Tag Archives: bpd recovery

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

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

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

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

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

On good outcomes for people labeled “BPD”:

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

On BPD as a medical diagnosis:

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

On how the word borderline can be useful:

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

On the developmental approach to working with people labeled BPD,

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

On suicide prevention:

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

On the value of medication in treating people labeled BPD:

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

On trauma as the cause of borderline states:

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

My Interaction with Dr. Ross

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

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

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

LloydRoss1

Lloyd Ross, Ph.D.

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

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

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THE BORDERLINE STATES

By Lloyd Ross, Ph.D.

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

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

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

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

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

The Causes of Borderline States

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

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

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

A Personal Example of Trauma

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

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

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

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

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

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

Understanding Borderline States Developmentally

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

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

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

The Identification Process, Splitting and Fusion in Childhood Development

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

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

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

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

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

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

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

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

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

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

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

Treatment for the Borderline, Suicidal or PTSD individual:

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

Electroconvulsive Shock; (ECT):

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

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

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

Bio-psychiatric Treatments:

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

Insight Oriented Psychotherapy:

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

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

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

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

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

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

A Brief Word on Narcissism

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

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

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

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

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

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

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

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

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

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

Bibliography

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ParallelPsychModels1

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

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

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

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

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

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

Melanie Klein: An Early Psychoanalytic Pioneer

To start with, why is this approach called Kleinian?

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

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

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

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

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

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

The Paranoid-Schizoid Position

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

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

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

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

Core Features of the Paranoid-Schizoid Position

The paranoid-schizoid position features:

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

My Emotional Experience of the Paranoid-Schizoid Position

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

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

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

Kleinian Theory Compared to Other BPD Models

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

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

PSPvsSearlesPhases3

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

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

How All-Bad Splitting Perpetuates the Past in the Present

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

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

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

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

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

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

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

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

Check out the Psycho Trailer.

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

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

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

Check out the Memento Trailer.

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

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

Check out the Beauty and the Beast Trailer.

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

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

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

The Paranoid-Schizoid Position and DSM Diagnoses

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

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

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

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

The Depressive Position and Healthy Personality Organization

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

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

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

Why are healthy people not borderline?

How can borderline people become healthy?

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

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

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

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

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

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

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

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

Here are details on The ACE Study.

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

Further Sources on Healthy Childhood Emotional Development

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

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

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

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

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

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

View a Youtube interview with Masterson.

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

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

Here is an Overview of Self-Psychology.

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

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

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

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

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

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

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

Here is Diener’s Book on Wellbeing.

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

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

Key Characteristics of the Depressive Position

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

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

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

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

My Experience of the Depressive Position and Therapeutic Symbiosis

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

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

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

Why Don’t Some People Reach the Depressive Position?

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

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

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

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

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

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

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

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

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

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I welcome any correspondance at bpdtransformation@gmail.com

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

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

– Edward Dantes

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

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

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

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

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

This article addresses how to replace BPD.

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

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

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

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

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

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

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

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

My Response to NEA’s Misinformation about BPD

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

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

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

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

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

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

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

My Manifesto Against National Education Alliance for BPD

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

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

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

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

Why Reducing BPD’s Stigma is Doomed to Failure

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

Two examples of such programs are instructive:

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

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

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

Abolishing BPD – The Ultimate Goal

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

Here is how a world without BPD would look:

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

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

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

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

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

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

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

How Would We Understand People Without BPD?

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

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

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

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

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

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

The First Step Toward Abolishing BPD – A New Name

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

If done well, renaming BPD would accomplish multiple goals:

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

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

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

Would BPD by any other name smell just as bad?

I doubt it.

Japan, Jim Van Os and the Abolition of Schizophrenia

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

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

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

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

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

The Emotional Dysregulation Susceptibility Syndrome

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

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

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

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

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

A Psychodynamic Model of the EDSS Continuum

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

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

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

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

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

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

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

You Don’t Have to Accept the BPD Label

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

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

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

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

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

#23 – The Borderline-Narcissistic Continuum: A Different Way of Understanding “Diagnosis”

For the purpose of understanding psychiatric problems in a more nuanced and optimistic way, here is a diagram from Donald Rinsley’s book Treatment of the Severely Disturbed Adolescent:

CAM00157Update

Please click on the picture to see it larger. Each row corresponds vertically to the rows above and below in describing degrees of emotional development, and each row describes emotional growth over time from left to right. The majority of the text in brown is Rinsley’s own diagram; the bottom additions in white are mine.

Donald Rinsley was among the most respected authorities on borderline and narcissistic conditions in the second half of the 20th century. He was a psychodynamic therapist who ran a psychiatric hospital for severely troubled adolescents in Topeka, Kansas in the 1960s, 70s, and 80s. He later worked extensively with personality-disordered and psychotic adults in an outpatient psychotherapy practice.

I believe that much can be learned from studying Rinsley’s diagram. It explains how psychiatric diagnoses were originally understood in psychodynamic theory – as problems in relating and functioning that occur along a continuum of severity and merge into one another. In other words, psychiatric conditions are not distinct disease entities; there are no clear lines that separate one from another.

At the upper and lower ends of each “disorder”, one cannot confidently say that a person is, for example, a higher level borderline versus a lower-level narcissist, since the conditions fade into one another. Note how the arrows denoting each region don’t stop before running into each other; they overlap.

Here are explanations of the diagram’s different rows.

Row 1: Mahler’s Phases of Child Development: Autism-Symbiosis-Differentiation-Practicing-Rapprochement-Object Constancy.

In this row, Rinsley lists phases of healthy child development that, when interrupted, can cause arrests in emotional development – i.e. psychiatric problems. Roughly, autism (which does not refer to autism as understood today) refers to the earliest period when a baby is unaware of the external world and feels fused with its mother at a body-level. Symbiosis is when the child starts to relate in a back-and-forth need-fulfilling way with its mother.

During differentiation, the baby realizes that it is separate from its mother psychologically as well as physically. In practicing, the child discovers and explores the external world via its newfound ability to walk. And in rapprochement, the child develops a good relationship to the mother as a separate person and faces conflicts around dependency/attachment and independence/autonomous functioning.

In these descriptions, “mother” is synonymous with “caretaker”, “parental figures”, and “the external world of people”. In the object constancy phase, the mother is finally perceived as a mixture of good and bad qualities, meaning that splitting is overcome,, and the child is increasingly able to regulate their emotions. It is this achievement that is lacking in borderline conditiions. For progression through these phases to occur, it is crucial that good-enough mothering be consistently available; otherwise the child can get “stuck” in a certain phase.

There is one area where I disagree with Rinsley. I don’t think it’s possible to put the phases of infantile development into a neat timeframe (as Rinsley attempts to do by saying that object constancy takes over in healthy toddlers at around 24 months, for example). I think children’s development is highly individual and that aspects of these phases continue to be worked on long after the first few years of life, even in emotionally healthy children.

