Tag Archives: hereditary BPD

#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.

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#28 – An Interview with Lewis Madrona, M.D. about BPD and our Mental Health System

For this article I’ve interviewed Lewis Mehl-Madrona, a psychiatrist from Maine with 40 years’ experience in psychiatric hospital and outpatient psychotherapy settings. Lewis is a practicing psychiatrist and healer with his own website, his own personal blog, and his own online articles.

Lewis and I did a phone interview which I have transcribed below. Here are some highlights of Lewis’ thinking:

On BPD as an identity:  “What the label BPD is is a story or identity that people are encouraged to take on. And it’s not necessarily a story that’s conducive to feeling well or being well…”

On DBT and its founder:  “Marsha Linehan would say people get better, hope, you can feel better, you can do these things and you will feel better.”

On BPD as a lifelong illness:  “I think it’s really insane to say that the label (BPD) is lifelong… I mean how do you know that?… It’s not even logical. It’s a pretty cruel world we live in where we make people incurable – is it so we don’t have to work hard to understand them?”

On Recovery:  “(In response to my question about can people labeled BPD truly get well)… Oh absolutely, absolutely. And you know I think that it’s the same work whatever your label is.”

On the role of medication:  “I think the role for medication in our society has become a replacement for community… The medications don’t produce lasting change… no real solutions take place.”

On writing your own story:  “The science behind BPD is not good at all… I always remind people that the DSM is mostly created by white males over 50 years old sitting in hotel rooms around the beltway of Washington DC. These may not be the people you want to write your story… The story you create might be a lot more interesting.”

For more context, read on to the full transcript. Please note that Lewis’ views are his own, and his interview appearing on my site does not imply that he agrees with or endorses my positions. With that said, here’s the interview:

Edward: Lewis, thank you so much for making time to speak to me. I found you through the International Society for Psychological and Social Approaches to Psychosis (www.isps.org), and you know that I run a website dedicated to challenging the medical model of Borderline Personality Disorder and promoting a recovery model. I’m going to ask you some questions I’ve put together about the label BPD, and I’d like you to answer however you feel is best, which may or may not mean directly answering the question. First, so that readers can get a sense of where you are coming from, let me start with asking you to describe your professional background, your training, and what you do now:

Lewis: Ok well, I went to med school at Stanford, then did a couple of years of training at the University of Wisconcin, then went off and did a PHD in psychology and a postdoc in neuropsychology, and then I came back and finished my residency training in family medicine in psychiatry at the University of Vermont. Then I did some extra time to be certified in geriatric medicine as well.

Currently I’m teaching family medicine at the University of New England in Maine, so I’m one of their faculty, and I also do the psychiatry consulting service at Eastern Maine medical center [Lewis has worked on psychiatric wards]. And then I have my evening and weekend life as a person who dabbles in the healing arts. What that means is doing healing work with people – because I’m native American, it’s kind of a native American flavor, I try to help people using that background. I grew up with my grandparents who were part of the Indian culture.

lewis1                                                                 Lewis Mehl-Madrona

For many years I’ve also had a psychotherapy practice, more so earlier in my career; I don’t do much outside therapy at this point. I’ve always done a combination of different medicines, psychiatry, psychotherapy, other healing arts.

I’ve worked in medicine for 40 years, starting in 1975. Actually earlier, 1973. I started doing psychotherapy in training in 1973.

Edward: Ok thank you; I can see you’ve had a lot of experience in the psychiatric system. Do you have an idea of how many clients you’ve worked with who were considered “borderline” or who would approximate the DSM label for “Borderline Personality Disorder”?

Lewis: You have to clarify the term “borderline”. When it was first created, borderline was meant to refer to people who were not psychotic, but had severe emotional issues – I can’t remember if it was Otto Kernberg or someone else who coined the term – but it was supposed to mean people who under high stress crossed the border into psychosis but could then cross back. It was people who oscillated between those states.

I don’t remember when it happened, but somehow borderline came to mean people who are incredibly good at getting what they need from systems, like hospital systems. That’s how people are using it now, to refer to manipulative people that we don’t like in the system. I think that’s how the term is commonly used now.

Over the years I’ve seen a lot of people who fall into that category, as labeled by others. And yes I’ve certainly done psychotherapy with quite a few people who were given that label at one time or another.

Edward: Ok, interesting. I guess what I had in mind was more the first description; people who have serious emotional issues, can become psychotic under stress, are prone to splitting, can’t regulate their emotions, and so on. Can you say something more about how you understand the word borderline – how does it describe the functioning, feeling, defenses present in these people?

Lewis: My personal belief is that it’s a fairly useless label. I think people are more individual. Such a label really doesn’t say much about who the person is and what do they need help with. I think by and large all of the DSM labels are like that. For the most part they’re not really based on science of any kind. You can say in general terms things like depressed, anxious, psychotic, etc – maybe give general labels people fit into, with overlaps. But the craziness we have now is just something else.

Personally I don’t find BPD to be a very useful construct. What the label BPD is is a story or identity that people are encouraged to take on. And it’s not necessarily a story that’s conducive to feeling well and being well. So I think that’s the danger of the internet because people can get together and embrace their story about who they are as borderlines. And it makes it harder, if that becomes your identity, to not suffer in that way, or to see that it’s just one way to describe however it is you suffer, and there are other more helpful ways.

Edward: Ok thanks, that’s an interesting idea about how taking on the borderline label becomes a story, a kind of self-fufilling prophecy in a way. I do see that when I read online forums focusing on BPD at Reddit, Psychoforums, Psychcentral. Can you say something now about the causes of “borderline” states – are they mainly psychological, biological, etc? I realize now in asking this that the question may not make sense to you in these terms.

Lewis: I think trauma and isolation are the big things leading to mental health labels – if you’re surrounded by community, you can tolerate a lot more trauma than if you’re alone. And I think that’s been the process of the 20th century; the process was to eliminate community and get everybody alone in little boxes. It’s easier to manipulate people when they’re alone in little boxes; it makes a more malleable work force and prevents unionization and collective bargaining. It prevents people getting supported by each other.

