Tag Archives: BPD medication

#18 – Heroes of BPD: Jeffrey Seinfeld

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

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

seinfeld1

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

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

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

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

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

Kim’s Early Childhood

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

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

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

Kim’s Early Therapy – The Out of Contact Phase

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

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

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

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

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

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

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

Dwelling on the Rejecting Object

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

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

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

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

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

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

The Safety of the Bad Object

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

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

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

Ambivalent Symbiosis

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

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

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

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

Seinfeld comments on this ambivalent symbiosis in the following way:

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

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

The Transition to Therapeutic Symbiosis

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

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

Regarding the developing therapeutic symbiosis, Seinfeld stated,

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

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

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

Strengthening the Therapeutic Symbiosis

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

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

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

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

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Comments on Seinfeld’s Case of Kim

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

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

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

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

Seinfeld As An Author

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

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

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

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

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

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

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

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

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

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

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

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

#2: Bad Object Conflict

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

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

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

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

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

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

#3: The Exciting Object

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

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

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

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

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

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

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

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

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

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

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

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

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

How To Interrupt the Rejecting-Exciting Object Cycle – Insight

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

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

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

Recovery as a Mythic Journey

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

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

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

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

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

Please share any comments you have below!

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I welcome any correspondance at bpdtransformation@gmail.com

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

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

– Edward Dantes

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#13 – The Science of Lies: Psychiatry, Medication and BPD

Disclaimer: This article is not a recommendation for others to come off psychiatric medications. Any decisions about taking, continuing, or discontinuing psychiatric medications should be made in consultation with a medical professional. This article should not be construed in any way as professional advice – it is one person’s opinion and experience only.

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Seven years ago, I made a decision that would define my future. Against my psychiatrist’s advice, I began tapering off three different psychiatric medications. Within three months, I had stopped taking them entirely.

At age 21, I had already been taking multiple medications for four years. These included antidepressants, antipsychotics, mood stabilizers, and antianxiety pills. At different times, I took Lexapro, Effexor, Xanax, Wellbutrin, Prozac, Seroquel, Paxil, Zoloft, Depakote, Zyprexa and Lamictal. For brief periods, they made me feel less anxious and depressed. For the most part, they did nothing to reduce my overwhelming fear, rage, and hopelessness.

At this time, my core problems had barely begun to be addressed. These problems included being completely unable to trust others, having no identity or self-esteem, and never having had a secure dependent relationship with a parent figure. Nevertheless, my parents were spending thousands of dollars each year on psychiatric medications that barely influenced my symptoms.

Finally, I realized the futility of continuing to take the pills and acted accordingly. I stopped taking them with full awareness of the risks involved. Since I stopped seven years ago, life has only gotten better. I have not missed the medications for one day.

Tragic Borderlines on Web Forums

On forums for Borderline Personality Disorder that I frequent, individuals with BPD sometimes list their current diagnoses and medications beneath their username. Reading their posts is often saddening, since many of them are struggling with overwhelming life problems.

It is rarely apparent that the medications make a great difference to these individuals’ experience of themselves or others. They will sometimes ask for recommendations of medication that work better. There is often the sense that if they could just find the right medication, their situation would improve dramatically.

Many such borderlines appear to be trapped in a Kafkaesque nightmare. They are on many medications, but not in effective long-term therapy. They have been told that their diagnosis (BPD plus other “comorbid” conditions) involves biological and/or genetic factors that all but require them to take medication. The medications may slightly reduce their suffering, but at the cost of painful side effects and an inability to feel positive emotions.

They do not realize that they are missing the most basic ego functions, are using primitive defenses like splitting and projection, and that their terrible emotional struggles stem from a crucial lack of nurturance and support in childhood. Without awareness and insight, these borderlines keep repeating the same ineffective, self-destructive strategies. These strategies allow them to survive but keep them chained to BPD symptoms. Their borderline personality structure based on splitting endures, being immune to any effect from the medication.

Such borderlines usually accept what their psychiatrists tell them without questioning:
1) The scientific validity of mental health disorders and the DSM,
2) The validity of biological and genetic causes of “mental health disorders”,
3) The real long-term effectiveness of medications for these supposed disorders, and
4) The potential risks of long-term medication use.