Row 2: States of Self-Object Fusion or Differentiation

In this row, Rinsley indicates whether a person sees themselves and others as fused (indistinguishable from each other; this is a psychotic state), split (self images experienced as separate from images of other people, but viewed as all-good or all-bad, a borderline state), or integrated (seeing a mix of good and bad qualities within both self images and images of other people, a neurotic/healthy state). Roughly, fused self/object images relate to “psychotic” states, split images to “borderline” or “narcissistic” states, and integrated images to “neurotic” or healthy states of minds.

Row 3: Specific Diagnostic Categories

Here Rinsley lists diagnostic labels that correspond vertically with the phases of child development and self-object differentiation from the higher rows: Autistic-presymbiotic schizophrenia, symbiotic schizophrenia, bipolar disorders, borderline personality, narcissistic personality, neuroses, etc. I will not describe specifically what these diagnoses mean; the reader who is familiar with DSM categories will recognize them.

The crucial thing is that the diagnoses overlap along a spectrum and thus are not distinct illnesses. Rinsley conceptualized diagnoses as morphing into one another as treatment progressed; for example, one could start treatment at an upper-level schizophrenic, become a “borderline” a year or two later, then become narcissistic, and finally end up functioning at a neurotic, essentially healthy level after several years.

As conceived by Rinsley, diagnoses never represented fixed “illnesses” that one had to have for life. Treatment could change diagnosis; there was the prospect of transformation. American psychiatry has fallen far from this viewpoint with its current pessimistic views of rigidly separate “mental illnesses” that one can only “manage.”

This reminds me of how many years ago, I attended a National Alliance of Mental Illness meeting. At this session people talked about how mental illnesses were “brain diseases” that one could “learn to live with”. Even back then I thought that was a pathetic, limiting idea. Who wants to just “manage their illness” when they could become truly well? Having realistic hope that one can transform oneself  is so much more motivating! In my opinion NAMI is not to be trusted, due to their reliance on drug company funding. This funding implies a tie to the hopelessness of the disease categories of modern-day psychiatry.

Row 4: Major Diagnostic Categories

Here Rinsley lists the broad diagnostic regions: firstly, psychoses, which include schizophrenias, bipolar disorders, and some lower-level borderline conditions. These conditions represent emotional arrests in the earliest developmental periods. They include people who have fused images of themselves and other people; i.e. the person cannot distinguish between themselves and other people at an emotional level (and they see themselves and others as all-good and all-bad).

The second group is characterological (personality) disorders. These include the borderline, narcissistic, and also schizoid disorders. These also exist on a continuum and flow into one another. They feature splitting as their primary defenses Such people can emotionally perceive differences between themselves and other people, but they still see themselves and others as all-good or all-bad. The shorthand “G (S O)” with the space behind S and O mean that good self and object images are perceived as separate from each other, but are not integrated with bad self and object images. By contrast, in the psychotic conditions, with S-O, the dash between S and O means that the person experiences a lack of separation or differentiation between images of themselves and other people; they cannot emotionally tell where they end and other people begin. This “fusion” phenomenon occurs in some people who gets labeled with severe borderline conditions, which are partly psychotic, but it is a chronic condition in schizophrenic states.

Finally, in the last major diagnostic group, the psychoneuroses, the psychic structure gets reorganized so that splitting is eliminated and the person can see good and bad qualities coexisting in both their self-image and in their images of others. The shorthand S (G B) means that good and bad qualities are perceived together in oneself and others without splitting.

Row 5: Quality of Internalized Self-Object Images

This row describes how supportive or comforting the person’s internalized images of other people are. The more positive experiences a person has had, the further to the right hand of this continuum they are likely to be. Unstable archaic images refer to states where a person feels psychologically unstable because they are not comforted by sufficient positive memories / internalized good experiences. This corresponds to psychotic conditions and to lower level borderline states. This deficit is the reason for the commonly cited inability to regulate emotions in Borderline Personality Disorder. I wrote about this in my article on Gerald Adler’s insufficiency model:

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

The “stable archaic introjects” refers to when a person uses splitting, but the positive images are predominant most of the time over the negative, so the person can regulate their feelings better. This corresponds to higher level borderline and narcissistic conditions.

Lastly, differentiated self and object states refer to the ability to see good and bad in the same self or other-image. In this way people can consistently be perceived as mixtures of good and bad. This makes truly mature relationships possible based on genuine caring and interest in the other person, as opposed to mainly using people for what they can do for you (as with narcissistic conditions), or being so deficient in supportive introjects that one has trouble comforting oneself or trusting others at all (as in borderline and psychotic states).

Row 6: Seinfeld’s Phases – Out-of-Contact, Ambivalent Symbiosis, Therapeutic Symbiosis, Individuation

In this row, I listed Jeffrey Seinfeld’s four phases in a way that corresponds vertically to the horizontal continuums in the rows above. Borderline states are associated either with the upper part of the out-of-contact phase, or more frequently, with the ambivalent symbiotic phase. As one progresses into the therapeutic symbiotic phase – corresponding to being able to trust and feel supported emotionally by other people consistently – one stops being “borderline” and progresses toward healthier narcissistic and neurotic levels of functioning. It occurs to me that it’s too bad these words still sound pathological and negative. Again, we need better words to describe challenges in relating and functioning, words to give people hope of becoming fulfilled and well, not just managing an “illness”.

Please see the article below for a detailed description of Seinfeld’s four phases. Understanding the relative strengths of positive and negative self/object images explains how schizophrenic states can evolve into BPD, which can evolve into NPD, which can evolve into neurosis/healthy personalities, etc. Really, all of these conditions represents problems with adapting and managing life problems; rather than “brain diseases” Given sufficient support, all of these conditions can evolve or morph into one another along the left-to-right continuum of emotional growth. Here are Seinfeld’s phases:

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

And here is an example of how a young woman progressed through the four phases, starting in the lower-level out-of-contact “borderline” phase”, progressing through the narcissistic phase, and finishing in the neurotic-healthy part of the spectrum:

https://bpdtransformation.wordpress.com/2014/08/17/18-heroes-of-bpd-jeffrey-seinfeld/

Row 7: Common DSM levels and Hedges’ phases

In this row, I put common DSM labels – schizophrenia, BPD, NPD, neurosis, etc. These are not truly valid illness categories, but they have some meaning if understood as part of a developmental continuum.

Below these labels, I put Lawrence Hedges’ descriptions of the four developmental levels which Seinfeld described in his phases. I haven’t written about Hedges yet, but he is my favorite psychodynamic writer along with Jeffrey Seinfeld. His descriptions of people’s problems are much more empathic, human, and hopeful than the DSM labels. More on Hedges in a later post.