So I think that a lot of what we see now [in terms of mental health and psychiatry] is so different from what we might have seen in the year 1900. People in general are so much more isolated now than in 1900 or 1800, and so it’s harder to build resiliency or regulate your moods when you’re always or mostly by yourself, and I think it’s crazy. For example the two parent child-rearing approach is insane; who ever thought that up was completely crazy. Healthy cultures have cross fostering, cross mothering, multiple mother figures at any given point, the idea of the whole village taking care of the children.

So I think some of this is political. And I relate these processes of isolation to more people getting these mental illness labels. I think more people are getting labeled everything, because there’s less social support and thus less resiliency. And some people of course have been severely traumatized in this isolation. When you’re isolated you don’t have anyone to go to to get nurturing, to help you feel better and regulate your mood…. almost everyone I see has trouble regulating mood, and are isolated, and the really amazing thing in the settings I work in [in psychiatric hospitals] is how little some of them are willing to do about it.

Often people come in and they want a drug to make them regulated and feeling happy, and that drug doesn’t exist; it’s not going to happen. I don’t know when we made that transition, I think it was probably in the 80s, when I was in training we used medication to make unbearable affects bearable so you can work with the feelings.

But as a a profession now we’ve trained people to think you should just take a pill and feel fine, and if it doesn’t work try another one and then everything will be great. And that embarks on the perpetual search for the right pill, which is a never ending story. I don’t meet many people who have found the right pill.

Edward: Ok, thank you and of course I agree with these ideas about medication. Now let me ask you about the way other therapists use the label borderline. Many therapists, including probably some you’ve heard, use the label borderline in a pejorative way to refer to people they consider difficult or unlikely to get better. Did you ever feel that way?

Lewis: Since I didn’t believe in the label borderline I wouldn’t have ever talked that way. It’s interesting because I’ve always given my cell phone to everyone I work with, which therapists who believe in the label BPD would say is insane, but I’ve never had anybody abuse that. The issues they have with clients; it seems it’s a side effect of a certain kind of power relation and not intrinsic to people, so I always give my phone to people and say if you’re in crisis I want to hear from you; it’s our goal to keep you out of hospital so I want to hear from you early. So my approach is probably a different approach than the people who roll their eyes and label people borderline.

Edward: Ok that makes sense. Let me jump in now and ask about therapists or psychiatrists who say that BPD is a lifelong mental illness and something that cannot be cured. Do you agree with that?

Lewis: I’ve definitely heard that more than I’d like to believe, and I think it’s really insane to say that some label is lifelong… I mean how do you know that, you’d have to be at the end of someone’s life to know that, it’s not even logical. It’s a pretty cruel world we live in where we make people incurable – is it so we don’t have to work hard to understand them? At least there’s people like Marsha Linehan who don’t believe that. I think she’s interesting since she began as a service user and did her own healing which is mostly Buddhism.

If you think about DBT it’s almost entirely basic Buddhism. She did her own healing and then she came up with a therapy that matched her own suffering. But really DBT works for everything because it’s basic Buddhism and Buddhism works for everything. But she would says people get better, that’s her whole message, hope, you can feel better, you can do these things and you will feel better. So there are people like her who don’t believe in the inevitability of perpetual life long suffering. Of course I certainly don’t believe that.

Edward: Ok yes I agree with your ideas against the idea of a lifelong BPD illness being bogus; this is a large part of what my website is about. Can you speak now a little bit about what sort of results you’ve had in working with these people – I guess now I’ll call them people who’ve been seriously traumatized and isolated, rather than “borderlines”, since it seems like you don’t think that way. Have you had good results with these people in terms of their feeling better, having satisfying relationships, working in jobs they like, and so on?

Lewis: Oh absolutely, absolutely. And you know I think that it’s the same work whatever your label is, I mean, What do we all need to learn how to do? – we all need to learn how to connect with other people because we all need others, we all need to learn how to regulate our moods and each other’s moods, we all need to learn to manage our suffering, and to a large extent most of us need to learn to eat better, to exercise, to do things that are good for us like yoga, tai chi and chi gong. We all need to live a healthier lifestyle, that involves meaning and purpose, having good relationships with others, and to the extent you can move in that direction, no matter what mental illness label you’ve managed to earn, you’re going to suffer less and feel better.

And so I think the work that I do is more experientially narrative. I’m trying to get at people’s stories about why they are the way they are, and then to look for ways in which that story could be altered so they can live differently. And I use a lot of what of what you could call DBT or a Buddhist approach or some of it is native American ideas. One of the profoundest things that Marsha Linehan pointed out is that life isn’t fair, and you have to live anyway, radical acceptance. Thomas Merton said things are sometimes not ok, and we may not be able to change them, but because it’s the right thing to do we need to try to change them whether it works or not. Part of recovery is also making an effort to be helpful to other people, and/or to change the political environment we’re embedded in.

Edward: Ok. So with the people you work with who get better, what are the most important things that help them to get better? I guess you’ve aleady talked about a lot of them – community, close connections to other people, living a healthy lifestyle, and so on?

Lewis: All the things I mentioned above; by and large that’s what we all have to do regardless of whether or not we’ve managed to achieve labelhood [i.e. been labeled BPD or some other DSM label]. We all need to cultivate community and find each other and build social networks that are nurturing and healing. We need to feel like what we’re doing is meaningful, that we’re creating value with the lives that we’re living. And we need to take good care of ourselves physically, exercise, diet, all those good things. Regardless of the label someone’s given you, it’s pretty much the same, what you need to do to get better.

Although we may have a different story to explain how we got to where we are. That’s the unique thing about doing therapy, no one’s story about how they got to where they are is the same. Each person has a wonderful story that needs to be cultivated and appreciated, and if it’s not satisfying hopefully changed to get to a more well story.