Psychiatry: The Science of Lies

There are many well-researched books on the unscientific, fraudulent, and patient-damaging practices of psychiatry. Here are my recent favorites:

The Book of Woe – Gary Greenberg
Mad Science: Psychiatric Coercion, Diagnosis, and Drugs – Kirk, Cohen, and Gomory
Anatomy of an Epidemic – Robert Whitaker

In brief, these books assert that psychiatry is the biggest scam going. It manufactures fake diagnoses through the DSM, then creates medications with questionable efficacy and dangerous side effects to treat them (and yes, there are an incredible variety of real human emotional problems – just not in the pseudoscientific way that the DSM defines them).

(Psychiatric drugs can cause dangerous, irreversible side effects, including tardive dyskinesia. Tardive dyskinesia is an often incurable disorder characterized by chronic involuntary muscle spasms of the face and tongue. About 20-30% of long term users of antipsychotic drugs, which are sometimes prescribed for BPD, develop it.)

These books present studies showing that the majority of mental health patients, including those with depression and schizophrenia, do worse over the long term with medications. Yes that’s right – long-term medication use makes the average person with emotional problems less likely to recover. Patients who only take medication for short periods or don’t take it at all do best. I have no doubt that this also applies to Borderline Personality Disorder.

This does not mean that a borderline individual who has taken medication for years cannot recover. Good therapy and the support of family and friends can greatly outweigh the negative effects of years of medication use. I am an example of that.

My View on Medication and BPD

My opinion is that medication has very little use in the long-term recovery process for Borderline Personality Disorder. The extent of its usefulness involves management of extreme short-term symptoms such as overwhelming anxiety, depression, and suicidal thinking. For a period of a few weeks or months, medication can be effective in damping down these symptoms. It can make other interventions possible, and in some cases even save lives.

However, beyond a few months, the scales shift. Long-term medication use reinforces the myth that BPD is a biologically-caused condition from which the individual cannot fully recover. It dulls down and limits access to negative and positive feelings, both of which need to be worked through for recovery. And medication works against a feeling of agency and personal power, two qualities which borderlines are desperately lacking.

Why Is It Impossible For Medication To Cure Borderline Personality Disorder?

Let us assume that BPD is a reliable diagnostic entity, as ridiculous as that notion may be. Why shouldn’t we create a medication that can alter chemicals in the brain in the exact way necessary to cure BPD?

One problem is that our understanding of the brain is very primitive and poor. There are about 100 billion neurons, or nerve cells, in an average human brain. If they were stretched out end to end, they would span about 620 miles. One million of them would be about 33 feet end to end. These neurons are connected by about 100 trillion synapses, or specialized connections between cells. Therefore, neurons interact in trillions of subtle and complex ways with each other, exchanging chemical signals constantly in ways we understand only superficially.

Not only do neurons interact with each other, but they interact in a dynamic, unpredictable way with the external environment through the sensory organs and physical intake mechanisms of the body. Our 100 billion neurons are uniquely influenced trillions of times daily by internal and external factors trillions of times every day.

Obviously, the brain is incredibly complex, and we understand relatively little about its workings at a molecular level. What our psychiatric medications are good at is dulling down certain chemicals that we know to be genereally associated with emotion. Medications affect dopamine, serotonin, and norepinephrine in blunt ways that prevent a person from feeling their negative (and positive) emotions as strongly. That is why they may usefully reduce symptoms like depression, anxiety, and suicidal thinking.

However, medications do nothing to cure the causes of these symptoms. In BPD, the central problem is a massive predominance of negative past experience that is encoded in the brain through many thousands of memories of neglect, trauma, and/or unsatisfactory relationships. The dominance of negative memories and the relative lack of positive memories is crucial. This dynamic creates defenses like splitting, and generates all the borderline symptoms contained in the DSM.

Therefore, a borderline personality structure affects a person’s every waking moment, stretching back in time to their early childhood. The only escape is a long-term positive dependent relationship with a new person or group in the present.

Since medications cannot replace bad memories with good memories, they are hopeless at curing BPD. Curing BPD via medication would require some kind of ultra-advanced nanotech treatment that would rewrite a person’s entire personality. It would erase their old identity and encode new positive “memories” to suddenly give them all the ego capacities that come with a healthy childhood. It would trick them into believing they were a totally new and different person.