CAM00157Update

The equivalencies for the bottom row would be roughly as follows:

Schizophrenia/lower borderline (DSM) = Out-of-contact (Seinfeld) = Organizing Experience (Hedges)
Lower-to-mid level Borderline PD (DSM) = Ambivalent symbiosis (Seinfeld) = Symbiotic Experience (Hedges)
Higher-level Borderline through Narcissistic PD (DSM) = Therapeutic symbiosis (Seinfeld) = Self-Other Experience (Hedges)
Neurosis-Healthy = Individuation (Seinfeld) = Independence Experience (Hedges)

Conclusion

My goal in this article was to give the reader a taste of how psychodynamic theorists think about schizophrenia, borderline, narcissistic, and neurotic-healthy mental states as existing along a continuum of emotional development. This viewpoint is different than the rigid DSM categories which dominate American psychiatry today.

In my opinion, this spectrum or continuum based approach, while not perfect, is more informative and realistic than rigid DSM categories. Since it is developmental, it implies the hope that one can grow beyond frozen emotional development to become emotionally mature. That’s why it’s my rough guide for thinking about “borderline” and “narcissistic” states, although I try not to use those words too much!

——————–

I welcome any correspondance at bpdtransformation@gmail.com

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

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

– Edward Dantes

#22 – Proof That Borderlines Are Motivated for Psychotherapy and Can Fully Recover

This post will answer critics who say: “Borderlines are not motivated to attend therapy. Borderline patients don’t stay in treatment. At best, therapy can manage but not cure BPD.”

These statements are absolutely false. Yet these myths continue to appear online, often being communicated to people recently diagnosed. As the studies below demonstrate, most people diagnosed with BPD do want help, most will stay in good treatment, and most do recover to different degrees.

Earlier posts have elaborated my dim view of the (non) validity of the BPD diagnosis. Since it cites studies using the BPD construct, this post might be viewed as hypocritical. That may be a valid criticism! Nevertheless, these studies provide evidence that people with “borderline symptoms”, however defined, can be motivated and recover both with and without therapy

Study 1:  88 Borderline Patients Treated Twice a Week for Three Years

Highlights: Led by Josephine Giesen at Maastricht University, Dutch researchers treated 88 borderline patients for three years with twice-weekly psychotherapy. Patients were randomly assigned to either Schema-Focused Therapy or Transference-Focused Psychotherapy, which are described in detail below.

After three years, a large majority of patients showed significant improvement, with many considered fully recovered and no longer diagnosable as borderline. In the group of 45 patients undergoing Schema-Focused therapy, more than half were no longer diagnosable as borderline after three years, and many more had improved significantly.

The researchers commented, “These treatments demonstrate that patients with BPD can be motivated for and continue prolonged outpatient treatment… Three years of treatment proved to bring about a significant change in patients’ personality, shown by reductions in all BPD symptoms, increases in quality of life, and changes in associated personality features.”

Here are details from the study:

Patient Population:  88 Dutch patients diagnosed with BPD. Average age around 30 years, with most patients in their 20s or 30s. Over 90% of patients were female. The group had average educational levels for Holland; about half had attended some college or completed a degree. As for functioning before treatment, around 50% were on state disability, 20% were working, and the remainder were students or stay-at-home wives/mothers.

Trauma in Patients’ Histories:  Over 85% of the patients reported childhood physical abuse. About 90% reported childhood emotional abuse or neglect. More than 60% also reported sexual abuse. Over half the patients had seriously contemplated or attempted suicide within three months before treatment. About three-quarters were taking some type of psychiatric medication.

Intervention: For a three-year period, patients attended two 50-minute sessions per week of either Schema-Focused Therapy (SFT) or Transference-Focused Psychotherapy (TFP). Treatment occurred at outpatient medical centers in four Dutch cities. The type of therapy given was randomized.

Definition of Schema-Focused Therapy: SFT is a psychodynamic treatment which assumes the existence of schemas (mental models of relationships) expressed in pervasive patterns of thinking, feeling, and behaving. The distinguished modes in BPD are detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. Change is achieved through a range of behavioral, cognitive, and experiential techniques that focus on (1) the therapeutic relationship, (2) daily life outside therapy and (3) past traumatic experiences. Recovery in SFT is achieved when dysfunctional schemas no longer control the patient’s life.

Definition of Transference-Focused Therapy: TFP is a psychoanalytically-derived therapy which focuses on the transference relationship between patient and therapist. Prominent techniques are exploration, confrontation, and interpretation. Recovery in TFP is reached when good and bad representations of self and others are integrated and when fixed primitive internalized object relations are resolved.

Therapist Composition: 44 different therapists treated the 88 patients. Over 90% of the therapists had doctoral or master’s level training. All therapists had previous treatment experience with BPD patients. Therapists averaged 10 years of experience working with borderline individuals.

Outcome Measures: Patient progress was assessed every 3 months for 3 years. The primary outcome measure was the BPDSI-IV, a 70-item scale measuring the severity and frequency of borderline symptoms. Patients also completed regular quality-of-life questionnaires. These included the World Health Organization quality of life assessment, a 100-item questionnaire covering level of satisfaction with interpersonal relationships, level of independent functioning, psychological wellbeing, and physical health.

Dropout Rate: Of 45 patients treated with Schema Therapy, only 11 dropped out during the entire 3-year period. So 75% of this group persevered in intensive therapy for at least three years.

Of 43 patients treated with Transference-Focused Therapy, 18 dropped out during the 3-year period. However, the study notes that 10 of these 18 drop outs disliked the therapy method or their therapist, and 5 of 18 had issues around TFP’s method of enforcing contracts. Many of these dropouts occurred in the first few months. In my opinion, TFP is a more rigid, less effective form of treatment, and so it’s unsurprising that more patients dropped out. There’s no reason these patients couldn’t do better in another treatment.

Understanding Improvement in these BPD Patients

So how was improvement in these patients measured?

To answer this, one has to understand the measures used in the study. The primary gauge was the BPDSI-IV scale, which was filled out by patients every three months for three years. The BPDSI consists of 70 items arranged in 9 subscales. For each of the 9 DSM symptoms, 7-8 questions are asked to determine how severe and frequent the behaviors/feelings have been over the past three months, from the patient’s perspective. Each question is rated on an 11-point scale, running from 0 (never, not at all, low) to 10 (daily, very intensely, high).

For example, several questions would ask about the intensity/frequency of a patient’s feelings of emptiness (DSM BPD criteria #7), several questions would ask about the intensity/frequency of a patient’s suicidal thinking/behavior (DSM criteria #5), several questions would ask about how unstable or intense the patient feels their relationships to be (criteria #2), and so on.