Edward: Ok, I like that description of changing one’s story. It’s so different than the DSM idea of managing symptoms of an illness. Can you discuss psychiatric drugs now – As a psychiatrist, how much do you use them with people, and are they more helpful or harmful, generally speaking?

Lewis: I use them as little as possible, and I think the role for medication in our society has become a replacement for community. If you have enough people around you, you have incredible support and you don’t need so much medication. If you’re isolated and by yourself, then medication stabilizes you whereas otherwise community would. So I tend to use the least possible medication to keep people out of hospital. Because I know if they get into hospital that they’re typically going to be given much more medication than they need. I think medication does allow some people to stay out of hospital; I don’t think it’s a good long-term solution.

The biology is clear that the brain receptors, over the course of a year or so on medication, tend to move back to where they were when they started the medication. The medications don’t produce lasting change, they just make it harder to get off the medication; you have to keep increasing or changing the medication to get an effect. The external world is a much more powerful shaper of the brain than any pill that you can take. If you haven’t changed your external world, and you come off medications, then you’re going to fall back to the same neurophysiological state you were in when you started the medication. This can become a vicious circle. The meds have to be increased, and switched, and so on; no real solutions take place.

Edward: Ok, thanks and I totally agree with this view on medication. I would add that taking medication strengthens the false narrative and identification that a person “has” a certain mental illness label that needs to be treated by taking that medication. Can you say something now about how working with more difficult people – people who might more often be labeled borderline – how is it different than working with less traumatized people? Does working with very traumatized people help you to work more effectively less difficult people?

Lewis: I think so… I don’t know that the level of trouble has much to do with the difficulty of the work. I think that sometimes people who are deeply suffering can be easier to work with than people who are suffering a little. Because if they [the deeply traumatized people] just do anything different they feel so much better and it can be incredibly motivating for them. I just personally enjoy getting to hear people’s stories. And figuring out how they might have a little less friction in their self-to-world interface. Some of the worlds that people visit are incredible, and to some degree we have to be grateful to people who are visibly suffering because they’re the canaries in the social mine shaft; they’re showing us we’re all unhealthy but for some reason they’ve visibly taken it on for us. Because of that I think we have an obligation, those of us who are feeling more well, whatever that means, to help people who are feeling less well, to suffer less.

To me the label BPD and other similar labels is sort of like a cultural story that’s been created for people to put on. It’s kind of like clothing that you wear and everybody’s encouraged to put on this same kind of clothing and behave in this kind of way. It’s almost like a prescription for the label BPD, like here, “Be this way, be a borderline”. I think it’s really unfortunate because people think BPD means something inevitable or they think that it’s true because some authorities say that it’s true.

But the science behind BPD is not good at all. Even the director of the NIMH Thomas Insel, who’s as hardcore a biological psychiatrist as they come, he said the DSM 5 is not acceptable as a diagnostic tool just because it’s so divorced from science. I always remind people that the DSM is mostly created by white males over 50 years old sitting in hotel rooms around the beltway of Washington DC. They may not be the people you want to write your story. You may want to find your own story about your suffering and your strengths. Their stories aren’t very strength based. The story you create might be a lot more interesting.

Edward: Ok, thank you. I like the last part there about the old psychiatrists and writing your own story. The idea of clothing people are encouraged to take on is interesting; I hadn’t thought about it in exactly that way. Ok, next questions, what are some books and experts you find useful in the mental health field? I was going to ask this question about BPD specifically, but given your earlier answers I’ll make it more general.

Lewis: Well of course everyone should read Mad In America [by Robert Whitaker], just because it’s so amazing. But in terms of books about therapy I like Marsha Linehan’s work, she comes across as amazingly compassionate and practical.

I also like Narrative CBT of Psychosis by Jakes and Rhodes; they’re very funny – they say “now that you opened the book, you can forget we put CBT on the cover, we only put it on there because the establishment requires us to put it on there.” And the the way they work with people is completely different.

I love everything RD Liang wrote, I suppose that dates me. I like the narrative work of Michael Wyatt. I like the guys in Finland, the Open Dialogue guys, Juuka Altonen, Jaako Seikkula, I can’t pronounce most of their names, but they’re pretty cool.

Those are the people that I try to have trainees read. I have trainees read Whitaker, John Weir Perry, RD Liang, Jakes and Rhodes. I like to share my own books of course.

Edward: Ok. I didn’t know you had written a lot. What have you written about?

I have a book called Coyote Medicine. It’s an autobiographical story of being an Indian in mainstrream medicine and how crazy it can feel at times. Kind of a cross cultural work .Then there’s Coyote Miracles, about people who have miracles, people who work with traditional healers. Then there’s Coyote Healing, also about working with healers. Then there’s Healing the Mind through the Power of Story – The Promise of Narrative Psychiatry which is a newer book.

And my latest book with Barbara Mainguy is Remapping the Mind, The Neuroscience of Self-Transformation. The word borderline is not in that book! We don’t like diagnoses. It’s better to get the experience, to get people to tell you what their experience is, than to use a label. It’s gotten harder to get people to tell you their experience. People come in to a therapy session and say, “I’ve been manic this week”, and I say, “Ok what does that mean? Tell me what happened?” There’s not a lot of use of the labels in any of my books.

Edward: Ok thanks, some good references there. I didn’t know you’d done all this writing. I’ll have to check it out. Now my last question, which you’ve kind of already answered: Is borderline or BPD a useful or accurate word to describe people? Would you replace it with something else?

Lewis: I would get rid of it. I think that it’s great to help people overthrow their label. If I ran the world, I would just say that some people are more well than others. And those who are more well should help those that are less well. And leave it at that.

Edward: Ok thanks again Lewis. I’m really glad you made time for this. Since you’re an ISPS member, I was pretty sure you wouldn’t answer the questions in the diagnosis-based way I asked them. And that’s great. Because I want to show people that many professionals out there don’t think BPD is a useful word and that there are other more hopeful ways of conceptualizing our suffering. And in the way you’ve answered my questions you’ve shown that approach. It’s particularly interesting because you’re a psychiatrist working across mental hospital and outpatient psychotherapy settings, and you still think the way you do. So thanks again for your time.