Unfortunately, such a magic bullet is not on the horizon.

The other problem is, of course, that Borderline Personality Disorder does not exist in a medical sense. It is a fictitious, non-scientific “non-diagnosis”. It is ironic that I mention the “disorder” so often in this blog, but don’t believe in its validity. In truth, there is no sharp dividing line between “borderline” and “normal”, nor can anyone reliably diagnose BPD. Human beings are so complex, the varieties of our problems so individual, that “disorders” like BPD simply cannot be scientifically applied, let alone “treated” via medication.

It does not make sense to even discuss how medication might cure BPD, given that BPD is not a unitary condition. As noted elsewhere, Borderline Personality Disorder finds better use as a metaphorical term, describing a spectrum or range of psychological difficulties, rather than as a medical diagnosis.

Why Do Psychiatrists Overprescribe?

Most psychiatrists working today in the United States have little training on how to do depth psychotherapy. They do not broadly understand emotional problems in terms of developmental experience. Rather, they are taught that mental health conditions are biologically based diseases needing to be medicated and managed, rather than understood and cured.

Why do psychiatrists prescribe so many pills to so many people, and increasingly to borderlines?

Reason #1 – Money

Underlying psychiatrists’ training is the profit motive. Psychiatrists – and the drug companies with which they are intertwined – have learned that seeing patients for “medication management” for 15-30 minutes at a time, one or twice a month, results in much more money than seeing the same patients for talk therapy 45-60 minutes at a time, multiple times a week. Psychiatrists often charge outrageous sums ($180-250 or more on average in my area) for these occasional, half hour or less sessions. They are making several hundred thousand dollars a year.

The move away from depth psychotherapy toward short-term treatment and heavy use of medication is therefore simple to understand. When hundreds of thousands of dollars per year are at stake, it is easy to convince oneself that psychiatric disorders really are valid, that psychiatric medication really is doing a lot of good, and that one is doing a service to society by promoting long-term medication use. Most psychiatrists are not bad people. However, many psychiatrists use defenses like denial, confirmation bias, and avoidance of contradictory information to maintain their belief that what they are doing is good for most people. It is amazing what people will deny when hundreds of thousands of dollars depend on it.

I am fully aware that there are good psychiatrists out there. There are psychiatrists who focus on therapy, on understanding the patient as a person, and on minimizing medication use. These practitioners are to be commended. The problem is, there are not enough of them.

Reason #2 – Simplicity

The other reason for psychiatric overprescription is that it’s easy. Working with a borderline patient in long-term psychotherapy, understanding their overwhelming pain, and helping their fragile inner self emerge is extremely challenging. It requires great patience and tolerance for managing negative emotion within the therapist.

Many less talented and committed mental health workers have unconsciously decided it’s easier to sedate difficult patients rather than understand them as complex individuals. How simple is it to give someone a pill and pretend that that is the best that can be done? Or to pretend that their problem is mainly genetic or biological, a simple matter of misfiring brain neurons, rather than a result of the individual’s unique personal history?

This situation is unfortunate, but it is incumbent upon borderlines to avoid these charlatans and find truly effective help.

Should Psychiatrists Be Blamed?

Should “bad” psychiatrists be blamed for overprescribing medication?

No.

Psychiatrists are able to overprescribe (meaning prescribe too many medications for too long) partly because consumers accept their practices. If we want the situation to be different, we need to look at ourselves and ask why we continue to buy their poisoned offerings. If more borderlines did what I did – stop taking endless medications, find ways to get effective therapy no matter the sacrifices involved, and reject the prevailing biological-determinist model of mental health disorders – then many more current borderlines would fully recover to become non-borderlines like me. None of this is easy, and in reality I am far more sympathetic than I sound in this paragraph.

In making these controversial points, I am fully aware that for a few mental health patients, long-term medication use is absolutely necessary. A few conditions like bipolar disorder have a proven biological component. However, that is not the case with Borderline Personality Disorder and many other so-called mental health “disorders.” As hard as drug companies are trying to increase their profits by to linking these conditions to genetic and biological causes – thereby legitimizing the prescription of more and more medication – they have so far abjectly failed. T

It is critical to understand the lack of any proven genetic basis for Borderline Personality Disorder, because that undermines a central argument of those who advocate medication. This topic is discussed in more detail in earlier articles on this blog including this one:

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

What Would a Good American Approach to BPD Look Like?