The scores relating to each symptom are then averaged, producing an overall rating for that symptom. (For example, the scores for all questions about emptiness would be averaged to produce one “emptiness score”, a number between 0 and 10.) These 9 average rating for the 9 symptoms (numbers between 0 and 10) are added up to give a “BPDSI-IV” score, which represents the severity of the patient’s borderline problems over the last three months. This number will be anywhere between 0 and 90, with 0 being perfect mental health and 90 being the severest borderline disorder.

Although I dislike the BPD diagnosis, I don’t mind the method used in this study, because it involves asking the “borderline” patients how they feel. In other words, the BPDSI scale is not a judgment by clinicians, it’s a report from patients.

Improvement in BPDSI and Quality of Life Scales during the first year:

With this understanding in mind, here is how the patients did over the first year:

borderlineimage1

In the top left graph, we see that in the schema therapy group (line with squares), the patients started out at an average BPDSI rating of around 35 (out of 90, with 90 being the most severe, representing the worst rating for each of the 9 BPD symptoms), but this had dropped to almost 15 by the end of the first year. The patients in the transference therapy group also improved, but a little less so.

The other measures are as follows:

The bottom left Euro-QOL scale is a measure of the patient’s subjective feeling of well-being on a scale from 0 to 100, with 100 being the best. We can see that it improved significantly for both patient groups over the first year.

The top right WHO-QOL scale is another quality of life scale, and the bottom right scale is a measure of psychopathology, neither of which I researched in depth. But the trend lines in each case are positive

Outcome In Terms of Symptom Reduction

Now let’s take a look at how the patients did in terms of each of the 9 BPD symptoms. Here is the graph of the treatment groups’ averages for symptom severity over time:

borderlineimage4

The left-hand numbers on each graph represent the average BPDSI rating for the group for that symptom. For example, for item C (top right), the “Identity Disturbance” rating (DSM symptom #3) started at an average of 5 out of a worst-possible rating of 10. This rating is an average for all the patients in the group. It then drops to an average of less than 2 out of 10 after the first year, an impressive reduction.

Average group ratings over time for all 9 BPD symptoms can be seen. From the top left, the items are: Abandonment score, Unstable Relationships sore, Identity Disturbance, Impulsivity, Suicidality, Emotional Instability, Emptiness, Anger, and Paranoid/Dissociative Tendencies. All of these ratings are from the patients’ perspective. The reader can see that in every case the trend is positive (symptoms getting less intense and frequent).

Detailed Outcomes Over Three Years

Lastly, here is data showing the patients’ progress over three years:

borderlineimage3

We can see that the patients improved a lot in the first two years, and tended to maintain that improvement between years two and three. I don’t interpret this pessimistically. After a significant period of early improvement, there is often a time where a person works to become more secure in their new level of functioning and relating. This may partly account for the “leveling off” of the scores between years two and three. If the patients continued in treatment (or on their own), they could improve further.

After three years, at least half of the Schema therapy group’s patients had recovered to the point where they felt well enough to no longer be considered “borderline”, and more than two-thirds were considered highly improved. “Recovery” was defined in this study as achieving a BPDSI score of lower than 15 out of 90, and maintaining that level through the end of the study. Other patients who improved a lot (e.g. going from a BPDSI rating of 50+ down to 25 or 20) would only barely be diagnosable as borderline, even if they weren’t considered “fully recovered”.

These studies tend to be very binary (e.g. people are either “recovered” or “not recovered”, but reality is not like that). It’s important to remember that improvement is a process; it’s never all or nothing!

Jeffrey Young’s Comments

Dr. Jeffrey Young of Columbia University is the developer of Schema Therapy for BPD. He commented on this study as follows: “With Schema Therapy, patients with BPD are now breaking free from lives of chaos and misery. Not only are they learning skills to stop self-harming behaviors, as they have with Dialectical Behavior Therapy, but a high percentage of BPD patients are finally making deeper personality changes that have not been possible until now.”

For Young, this study demonstrates that therapy for BPD can lead to full recovery, and that longer-term psychodynamic therapy can be very effective. However, his comment might be a little grandiose, as people with borderline symptoms made “deeper personality changes” long before he invented Schema Therapy.

Young’s group added that this intensive schema therapy may have advantages over Dialectical Behavioral Therapy. According to Young, “DBT relieves many of the self-destructive behavioral symptoms of the disorder, but may not reduce other core symptoms, especially those related to deeper personality change.”

Interestingly, Young noted that part of schema therapy’s success may involve its emphasis on “limited reparenting”, i.e. on the creation of a loving relationship between patient and therapist. This is closely related to what I discussed in article #10, in the phase of Therapeutic Symbiosis:

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

More information is available at www.schematherapy.com, and I adapted the statements above from this webpage – http://www.schematherapy.com/id316.htm

My View on Schema Therapy

I am by no means an expert on Schema Therapy, and I have no affiliation with Dr. Young. My understanding is that SFT involves a mix of cognitive-behavioral and psychodynamic techniques. It focuses on building a positive therapeutic relationship, on better managing daily life, and on working through past traumatic experiences. These elements are common to most therapies.

Schema therapy also contains an object-relations (psychoanalytic) foundation, in that it conceptualizes the borderline patient as using “schemas” in their mind to represent and relate to themselves and others. Examples of these are punishing parent and angry child, uncaring parent and abandoned child, etc.

Schema therapy helps the borderline patient understand how these faulty models developed – often due to trauma and poor parenting – and to stop the replaying of negative past interactions from destroying the potential for new, better relationships in the present. In this sense, it is based on Fairbairn’s object relations model, discussed below.

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

As Fairbairn said, “The psychotherapist is the true successor to the exorcist. His business is not to pronounce the forgiveness of sins, but to cast out devils.” 🙂

How Individuals Get Lost in Group Studies

My biggest criticism of this type of study is that it obscures individuals’ experiences behind numbers and averages. Of course, its intent is not to provide individual detail. But,I would like to hear from individual patients what their life experience was like at the end of treatment compared to the beginning. I’m sure many would speak very positively about their progress. Since we don’t have that, I recommend the reader to case studies referenced in these posts:

https://bpdtransformation.wordpress.com/2013/12/15/what-to-do-if-you-are-diagnosed-with-bpd/

https://bpdtransformation.wordpress.com/2014/08/17/18-heroes-of-bpd-jeffrey-seinfeld/

The Mystery of Why People Are Still Pessimistic About BPD Treatment

In the bigger picture, this study’s results are obvious. Intensive help helps people, just like the sky is blue and the sun rises in the east. “Borderlines” are no exception to this. If they can access effective support – and are given a reasonable sense of hope – people diagnosed with BPD will do very well. What we need to be doing is getting more people access to effective treatment, and leaving behind the outdated myths that BPD is untreatable or incurable.