Lewis: My pleasure. Take care.

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For more information about Lewis Mehl-Madrona, please see:

Lewis’ Personal Website

Lewis’ Personal Blog

Lewis’ Articles on Future Health

Lewis’ Books on Amazon

Lewis’ Professional Resume

[Note: Lewis knows me me under my real name, which is not Edward (see the “About” page). He consented to have the interview appear here, understanding that I disguise my identity because I prefer my employer not to know about my history in the mental health system.)

#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”!

#25 – Who Was The First Borderline? – From Cavemen and Dinosaurs to Creationism and the FSM

Where did BPD come from, and how was it passed down to modern humans? This is one of the more vexing questions of our age. For an answer, we must turn to the all-knowing wisdom of American psychiatry, which proclaims:

Grandparent1

“BPD is strongly inherited.” This seems like an answer to where BPD comes from. But is it? According to psychiatry, BPD is mostly in the genes. But how could this dreaded disease have originally developed? It didn’t magically appear out of thin air. This begs the question:  From whom was BPD first inherited? Who – or what – was the real “first borderline”?

In this essay, I will take psychiatry’s thinking to its logical conclusion. If BPD is “inherited”, we should be able to track down the ultimate source of this nefarious malady. Prepare to embark on a fascinating journey of discovery. My theories are based on exciting new research by paleo-psychiatrists – scientists who study mental illness in prehistoric creatures.

Early Speculations on BPD’s Origin

Early paleo-psychiatrists raised questions like the following in their search for the first borderline:

Was the first borderline an Egyptian slave who began to have mood swings under the stress of building the pyramids, 4,000 years ago?

Pyramids2

Was the first borderline a Bronze Age Mesopotamian mother who, traumatized by hard farm work, began to view her fellow Sumerians as saints or devils, 8,000 years back?

MesopotamianSpeech

Or was the first borderline an Aboriginal hunter-gatherer who, after too many attacks by dingo dogs, developed identity diffusion in the Australian outback 12,000 years ago?

AboriginalNew

Did one of these ancient people first become borderline, and then transmit the invisible plague to their prehistoric children and on to us?

(Aside: Recent genetic studies by paleo-geneti-psychiatrists have suggested that, in addition to the normal gene-coding letters A, C, G, T, the nucleobases B, P, and D are present in the genomes of people with BPD. So genes in a healthy person, which originally read GATCGGCAGGAACAT, would come to read GATBPDCAGBPDGAABPD. This is why I’ve been terrified to get my genes mapped, for fear those cursed combinations will appear in my DNA strands, to be inevitably passed on to my children.)

BPD and Early Man

Returning to the main story, the answer is no. BPD extends back far past early Egyptians, Mesopotamians, and Aborigines. Paleo-psychiatrists recently found that cavemen exhibited Borderline Personality Disorder. Witness the following image, found on prehistoric cave walls at Laschaux, France, but concealed from the public until now:

cavemenSpeech

With this life-like painting revealed, it is scientifically proven that BPD extends at least to our caveman ancestors. This is so easy to figure out, even a caveman can do it.

So perhaps BPD originated with these forward-thinking cavemen, who would have been traumatized by living in rotten, damp caves.  But couldn’t cavemen have inherited BPD from earlier humanoids?

Through the theory of evolution, we know that humans evolved from early apes (or at least, people who think the earth is more than 6,000 years old know this). So maybe the situation looks more like this:

ApesSpeech

These monkeys are not going to tell us anything definitive, but that bonobo looks suspicious.

Prehistoric Megafauna and BPD

Early apes are an interesting potential source of BPD. But other evidence suggests that the vile pathology worms its way back further. Each of these early humans and apes evolved from other life-forms, any of which could have been the first carrier of the abominable affliction. The plot thickens, and if we want to know where BPD truly came from, we must gaze deeper into the past.

Paleo-psychiatrists recently found this fossilized face-off between the last saber-toothed tiger and the first prehistoric mountain lion. From their facial expressions, it was deduced that they were snarling the following at each other:

sabertoothlionSpeech

But of course, if prehistoric big cats had borderline symptoms, it begs the question of where they inherited them from. Peering further over the horizon, here is cave art drawn by a Paraceratherium, revealing fantasies it was having about the cause of its family’s BPD symptoms:

TRexParaSpeech

So in this image, we have evidence that BPD existed at least 15 millions years ago, in the age of the megafauna or giant mammals. But there’s more.

Psychiatry’s Return to the Days of the Dinosaurs

Excited by their study of the megafauna, paleo-psychiatrists dug ever deeper into forgotten times. The two creatures below were recently unearthed from a prehistoric swamp after being buried by a 65-million-year old mudslide. Paleo-psychiatrists determined that they were saying the following:

StegoAnkylosaurSpeech

Well, this picture is not exactly about BPD. But given the high comorbidity between Avoidant PD, Narcissistic PD, and Borderline PD, it can be said with confidence that BPD dates back at least 65 million years. If avoidant and narcissistic dinosaurs roamed early Earth, then giant reptilian borderlines would have been lumbering around too.

Indeed, all sorts of personality-disordered dinosaurs must have existed in the Cretaceous, Jurassic, and Triassic eras. This makes it much more difficult to trace who the first borderline was. But it does enable us to watch The Land Before Time and Ice Age: Dawn of the Dinosaurs with a new understanding of these monsters.

The search begins to seem endless. Who was the real first borderline? This situation brings to mind the Where’s Waldo? books, when you can never find the little guy in red and white stripes. Or perhaps it should be Where’s the Borderline?:

WaldoSpeech

Sorry. Back to the topic at hand.

