to treat personality disorders including BPD.

The Difficult Borderline Patient, Not So Difficult to Treat – by Helen Albanese. This book has a strange title, but it’s a great book! It was written in 2012, by a Texas-based university therapist who has worked with borderlines for decades and is very optimistic about BPD. In this short volume, she describes her understanding of how borderlines repeat and cling to past traumatic experience. She describes how therapists can help separate the borderline from bad external relationships and promote the development of an authentic self.

The Angry Heart: Overcoming Borderline and Addictive Disorders – by Santoro and Cohen. This was one of my first introductions to BPD. It is a very empathic and informed view of BPD and how to recover from it, from a mainly cognitive-behavioral viewpoint. However, it does not have the lengthy case studies of some of the other titles above.

Listening Perspectives in Psychotherapy and Interpreting the Countertransference – Lawrence Hedges. I hesitate to recommend these books because they is quite technical. However, they moved me toward my current viewpoint about BPD being more useful as a metaphorical term than as a mental health diagnosis. In this work, California psychoanalyst Hedges explicates his theories about Borderline Personality Disorder, as well as about psychosis, narcissism, and neurotic conditions. He explains how these conditions are formed in past childhood trauma and perpetuated by adult relational patterns and defenses. However, Hedges also believes that these disorders do not exist as distinct medical entities,  and he explains why. When I went to Los Angeles last year, I got a chance to meet Hedges in person. He is still very optimistic about borderline-spectrum conditions. He told me how he, his colleagues, and his supervisees had treated dozens of people with severe borderline conditions over the past several decades, often with significant success.

Online and Print Accounts of Recovery by Borderlines, in their own words

Borderline Personality From the Inside Out – by A.J. Mahari

You can find A.J.’s website at http://www.borderlinepersonality.ca
In my opinion, A.J.’s website is the best online source of information about BPD. A Canadian blogger who was diagnosed as borderline many years ago, A.J. writes with great wisdom and experience about every aspect of the borderline experience. By the mid 1990’s, A.J. had meaningfully recovered from BPD, and she has spent the last 15+ years encouraging others to do the same. She also offers “recovery coaching” services to current borderlines. If I had known about her 10 years ago, I would not have hesitated to get coaching from her (well, being honest about myself 10 years ago, I might have hesitated, but that’s another story! 🙂

Healing from BPD – by Debbie Corso.
Debbie’s website is – http://www.my-borderline-personality-disorder.com/
Debbie is a young woman from California who tells the story of her journey to recover from Borderline Personality Disorder using DBT. Over the past few years, Debbie has progressed to the point where is no longer diagnosable with BPD, and she is a great example of how motivation and hard work can lead to successful recovery. I highly recommend her website and blog.

Get Me Out Of Here: My Recovery From Borderline Personality Disorder – By Rachel Reiland.

Rachel Reiland, a young mother and wife, suffered from severe BPD which manifested itself in symptoms including anorexia, promiscuity, and suicide attempts. In this book, she tells the story of how she faced these challenges using intensive psychotherapy and the support of her family and friends. By 2004, when she published this book, she had meaningfully recovered from BPD, and her recovery has been stable and lasting for the past 10 years. Today, Reiland does radio interviews, blog postings, and generally spreads the message that recovery from BPD is real and possible. More information about her can be found at http://www.getmeoutofherebook.com

The Buddha and the Borderline: My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating – by Kiera Van Gelder

This is another moving account of long-term recovery from BPD. Van Gelder honestly describes her traumatic family history and the resulting behaviors it led to including drug addiction, suicidal thinking, and severe mood swings. She courageously sought help via group therapy – the book contains interesting accounts of how DBT works in groups – and via the unconventional methods of Buddhist spirituality and online dating.  These unusual things that helped Van Gelder are reminders that every recovery process is different, and that what works for some people may not work for others. I would not use online dating, but I’m glad it helped her!

———————-

I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or would like to more effectively help someone who is borderline, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

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

– Edward Dantes

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

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

The Broken Brain / Genetic Causation Theory of BPD

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

Cui Bono?

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

The benefits of promoting a genetic basis for BPD include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Can Brain Scans Prove a Genetic Basis for BPD?

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

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

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

Twin Studies

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

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

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

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

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

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

Views of Present Day Psychiatrists, Therapists, and Family Members

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

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

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

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

The Tragic Effect of Genetic Theories of Mental Illness and BPD

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

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

My Own Experience as a Refutation of Genetic Theories

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

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

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

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

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

—————————-

Further Reading

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

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

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

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

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

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

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

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

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

———————————

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