It’s amazing how such common sense escapes people who say, “borderlines don’t seek help, borderlines won’t stay in treatment, borderlines can’t be cured etc.” In my opinion, they are about as well-informed as people who think the Earth is flat.

Here is the original study of the 88 Dutch patients: http://archpsyc.jamanetwork.com/article.aspx?articleid=209673

Other Studies on Psychotherapy’s Effectiveness for BPD

This study is one of many investigating psychotherapy’s effect on BPD. Below are additional examples, one from a hospital outpatient program, one from DBT, and one comparing different psychotherapies:

Treatment of Borderline Personality Disorder with Psychoanalytically-Oriented Partial Hospitalization, An 18 Month Follow-up: http://psychiatryonline.org/doi/abs/10.1176/appi.ajp.158.1.36

Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug Dependence: http://www.ncbi.nlm.nih.gov/pubmed/10598211

Evaluating Three Treatments for BPD: A Multi-wave Study: http://www.borderlinedisorders.com/images/AJPRCT.pdf

All of these studies show positive results. Again, this is not rocket science – good treatment helps people diagnosed with BPD!

What If Borderlines Don’t Get Good Therapy?

But what is people diagnosed with BPD don’t get good long-term psychotherapy? Do they inevitably do badly?

No.

Several studies address this question, including the one summarized below:

http://www.borderlinedisorders.com/images/AJPRCT.pdf

Here are the highlights of this study:

Study 2:  290 Borderline Patients In Massachusetts

Patient Population: 290 patients diagnosed with BPD, assessed at McLean Hospital in Massachusetts. They were first treated as inpatients during brief hospital stays.

Method of Study: This was a longitudinal-observational study. The patients were interviewed every two years for at least 10 consecutive years, starting in the early 1990s. During interviews, their level of functioning in work/school, satisfaction with interpersonal relationships, and degree and frequency of borderline symptoms were measured. After 10 years, 90% of the original cohort of 290 patients were still participating.

Therefore, this study followed the “natural course” of BPD. This medical-model idea is misleading (the notion that BPD has a “natural course”), but I won’t go into that now. Suffice it to say that the researchers in this study did not “treat” the patients – they just followed them after hospitalization and went to great lengths to see how they were doing every two years.

High Remission of Symptoms: After 10 years, 93% of the formerly borderline patients had experienced at least two consecutive years during which they no longer qualified for the BPD diagnosis, according to DSM criteria:

Time to Remission

Low Recurrence of Symptoms: After 10 years, among the 93% of patients who achieved symptomatic remission, only 29% became “borderline” again. In other words, once they improved to the point of no longer being diagnosable as borderline, a large majority did not get worse and become “borderline” again:

Time to Recurrence

Good Social and Work Functioning: After 10 years, 78% of patients had achieved good psychosocial functioning – defined as good performance in a job for at least two years, along with at least one emotionally sustaining relationship with a partner or friend:Good Functioning

To me this last slide is questionable, as it’s not clear how “good work performance” was defined (and a certain period of work is not a prerequisite for “recovery”, anyway). Nevertheless, this study shows how, in a group of previously hospitalized borderlines, most people improve to the point where they are able to function in a job and have an intimate relationship. Again, the study authors provided these patients with no treatment beyond brief hospitalization, although many probably sought help on their own.

Other Longitudinal Studies of Borderlines Are Also Positive

There are many other ways to critique this study; for example, one could say it only applies to “borderlines” in the northeastern United States who went through McLean hospital. However, other studies following borderline patients for decades reach similar conclusions.

These include Thomas McGlashan’s Chestnut Lodge study (Maryland, USA), Michael Stone’s “Fate of Borderline Patients” study (New York, USA), and Joel Paris’ longitudinal study of borderlines (Montreal, Canada). All of these studies concluded that a large majority of borderline patients improved significantly, and many recovered in the long term. Collectively these studies included over a thousand patients. These studies can be found by searching online, as well as through the books by McGlashan, Stone, and Paris on Amazon.

The Limitations of Naturalistic Studies Based on Diagnosis

The anti-psychiatry side of me says that these longitudinal studies reveal what a meaningless and unreliable diagnosis BPD is. It doesn’t make sense that some percentage of people are initially borderline, then at varying points in time they are suddenly no longer borderline, then a few of them are borderline again, and so on.

Maybe BPD was never a valid illness to begin with. But such common sense seems to escape Harvard-educated researchers like Zanarini 🙂 Then again, to admit that what they’re studying is an unscientific fabrication wouldn’t be great for their careers, nor for receiving funding from the National Institute of Mental Health.

Although these studies have flaws, I hope readers will see that people diagnosed with BPD do seek help, and that they can recover to be emotionally well and free of “borderline” symptoms. These are not just opinions. They’re facts.

On The Nature of Quasi-Experiments

Lastly, it is important to understand that these studies – like most in psychology – are quasi-experimental. This means they are not perfectly controlled experiments, because when studying human beings many factors simply cannot be controlled. One can never study a person as reliably as one studies solar radiation or the molecular structure of uranium.

No one quasi-study can “prove” a point definitively. Nevertheless, quasi-experimental studies can estimate the effect of a variable(s) on a group of people under certain conditions. And a pattern of quasi-studies with similar results can show that something real is happening

These studies should also not be interpreted as applying to any particular person. Rather, they are averages of many different people’s outcomes, and only have meaning on a group level.

Wow, I am exhausted thinking about all this data. Time to get a beer!

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I welcome any correspondance at bpdtransformation@gmail.com

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

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

– Edward Dantes

#21 – My Nightmare of Psychiatric Hospitalization

“Mood disorders are biologically-based mental illnesses”, the psychiatrist announced authoritatively, surveying the 15 young-adult patients in front of him. “But while these illnesses might be biological, it doesn’t mean you can’t manage them effectively.”

My mind reacted explosively: How the fuck could you possibly know this, you pathetic excuse for a mental health “professional”? What actual evidence do you have?!

I desperately wanted to shout at him. But I remained silent, slouching backward in my chair in the mental hospital’s group therapy room.

After concocting a suicide plan that almost succeeded, I had been involuntarily committed to this hospital for my own protection. But I was now becoming a captive of a different kind: a prisoner of psychiatry’s hopeless ideology.

This is the story of my time in a mental hospital – what it taught me about myself, about my fellow human beings with “mental illnesses”, and about the web of lies that is American psychiatry.

Descent Into Hell

In my early 20s, having suspended my college career, I returned home to live with my family.  Living three hours away at college had become increasingly difficult – I felt isolated, depressed, scared, and hopeless. I couldn’t live on my own – my father’s physical abuse, and the lack of love in our family, had left me not knowing how to make friends, date girls, or feel secure living alone. But once I got home, the feelings of hopelessness continued unabated.