Early Avian and Mammalian Ancestors

As I was saying, paleo-psychiatry keeps making new discoveries. To trace the passage of the fearsome plague that is BPD into humans, we should also investigate the earliest birds and mammals, who shared common ancestors and lived alongside dinosaurs. Early mammals lived in a traumatic environment, which we know is a risk factor for BPD. Perhaps the trauma of living with big, scary dinosaurs was transmitted into their genes, creating a vulnerability that led to BPD in humans.

One can imagine the following scenario:

BirdSpeech

As well as this one:

ShrewTRexSpeech

It makes sense that borderline traits might develop and be genetically transmitted in such an environment. But couldn’t BPD have developed in pre-dinosaur times, and been transmitted from an even earlier starting point?

A Never-Ending Goose Chase

We must commend paleo-psychiatrists for their efforts to trace the early animal origins of BPD, efforts which are as scientific and respectable as those of modern-day psychiatrists to study BPD in humans.

But despite heroic efforts, paleo-psychiatrists have not traced BPD’s ultimate origin, which remains shrouded in mystery. It seems straightforward to follow the evolution of BPD from modern day humans, past cavemen, through early mammals and dinosaurs, all the way to the earliest forms of life. But this process never reaches a satisfying conclusion. With evolution working as it does, there would always be another creature from which to inherit BPD.

We can even imagine unicellular cells, flitting around the primordial fires of early Earth, transmitting their borderline traits to the first multicellular organisms:

AmoebaSpeech

But let’s not go there.

Creationism – A Solution to the Conundrum?

There is another possibility. What if evolution is wrong, and another theory explains BPD’s origin and heritability? What if Earth is only 6,000 years old, as creationists solemnly preach, and as some of our finest public schools teach as an alternative to evolution?

Creationism would elegantly explain how BPD developed. Under creationist teaching, BPD would be a result of the trauma that early humans experienced living alongside dinosaurs and other “prehistoric” creatures. If God created the Earth 6,000 years ago, he would have put all the creatures in history together, even if it resulted in strange alterations to traditional Biblical stories, like this:

NoahSpeech

And this:

WiseMenSpeech

And this:

JesusDinosaurSpeech

No wonder the authors of the Bible wanted to cover up this sordid state of affairs. Living alongside dinosaurs would have made things scary and unpredictable for early humans. And as we know, such traumatic environments are a prime cause of BPD. Therefore, 6,000 year-old dinosaurs may have been the primary reason that BPD developed and was genetically passed down from early to modern humans.

Thus, the trauma of living alongside these monstrosities would have affected mankind’s genes such that BPD would quickly develop as a distinct disease.  As Jonathan Swift might have said, this is “a modest proposal”, but a convincing one.

Just imagine the following scene, which would have been a daily occurrence 6,000 years ago:

DinosaurBoatChaseSpeech

And this:

WomanDinosaursSpeech

Who would not develop borderline symptoms in such conditions?

And imagine having to live alongside abominations never preserved in the fossil record (the fossil record having been planted to trick creationists into believing in evolution, of course), like this:

AbominationSpeech

How horrifying! Thank goodness the dinosaurs and swamp-monster abominations were finally wiped out in an almighty Ragnarok-like battle against invading aliens:

DinosaursAliensSpeech

If dinosaurs and aliens had not annihilated each other a few thousand years ago, then modern civilization would never have developed. If dinosaurs did not die out, we poor humans would have been stuck with dinosaur-induced BPD symptoms, but without the gentle ministrations of modern psychiatry to help us manage them. So let us give thanks that aliens and dinosaurs wiped each other out, because DBT wouldn’t be possible with Tyrannosaurs constantly chasing us.

For me then, creationism provides the best explanation of BPD’s origin. It seems that we must renounce evolution, and accept the fact that the Earth is only 6,000 years old, since no other theory explains BPD’s origins so simply and elegantly. Remember Occam’s Razor – the simplest explanation is usually the correct one.

Alternate Explanations: Pastafarianism

However, there are other explanations. I was recently contacted by a Pastafarian paleo-psychiatrist, who suggested that the Flying Spaghetti Monster might be the cause of BPD. (For those of you who don’t know, Pastafarianism is the religion which teaches that a Flying Spaghetti Monster created the universe. Visit the Church of his Noodly Appendage at http://www.venganza.org )

So, instead of this scenario leading to BPD:

GodCreationSpeech

The following scenario would have accounted for the illness:

SpaghettiMonsterSpeech

However, try as I might, I cannot think of a real reason why the Spaghetti Monster would want to create BPD. His job is to create the universe and feed people pasta, not generate mental illnesses. So this doesn’t fly with me, even if the Spaghetti Monster “flies” in another way.

The Scientific Integrity of My Research

For those of you who think this is a joke, it is not. Do not hurt my feelings by commenting that these theories are unscientific. I am earnestly supporting the efforts of our nation’s finest  psychiatrists in tracing the source of BPD, a pathology which even they admit “the causes and origins of are unclear”. What could be more noble than shedding light on the origins of such a misunderstood affliction?

The Learning Doesn’t Stop Here

Despite their confusion around the inheritance issue, there is much more to be learned from psychiatry’s penetrating insights into BPD.

Psychiatry wisely teaches us that BPD is a “severe illness”, that BPD has a “course” and an “outcome”, that a certain percentage of the population “has it”, how psychotherapy and medications can “manage it”, and so on.

We must give thanks to psychiatry for creating such a wonderful and sympathetic way of understanding human emotional problems. Hearing the pontifications of psychiatrists on BPD is like listening to beautiful classical music.

If you want to learn more about these encouraging, scientifically-sound ideas via our government’s finest websites, as well as from many forums about BPD, make sure you are prepared. Before you research BPD’s cause and origins on Google, you will need:

  • A good sturdy chair.
  • A thick pillow to keep your ass from getting sore.
  • Eyedrops
  • Pain relief ointment for your mouse-clicking finger.
  • Tissues
  • Headache medications.

And take heart: Everything you learn about BPD from traditional psychiatry will be just as scientifically valid as my research above. Good luck!