An effective approach to BPD in America would involve a massive increase in the number of therapists specially trained to treat BPD intensively via long-term therapy. It would include a massive decrease in the average cost of treatment, or the provision of greater subsidies, to allow the many poor and disadvantaged abused borderlines to fully participate in intensive treatment. It would also include a massive decrease in the number of psychiatrists treating BPD with medication, and an equally massive drop in long-term medication use (meaning medications used for more than a few weeks or months at a time).

Paradoxically, these changes would probably save our economy money in the long run. If good therapists treated more borderlines at lower cost using less medication, many more borderlines would recover. After several years of treatment, many former borderlines would become productive members of our economy for decades. They would generate much more money for employers, earn more money, and spend more money. The number of borderlines working part-time jobs in fields far beneath their capacity or interests would lessen. The number of borderlines not working at all, or on disability, would likewise decrease greatly, resulting in huge savings for our welfare system.

This scenario is a huge contrast to our current practices, which involves medicating borderlines (or not treating them at all) such that their symptoms remain muted but essentially the same. For these unfortunate people, their independent functioning and ability to contribute to the economy remains weak or nonexistent, and they are a continuing burden on the economy.

The positive scenario described above is extremely unlikely, due to the uniquely capitalistic and competitive ethos that characterizes American corporate culture, and due to the ease with which many people are tricked into believing its lies. Drug companies and psychiatrists have realized there is little profit in treating borderlines as complex people needing long-term psychotherapy and short-term medication. Instead, many psychiatrists, and almost all drug companies and their shareholders, are invested in prescribing as much medication as possible regardless of the damage done to the patient.

Borderlines as Collateral Damage

The current treatment of BPD means that many less borderlines are recovering than would be if psychotherapy were emphasized over pills. To drug companies and psychiatrists, these “non-recoveries” are essentially the collateral damage that is necessary as part of their profiteering operation.

In this way, the continued suffering of borderlines because of drug companies’ promotion of pills (relative to how much better borderlines could do under non-drug approaches) is loosely comparable to the environmental destruction wrought by industrial companies as they extract natural resources. Many oil, gas, timber, and mining companies have happily profited by damaging rivers, forests, and oceans in ways that only become apparent much later on. In their short-term worldview, it’s fine for others to bear long-term costs while they make off with short-term profit.

In a similar way, the CEOs and shareholders of drug companies are either unaware or unconcerned about how medications are hurting borderlines in the long run. The key thing for drug companies is that they are making money, not whether the patient is being cured. A carefully cultivated illusion of efficacy, built up around medication’s short-term symptom-dulling effects, supports the profit-making process. If the patient can be deceived into thinking their “disorder” is biological and into taking medication for a longer time at high cost, then so much the better.

In this view, borderlines and other mental health disordered patients are the “tragedy of the commons” of the psychiatric industry. They have to bear the costs of the long-term negative effects of overprescription and ineffectiveness of psychiatric drugs. Meanwhile, psychiatrists and drug companies are long gone with billions of dollars in profits.

Conclusion: Becoming An Educated Consumer

If you have been diagnosed with BPD or have a family member with BPD, do not let yourself become another victim of the psychiatric establishment. Educate yourself. Read books like the ones mentioned above by Greenberg, Whitaker, and Cohen which lay bare psychiatry’s lies. Read the emerging studies referenced in these books, which show that people taking long-term medications do less well on average than those who take them short-term. Question whether biological-genetic explanations of BPD are founded on solid scientific research. If you talk to your friends and neighbors about mental health disorders, discuss with them what you have learned about psychiatric drugs.

The only reason drug companies and psychiatrists continue to survive and profit is because we let them. If we stop buying their products in, they will mostly shrivel away, leaving a much smaller industry providing short-term, acute-need medication. The only weapon against these corporations is an educated consumer.

I am a mortal enemy of our present-day psychiatric industry, being focused as it is on the long-term prescription of medication alongside elaborate cover-ups of the long-term effects. I hope that people reading this article will open their eyes to the biggest ongoing scam in our society, that of American psychiatry. People that can see through their lies are an existential threat to the entire industry and the thousands of jobs that depend on it. I only hope that its house of cards will come tumbling down sooner rather than later.