It’s hard to describe how bad things were to someone who hasn’t experienced these feelings.  I remember wishing that I could escape my mind and teleport into the body of another person whose mind was not as “diseased”. I read Dante’s The Inferno, and felt that I was literally living out the punishments of those condemned to the seven circles of hell.

Something felt profoundly unstable and “wrong” at the core of my being. It frequently felt as if my existence was under threat, that my core self might at any moment disintegrate. I remember reading an astronomy book describing how comets orbited the event horizons of black holes, constantly at risk of being sucked in and destroyed forever. That was how I felt.

To put these feelings into a more understandable context, they were based on the belief that I had no chance of a successful adult future. I saw other young people having relationships with the opposite sex, but I had no idea how to talk to a girl at the time. I couldn’t think clearly about getting a degree or starting a career, because getting through the next day felt overwhelming, let alone concentrating on schoolwork. I couldn’t enjoy anything – movies, reading, friends, etc. The all-consuming anxiety made every day a struggle.

Suicidal Intent

This horrific state of emotional affairs set the stage for me to become seriously suicidal. After returning home, I decided that I had tried everything and didn’t deserve to suffer like this. I formulated a plan to end my life, which won’t be elaborated except to say that it involved a lethal method and might have succeeded. I prepared loving letters for my family and friends, and planned the date I would end everything.

After I made my suicide plan, I remember walking outside during a sunset. We lived near the ocean at the time. In my fragmented state of mind, I looked at the beautiful sea, the sunlight glinting off the waves, and felt an overwhelming sadness. Part of me was urging myself to find a way to survive, but I couldn’t see any hope. Despite the despair, I still appreciated the natural beauty of the ocean.

My Plan Fails

My plan failed because I am a bad liar. My friends noticed that I had withdrawn socially, was barely communicating, and had stopped taking physical care of myself. All my energy was focused on ensuring the suicide attempt’s success by planning it down to the smallest detail. But knowing my history of abuse, my closest friend sensed something was wrong. When he asked me what was going on, I denied any suicidal intent. But the next day, he found an opportunity to look through my bedroom while I was out of the house. Showing a remarkable sixth sense, he rapidly located my suicide notes stashed in the side pocket of an old backpack. I will always owe him for this.

When I returned home, my friend had told my parents everything and the emergency psychiatric response team was rushing to our house. I was completely taken by surprise. Two policemen and two psychiatric specialists soon entered our house and questioned me. I tried to deny that I was actually planning to kill myself, but it was no use.

After a brief discussion, I was led out of the house – in handcuffs – and put in the back of a police car. I was to be taken to the local emergency room, since space was not yet available at the mental hospital. The police explained that I was not being arrested; handcuffing someone was their protocol when someone is involuntarily committed to a mental facility. This made little sense, but I was in no position to question them.

The Emergency Room

The next day or so is a blur. I had to stay overnight at the hospital emergency room, where I could not sleep because of nurses talking loudly. A guard constantly watched my room; at one point he explained that I was being put on a “5150 hold”, which meant I was to be detained for at least 72 hours for evaluation. My mind churned the whole night, going through endless scenarios: Where was I going? What were my parents thinking right now? How dare my friend get them to call the police without asking me? Am I crazy? Should I lie to the doctors, get out of the hospital, and follow through on my suicide plan? Had I been wrong to give up hope? Might hospitalization not give me some time to find a better escape, one that allowed me to survive and live? Shouldn’t I give myself another chance? How could life be so hard?

The Mental Hospital

In the morning the guard told me to get ready because we were going to the psychiatric hospital. I expected to travel normally in a car, but instead I was strapped to a hospital stretcher and rolled into the back of a locked ambulance. I had the humiliating sense of being a prisoner, with everyone knowing why I was held hostage – because I was crazy and wanted to kill myself. The trip took almost an hour; at this point I hadn’t slept for about 36 hours. We finally arrived at the hospital, where I was wheeled inside a self-locking gate that led into “the ward”.

A Moment of Humor

Despite my horrible mental state, part of me was fascinated to see inside a real-life “asylum” for the first time. I was thinking about the movie One Flew Over the Cuckoo’s Nest, which I had recently seen. The ambulance drivers were pushing my stretcher along a hallway, taking me for evaluation in the Intensive Care Unit (ICU) – the place for the hospital’s craziest patients, as well as those arriving for initial assessment.

As we turned a corner, we came upon a long-haired, wild-looking young man. He looked like a young Jon Bon Jovi and wore an ill-fitting blue hospital gown. Four or five nurses faced him with looks of frustration on their faces.

“You’re nothing but a bunch of vaginas and penises to me!” shouted the young man in a loud, high-pitched voice. “Vaginas and penises! That’s all you are! You can go fuck each other for all I care! Go fuck each other, you hear me? What do you think about that, you motherfuckers?”

I could not help smiling at this. I was thinking, What kind of place is this? Are these people all crazy?

The nurses tried to convince him to go to his room, but the patient continued his verbal assault, eventually challenging a male nurse to fight him in single combat. At this point, two of the male nurses forcibly wrestled him to the ground. They pulled up his gown, and a female nurse plunged a syringe into his bare bottom. It must have been a fast-acting tranquilizer. With this done, the male nurses dragged his limp body to a nearby room.

I made a mental note not to call the nurses “vaginas and penises.”

The Strange Ward

Upon arrival, I was assessed by a series of nurses, who asked questions like the following:

“Are you planning to hurt yourself right now?” (No…)
“What’s your height and weight?” (6’2, 175)
“Are you carrying any weapon or sharp object?” (No… Of course, they had to body-check me)
“Will you tell us if you start feeling like you want to hurt yourself?” (Yes…)
“Are you feeling pain anywhere in your body?” (No…)

It was all so awkward. No one asked why I was there, or what had been going on to make me suicidal. They said the psychiatrist would talk to me. I had to fill out a superficial anxiety and depression questionnaire, and was then shown to my room.

The ward was a spartan place of accommodation. The rooms didn’t differ much from prison cells seen on shows like MSNBC’s Lockup. Each room had a small, uncomfortable bed bolted to the floor along with a basic toilet. They also had some old wooden cabinets, which made them luxurious compared to jail! Almost nothing else was in the room. Every 15 minutes, all day and all night long, a nurse would come to check that I hadn’t discovered some ingenious way to hurt myself. This made it hard to sleep at night.

Soon I wondered into the ward’s common area, a large square space with old sofas and a TV. Ten or twelve mostly young adults were sitting there, watched by three or four nurses. Some were staring into space, others watched the TV, one woman was talking to herself. Everyone seemed to be quietly doing their own thing. I had no interest in talking to anyone at first. I thought they were all crazy and hoped I didn’t become like them.