The Scientific Process by which BPD Sprang Into Being

Now, if BPD first developed in early humans living alongside dinosaurs – who wouldn’t have referred to their symptoms as “Borderline Personality Disorder” – it is interesting to consider when the term BPD first emerged in modern psychiatric usage. Below is an imagining of the scientific process by which BPD may have developed.

A Conversation Between Two Medical Doctors of the Mind (i.e. Psychiatrists)

Date:  March 1st, 1939
Setting: Psychiatry Conference, somewhere in WW2-era America…
The players: Dr. Chillingworth and Dr. Hadley

(Setting – Drs. Chillingworth and Hadley are smoking it up outside a beautiful hotel, discussing the current state of the psychiatric art..)

Dr. Chillingworth: “I’m so thrilled to be back at our nation’s premier psychiatry conference. Our catalogue of mental afflictions is crying out for new names. You know, my dear Hadley, I don’t think we’re upsetting people enough by calling them neurotics and hysterics. The masses need to know when there’s something wrong with them, and those labels just don’t do it for me anymore. We need something to really get the blood boiling.”

Dr. Hadley: “I agree, dear Chillingworth. I call the crazy ones schizophrenic, but they don’t even react! It’s most disturbing. I wonder where we’ve gone wrong.”

C: “Ok, let’s put our minds to it. What name will really upset people?”

H: “How about “Weirdo Syndrome”? You know, for the bizarre folks who aren’t totally crazy, but we don’t know what else to call them?”

C: “Oh humbug! Is that the best idea you have?!”

H: “Forget that. What about “Queer Disorder”. It could be a brand new affliction. We know there’s something wrong with the homos; everyone suspects there’s a malignant germ plasm in their blood!

C: “No dice! Our friend Dr. Beavis beat you to the punch – he’s presenting this idea tomorrow. Don’t worry, homosexuality will be an official disorder. Come on, we need something original!”
(Historical note: Homosexuality was an official DSM disorder until the mid 1970’s).

H: “How about….. “borderline”? We can use it on the ones who aren’t neurotics, but aren’t raving psychotics? You know, the people who are always pissing me off.”

C: “Yes!! Yes. That’s it. … “Borderline!” Wow…. It’s a bunch of bullshit – it doesn’t mean anything. But that’s why it’s brilliant. People won’t know what it means, so it will work perfectly. Let’s use it!”

H: “But how can we be sure that people will buy it, Chillingworth?”

C: “That’s easy. We list things about people who aren’t raving psychos, but are “messed up”. We say if you fit enough of the criteria, you’re a borderline! We make it all sound very scientific and official. The criteria could be things like being irritable, having mood swings, having relationship problems, being impulsive, etc. etc. Things anyone can have, taken to an extreme. Anything we can make up about people we don’t like.

H: “But do you really think people will believe that? I don’t know…”

C: “Of course they will! Give yourself some credit, Hadley; stop overestimating your fellow human beings. Most members of our species are uneducated idiots. If psychiatrists repeat a made-up label loudly and often enough, people will believe it. Remember, the public think we’re experts.”

FreudJungSpeech

H: “This is great! But you know, I just realized something, Chillingworth. You’re pretty messed up yourself.”

C: “Tell me something I don’t know!”

H: “Indeed. Moving on… do you think that, many decades years from now, people might think this “borderline” label we dreamed up is real, and a whole industry will be based around labeling and managing these “borderlines”? I don’t know if I would feel good about that.

C: “Oh stop whining! The Borderline affliction will become real, because we say it is. We became psychiatrists so we can be exalted as experts and given bundles of money. Who cares if we have no idea why people act like they do? And who gives a damn about people in the future? Our genius is that we have no idea what we’re talking about, but people pay us anyway. Have faith, my friend.”

And thus was born “Borderline Personality Disorder.”

(Historical note: BPD was in fact “born” after psychiatrists in the late 1930s invented the term out of thin air. Perhaps not exactly like this. But close enough…)

—————————–

My thanks go to Sameer Prehistorica (http://sameerprehistorica.deviantart.com) and Harry Wilson (http://harry-the-fox.deviantart.com) for allowing the use of their beautiful art. Also, credit to http://www.speechable.com, a great, free resource for attaching captions to pictures).

I welcome any correspondance at bpdtransformation@gmail.com

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

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

🙂

– Edward Dantes

#19 – Hope, Meaning, and the Elimination of Borderline Personality Disorder

My goal for this blog has been to promote a new, more hopeful understanding of what is today called Borderline Personality Disorder. In writing this post – which will discuss hope for recovery from emotional trauma, but later argue that this hope might be better served by eliminating the diagnosis of BPD entirely – the following quote from Macchiavelli comes to mind:

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order; this lukewarmness arising partly from fear of their adversaries, and partly from the incredulity of mankind, who do not truly believe in anything new until they have actual experience of it.”
– Niccolo Macchiavelli (1469-1527), The Prince

For the purposes of BPD’s validity, this quote can be understood in terms of the “old order” of psychiatry – which profits both financially and via creating the illusion of scientific knowledge in psychiatrists – being opposed by those of us who argue as “reformers” that psychiatric diagnoses are invalid, unreliable and unhelpful. The reform position is that recovery from severe emotional trauma can be achieved without the need for psychiatric diagnosis. As the quote suggests, the idea that BPD does not exist as a valid diagnosis can initially be hard to believe.

Hope for Recovery, In All Its Forms

Today I’ll discuss what is among the most important topics for Borderline Personality Disorder: Hope. When a person is struggling with “borderline” symptoms – meaning intense difficulty managing their emotions and relationships, among other things – having realistic hope for improving one’s situation is critical. During difficult times, hope has felt as important for me as the oxygen a climber on Mount Everest carries for survival, or the fuel that a rocket returning from deep space uses, without which an astronaut would be doomed.

People may prefer to think of their hoped-for state as recovery, freedom, improvement, achieving goals, or something else; it is very individual. However their hope is defined, most BPD-diagnosed people express a strong desire to improve their situation.

Realistic hope

What makes hope realistic? I would suggest at least two things; 1) That hope is not taken for granted, and 2) That it is based upon convincing data.

#1, “Not taking hope for granted”, means realizing that improving one’s situation demands serious commitment and work, requires a willingness to confront oneself about difficult issues, and involves depending on other people for help.

#2, “Based upon convincing data”, means that realistic hope (for one’s desired outcome) must be based upon reliable and trusted information. To hold onto hope, a person needs a view of reality that is as accurate as possible in terms of representing the external world.

When I first searched for information about improving from BPD, a lot of what I found appeared pessimistic or even hopeless. Many publications said that the best outcome possible involved learning to better manage this painful lifelong “illness”, and some said that borderlines were untreatable or evil. Family members ranted about how difficult and unchanging their “borderlines” were. None of these things made me feel hopeful.

In earlier posts, stories and data were presented that, for me, provide realistic hope for recovery, healing, and achieving a “cure” of symptoms approximating what is described in the BPD diagnosis:

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

https://bpdtransformation.wordpress.com/2013/11/23/how-did-i-recover-from-borderline-personality-disorder/

The “Information War”

This data contrasted sharply with the earlier pessimistic, hopeless accounts about BPD I’d encountered. Sometimes it felt as though I was reading about two completely different conditions. For some time I fought an “information war” in my mind, trying to judge which of these conflicting versions of reality was right – or perhaps, whether both were correct, acting as self-fulfilling prophecies in different situations.  The increasingly numerous accounts I found of individuals with BPD diagnoses doing well, combined with my own life experience, eventually convinced me that realistic hope for getting better from what I then thought of as BPD did exist.

In my case, realistic hope meant that with sufficient support from family, friends, and my therapist, I had a very good chance of doing well, like many others who had encountered similar challenges before me. For other people, the hopeful narrative may be somewhat different; this makes sense given that we are unique individuals, and given my contention that BPD is an invalid, unscientific label which does not represent the same phenomenon from person to person.

Now, let us turn to look at some societal obstacles that impede realistic hope for BPD recovery.

The Failure of the American Mental Healthcare System

It can be useful to analyze the notion of realistic hope in the context of American psychiatry and its conceptualization of Borderline Personality Disorder. It is my position that psychiatry’s “medical model” approach to psychiatric diagnoses, its biological reductionism, its overemphasis on medication, and its oversimplification of an individual’s emotional struggles, all impede the spread of realistic hope regarding BPD (or more correctly, the hope for recovery from severe emotional trauma and/or the lack of healthy emotional development, in all its variations).

A Story: Emma

Let us discuss these ideas with a fictional example. Emma is a 21-year-old woman who grew up with an alcoholic, abusive father and an overstressed, emotionally neglectful mother. As a young girl, Emma was sexually molested several times by her father. Since finishing high school, Emma has lived at home with her mother, who works two jobs to provide for Emma and her younger sister. The father abandoned the family several years before, increasing the stress on the remaining family members.

Over the past three years, Emma has felt increasingly depressed and anxious most of the time. She is unsure how to make meaningful relationships with other young people. Never socially confident, Emma has become increasingly socially isolated as her old high school friends move out of town.  Due to her depressions, she cannot keep a regular job, and she goes through a series of short-term boyfriends who use her for sex and then abandon her, reminiscent of her father’s behavior. Unable to tolerate her increasing feelings of aloneness, and frustrated with her mother’s lack of understanding, she begins binge eating and purging, and also cuts herself when feeling particularly hopeless.

Finally, Emma overdoses on psychiatric medication in a desperate gesture that is really a call for help, leading her to be hospitalized for the first time. When evaluated by a doctor, she is seen as fearing abandonment by her mother, having an unstable self-image, practicing self-injurious behaviors, being unable to regulate her feelings, seeing others as all-good or all-bad, and so on. Obviously, she would be a prime candidate for receiving a BPD diagnosis according to traditional American psychiatry.

However, I want to focus on two possible ways that the hospital doctor could respond to Emma, and how these approaches might or might not promote realistic hope in Emma’s mind.

The Medical Model’s Diagnostic Approach

In the traditional psychiatric (medical model) approach, the treatment provider might communicate something like the following, “Emma, you’re suffering from a psychiatric illness called Borderline Personality Disorder. We don’t know what causes this condition, but it’s believed to result from a combination of genetic, biological, and environmental factors. BPD causes people to have problems regulating their emotions, and that is what is creating your symptoms like depression, anxiety, and rage. This is a tough condition to have – there’s no cure for it – but if you take medication and attend therapy, the symptoms can be managed.”

Usually, such an approach involves the doctor asking Emma what her symptoms are, but not going into detail about possible causes for these symptoms based on her personal history. Several emotional messages are conveyed by this approach. The first would be that there is something innately wrong with Emma. Emma would probably feel that she has a mental “disease”, that she is stuck with this illness for life, and that her prospects for finding personal fulfillment are poor.

The second message is that Emma’s past history and relationships are unimportant in relation to her “diagnosis”, or perhaps not related at all to her present problems. Rather than her current feelings and actions being understandable reactions to the deprivations she has experienced throughout life, she is told that a “disorder” is mysteriously causing her symptoms. Paradoxically, getting diagnosed with BPD does not give Emma any deep insight into why she is behaving or feeling the way that she is. The last, related message is that Emma is seen as a label, rather than as a person.

In my view, the ideas presented to Emma in the above example – i.e. “you have a psychiatric disorder called BPD, this mental illness is causing your symptoms, there is no cure for it” – are examples of outrageous lies coming from the pseudoscience that is psychiatry. In the posts below these distortions are expanded upon:

https://bpdtransformation.wordpress.com/2014/03/16/the-science-of-lies-psychiatry-medication-and-bpd/

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

https://bpdtransformation.wordpress.com/2014/01/16/a-unicorn-the-paradox-of-the-bpd-label/

In this last article – “A Unicorn: The Paradox of the BPD Label” – I originally wrote that BPD has value as a label allowing people to find help and support. My thinking here has changed, such that I would now strongly endorse only the second half of the article – i.e. starting with “Why I Do Not Believe in BPD.” As I’ve read more about how psychiatric diagnoses oversimplify people’s stories, fail to meaningfully address the causes of people’s problems, and lack scientific validity, I’ve become increasingly reluctant to attach value to the label “Borderline Personality Disorder”.