A nearby board listed group therapy sessions that occurred each day. I cannot remember what type of therapy they all were, but there was at least one Dialectical Behavior Therapy and one Cognitive Behavioral Therapy session.

Group Therapy

I went to a couple of these group therapies the first day. The CBT session featured a young psychology intern lecturing. He drew pictures explaining how thoughts, feelings, body, and the outside world were interrelated. I found it so superficial as to be no help in understanding anything (I was in a very negative mindset at the time). I wondered why they were not asking people to tell their own stories, or at least for their responses to the information provided.

I would soon find that exactly the same lecture was repeated every two days, with no variation based on the patients. Anyone new got to hear it for the first time, while everyone else got a repeat.

In the DBT session, the speaker explained the concept of wise mind, the place where emotions and thoughts overlap. He described how to distract oneself from negative feelings and be “in the moment.” He also stressed repeatedly “thoughts are not facts!”. The tone of this session annoyed me, because it felt like we were being talked down to like simple-minded children, or like computers needing to have our software reprogrammed.

The Psychiatrist

Being horribly depressed and ashamed, I was not in a mindset to appreciate these sessions anyway. I spent most of the time in my room brooding about the thwarted suicide plans, thinking bitterly about how unfair life was. On the second day, the psychiatrist assigned to my case called for me. I went into a small office to find myself facing an old man who looked like a mob boss out of the Godfather. He appeared Italian, with dark, tanned skin, and a smooth sense of accomplishment about the way he spoke.

“What’s so bad that you want to kill yourself?” he asked me.

I remained silent for a while, then told him about how depressed I was, how I couldn’t stop obsessing over negative thoughts, and how my father had physically abused me.

The psychiatrist thought about this, then asked for my family history of “mental illness.” I described how my dad had severe OCD and depression.

“It sounds like you have OCD too, plus depression” the psychiatrist said. “We have medications that will really help your obsessing, and they’ll help the depression too.” He prescribed three medications – including two antidepressants and an antipsychotic mood-stabilizer, if I remember right – all of which I was to start taking right away. At that time I didn’t know much about medications, otherwise I would have refused his prescription, or at least refused to take that many.

The psychiatrist also prescribed writing exercises. I was to “obsess” in a journal for thirty minutes a day – writing down every negative thought that came to mind. And the rest of the time I was meant to tell the negative thoughts to “go away, I’ll deal with you later!”

Toward the end of the session, I told the psychiatrist about my BPD diagnosis also. He responded that this was a tough condition that could be “comorbid” with OCD and depression. He said something like, “We don’t have a cure for borderline personality, but the symptoms can be managed”. I hated this idea right away. If I couldn’t really get better, what point was there in trying?

“These type of things can get better. We want you alive, that’s why you’re here and that’s why we’re treating you,” the psychiatrist said. I didn’t like this one bit – the messages seemed to be all confused – but it was more positive than some of the other things he said.

My View of the Psychiatrist

The psychiatrist’s worldview was alien to me. I intuitively felt that the medications would not help, while the writing exercises seemed ridiculous. The psychiatrist didn’t appear to see me as an individual. Instead he saw “borderline” and “depression” and “OCD” sitting in the chair, and he was trying to manage these “illnesses.”

When the psychiatrist said that BPD could not be cured, I felt furious. If I had a gun, I would have liked to shoot him right there and then. I imagined how satisfying it would be to put a bullet through his forehead, see his chair topple over onto the ground, the blood spilling everywhere, and for there to be one less idiot psychiatrist able to medicate patients into oblivion. It made me think of the opening scene in the movie Casino Royale, where James Bond confronts the traitorous section chief, whom he dispatches with a handgun (shown in the last 30 second of this clip):

Of course, I did not execute the psychiatrist. Nor would it have happened if I had had access to a weapon. Even in my crazy state, some part of me knew that this man probably had a family and didn’t mean badly – he just didn’t know how to understand people other than as illnesses. But my fantasies of hatred for his views were vivid, and I wanted to destroy what he stood for.

The Dead Zone

Over the next few days, I went to several more group therapy sessions, which continued to feel superficial and boring. I wanted someone to listen to my experience, not hear lectures about the mind and how to rigidly cope. But I started to become less suicidal and began talking with some of the other patients.

I continued meeting with the psychiatrist daily. He would only see me for a few minutes, asking how the medication was working and if I was having any more suicidal thoughts. I thought it was ridiculous that he was not talking to me for a longer time, getting to know me and understanding what might have caused me to become so hopeless. I would always say that I didn’t know how the medication was working, because I couldn’t possibly tell what was the effect of the medication and what was due to other factors. This frustrated him.

Before I spoke to other patients, the atmosphere on the ward often seemed stagnant, tragic, empty. It felt like being in a morgue with dead people walking around. The nurses “managed” the patients – watching them take their medications, controlling the difficult patients, coordinating mealtimes. Their were some kind nurses, but the majority seemed not to care about getting to know the patients. The most positive thing about the ward was its breakfasts – I remember we got French toast, bacon, eggs, and cereal most days!

The Other “Crazy People”

After about four days, I asked the psychiatrist when I could leave the hospital. He wanted my family to meet with the social worker and establish a plan for my starting therapy, plus establish ground rules to prevent me from hurting myself. This involved restricting my access to money for a period.

I was to stay for a few more days and, if it seemed like I was functioning ok, attending some groups, and not feeling suicidal, then I would be released. Until my release, since there was not much to do most of the time and I was feeling better, I began talking to other patients. That was one of the most interesting things about my stay. Let me describe a few of my fellow “crazy people”:

“Paul” was a big Latin-American man in his late 50’s with a jovial, outgoing personality. He spoke a little strangely, but was very friendly. He would always call me “Sir Edward” for no apparent reason. I told him about my English heritage; he was fascinated by my grandfather, a Jewish scientist who escaped from Nazi Germany. He told me how his family emigrated from South America to the US and established their own hotel business. Like me, Paul was a big racquet sports fan. We would talk about Agassi, Sampras, Federer, etc. debating who was the best. We had several table-tennis battles in the court-yard of the hospital ward. I would always beat him but it was close. I eventually asked Paul why he was there – to me, he wasn’t crazy at all. He said he had bipolar episodes, but they were now controlled with medication. I never saw any evidence of him being manic or depressed.

“Nicky” was a young woman in her early 20s. She was an attractive brunette, the kind of young woman to whom I was attracted but scared to approach. Eventually I struck up a conversation and found out that she had been hearing critical voices after using drugs, which led her to be hospitalized. She had a difficult relationship with her parents that led to the drug use and breakdown. But she kindly supported me when I told her how difficult things had been with my family. She also had coloring books which she would bring into the common area and get me to work on with her.

“Susie” was a middle-aged bipolar woman who had been experiencing hallucinations of sharp-fanged animals invading her apartment. She had had a difficult childhood with physically abusive parents. Nevertheless, she was an intelligent, interesting lady who had a successful career in a professional field. We would play board games together and she would beat me at Scrabble. I shared with her what had brought me to the ward, and she was warmly supportive. She reminded me of how important I was to my family; how hurt they would be to lose me.

“Ray” was a young man diagnosed with schizophrenia who had hallucinations and had been hospitalized several times. But he was a sweet person. It was clear that he wanted to be liked and to connect with other people, despite his “illness”. He didn’t even seem crazy to me. It turned out he had been able to work part-time on-and-off for several years, but the psychotic episodes, which I saw no overt evidence of, kept interfering with his functioning. He was on at least four or five different medications, which seemed like a lot. His mother would visit the ward every day and she clearly cared about him a bunch, sitting with him and holding him as if he were a young child. I was touched by her devotion, and introduced myself to the mother, telling her how nice I thought Ray was. I hope he got better going forward.

“Anouk” was a Middle-Eastern woman whose husband had physically assaulted her, leading her to flee from him, become severely depressed and suicidal, and eventually require hospitalization. She had a warm, motherly personality that was attractive to me at the time, lonely as I was. She told me about her five daughters and her dreams for their careers, and about how evil her husband was! She took a particular liking to me, and would give me high-fives and hugs when she saw me in the corridors. This went on even though patients weren’t meant to touch each other; somehow it seems that psychiatry has forgotten that friendly touch can be a healing thing.

“Jeanette” was another pretty girl in her early 20s. She had been admitted after running away from home and hitchhiking cross-country to “find herself”. She believed that plants had personalities and that you could be friends with them. She would keep a special hard-boiled egg in her room that had significance to her. Apart from these things, she spoke just like a normal person. I found her energetic personality quite likeable. But she was a social rebel and frequently argued with the nurses about rules. When they wouldn’t let her family bring in an I-pod, she became furious and acted out by stripping down naked and running through the common area with no clothes on! She was an absolutely gorgeous blonde. Hopefully she got better, and some lucky guy got to experience her beauty in a more private setting!

Reflections on The Patients Versus the Staff

Ironically, I got much more help from talking to patients than from the staff. The nurses mostly didn’t care about the patients as people, simply wanting to keep them under control. All the patients could sense this. The psychiatrist was worthless since we spoke only a few minutes a day about medication and practical matters.

But several patients treated me with genuine kindness. I kept in contact with a few of them afterwards via email and phone (even though the hospital warned against contacting other patients post-discharge… another stupid policy). To me, these patients didn’t have “mental illnesses”; they were just people dealing with serious challenges in living. I felt as if anyone could have reacted the way they did facing the same life challenges; but that wouldn’t make them “schizophrenic” or “borderline” or whatever. This experience influenced my thinking about BPD and other so-called “mental illnesses” being invalid diagnoses.

Several patients told me they hated taking medications, that they didn’t feel these medications helped, and that they got little out of the group therapy. One depressed man refused to take any medication; he just wanted to be there to be safe. The one good thing about the hospital – and I must acknowledge this for my own case – was that it kept me safe during a time when I might otherwise have hurt myself. For that protection I am grateful. I improved somewhat by the time of discharge, and was less of a risk to myself afterwards.

Psychiatry Doing More Harm Than Good

I believe that in many cases, mental hospitals dominated by psychiatry’s medical model do more harm than good. Ironically and perversely, psychiatry thereby becomes an obstacle to the recovery of the very people it is supposed to help. It promotes the message that people have biologically-based “illnesses” that they are stuck with for life. As I discuss in many other articles, this is a complete lie. And yet, it is presented as if it is the best that people can hope for.

Why limit people’s dreams with this type of reductionistic thinking for which there is scant evidence? Why not tell them that they are heroically dealing with understandable reactions to extremely challenging life situations, and that with understanding and love, they are likely to get better?

The answer, in large part, is that psychiatry’s reductionistic view of emotional problems as “mental illnesses” has infected the minds of most psychiatrists, who in turn infect their patients. And thus is promoted the pessimistic view of mental illness as a lifelong “disease”, rather than as a primarily psycho-social experience that can be overcome with sufficient support.

Psychiatry is also eager to prescribe as many medications as possible, which unfortunately do nothing to address the root causes of people’s problems. A prime motive is to perpetuate the billions of dollars in profit that companies like Eli Lilly, Janssen, Pfizer, etc. make, and to support the psychiatrists and shareholders allied with these companies. Helping the patient comes second, and if these patients could have done better with other forms of treatment and/or without medication, then too bad.

In my opinion, the network of drug companies and psychiatrists who weave lies about medication represent a fraudulent house of cards. Patients can protect themselves by learning just how ineffective medications really are over the long term. If more of us educate ourselves, then psychiatry will be progressively undermined. Newer studies are showing that most psychiatric drugs are barely or no more effective than placebos, and that the long-term side effects can be very dangerous. This is discussed in detail in the many articles on http://www.madinamerica.com

Lastly, the whole approach of the hospital was to “manage illness”, not promote healing and recovery. Even though there were signs on the walls extolling positive values like Hope and Responsibility, the interactions with the nurses, psychiatrists, and group therapists did not promote a sense of “we’re in this together” or “you can recover and do what you want.” Rather, the emotional message was, “You are the sick people, and we are the “normal” ones who will teach you how to manage your unfortunate afflictions.” Ironically, many of the patients were more helpful to me than the mental health professionals.

Conclusion: A Sad Reality

Such is the reality of inpatient mental health treatment for many in 21st century America. I urge people to avoid inpatient facilities wherever possible, unless they are in real danger of hurting themselves or others, in which case hospitals can provide a critical protective function. As much as possible, seek help from outpatient therapists, family, and friends who are outside of the traditional psychiatric system. I believe the chances of recovery from BPD and other conditions is greater following this path. Getting stuck in a cycle of going in and out of hospitals, being overmedicated, and being treated as if one is an illness, doesn’t promote recovery.

I would also direct readers to these websites that are great resources promoting recovery outside of the traditional psychiatric system:

http://www.madinamerica.com – Many fascinating articles about the worthlessness of psychiatric diagnosis, the ineffectiveness of medication, and the value of therapy, understanding, and love.

http://www.mindfreedom.org – Another anti-diagnostic site that rejects labels and is similar to Mad In America.

http://www.isps.org – The International Society for Psychological approaches to Schizophrenia and other psychoses. Many of the clinicians listed on this site are also well-trained in treating Borderline Personality Disorder. Much of their writing about psychosis could be applied to BPD. They are an extremely empathic, innovative, and optimistic group.

Feel free to share any experiences you have with “the psychiatric establishment” in the comments!

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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

#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.