Formulation: An Alternative to Diagnosis

Returning back to Emma’s case, if labeling her with BPD is not helpful, how might she be understood instead?

The Formulation approach, which has been pioneered by mental health workers in the United Kingdom, would offer something like the following:

“Emma, you’re obviously in a lot of pain right now. From what you’ve told us, things have been incredibly hard over the past few years, and you’re not able to rely on your mother for emotional support. The way your father treated you has also had an incredibly powerful negative influence. Given your history, you must feel incredibly alone, and it’s no wonder that you feel hopeless, scared, and abandoned. Your behaviors of purging and cutting yourself make sense; after the trauma you’ve experienced, anyone might react this way to manage their overwhelming feelings.”

“Although it’s difficult, we feel that your situation is far from hopeless. But to feel better, you’re going to need help. You may benefit a lot with support from someone who can understand your story, assist you in managing your current feelings, and help you find practical ways to improve your current life. We have therapists who have successfully helped people with similar family histories to yours, and when you come to feel better and leave the hospital, we can refer you to an outpatient therapist who can continue to help you.”

Differences Between Diagnosis and Formulation

Obviously, this approach is starkly different from the traditional psychiatric approach. Firstly, Emma is not diagnosed with anything – the terms “Borderline Personality Disorder” or “BPD” are never mentioned. Rather, her symptoms are understood as perfectly logical reactions to the trauma she has experienced. In that way, Emma can start to make sense of what has been happening to her, and she will be less likely to feel crazy or defective. Emma’s past history and present circumstances are used to create a narrative explaining her present problems.

Secondly, a message of hope is strongly promoted, with the idea being that recovery is likely if Emma receives effective support. “Illness” and “disorder” are never mentioned as causes of her problems; therefore, Emma is not led to feel that there is something innately and irreparably wrong with her brain. Instead, Emma is told that her personal history matters, and that understanding how it relates to her presenting problems can help in managing her distress and improving her life.

Obviously, these approaches are poles apart, and might be considered black and white examples of how an actual mental health worker would deal with a patient such as Emma. Nevertheless, I have read about many people who are treated similarly to the first example, in which a psychiatrist diagnoses them with a mental “disorder”, while completely failing to understand the individual as someone with a history contributing to their problems. In my opinion, this traditional psychiatric approach is destructive to and precludes realistic hope.

Lucy Johnstone and Formulation

I must give much credit here to Lucy Johnstone, a British clinical psychologist whose writing on formulation inspired me. Here is an excerpt of her viewpoints on traditional psychiatry and the destructive effects of psychiatric diagnoses:

“Psychiatric diagnosis underpins the whole biomedically-based model of mental health. Any science needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge. If this cannot be established, the whole model breaks down and all psychiatry’s other functions – indicating treatment, carrying out research and so on – will be fundamentally undermined.”

“ ‘Diagnosing’ someone with a devastating label such as ‘schizophrenia’ or ‘personality disorder’ is one of the most damaging things one human being can do to another. Re-defining someone’s reality for them is the most insidious and the most devastating form of power we can use. It may be done with the best of intentions, but it is wrong – scientifically, professionally, and ethically. The DSM debate presents us with a unique opportunity to put some of this right, by working with service users towards a more helpful understanding of how and why they come to experience extreme forms of emotional distress. We already have a situation where the strongest defence of DSM is: ‘We know it’s flawed, but it’s the best we have – what could we do instead?’ The simple answer is, ‘Stop diagnosing people.’”

These quotes come from the following source: http://www.madinamerica.com/2013/01/time-to-abolish-psychiatric-diagnosis/

Lucy Johnstone’s positions are very close to my thinking on the pseudo-diagnosis of Borderline Personality Disorder. To promote hope in people who have been severely traumatized and have great difficulty managing their emotions, perhaps it would be helpful to stop diagnosing them as “borderline.” Instead, we could understand them as individuals with unique histories that have contributed to their current problems, while encouraging them that they have strengths that can lead to recovery.

And here are some of Johnstone’s thoughts on “Formulation” specifically, in this case related to a person labeled as “psychotic”:

“In Britain, formulation is considered to be the core skill of the profession of clinical psychology… Formulation can be defined as the process of co-constructing a hypothesis or ‘best guess’ about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It draws on psychological theory and evidence in order to suggest the best path to recovery.  Unlike diagnosis, it is not about making an expert judgement, but about working closely with the individual to develop a shared understanding which will evolve over time…”

“We can see that the formulation is personal to (the patient), and helps to make sense of her experiences… It suggests an individual pathway forward, which will probably include developing a trusting relationship with a worker or therapist, learning ways to manage and cope with her voices, perhaps gaining support from others with similar experiences, and talking through her past. All of this is in stark contrast to the messages of shame, damage, hopelessness and despair that are conveyed by a diagnosis, and that too often lead with tragic inevitability to medication, admission and a lifetime career as a psychiatric patient.”

Source: http://www.madinamerica.com/2013/01/thinking-about-alternatives-to-psychiatric-diagnosis/

When Belief in the System Fades

In my view, psychiatry and its zoo of imaginary diagnoses militate against hope, personal meaning, and understanding. Psychiatry’s diagnosis-based ideology could be likened to a precariously perched house of cards. As more people understand that diagnoses like “Borderline Personality Disorder” are scientifically invalid, they may increasingly question the medical model underlying them. Over time, increasing numbers of patients and professionals may become unwilling to accept these labels. At a certain point, belief in the current system – the ideas that psychiatric diagnoses are real entities, that they can truly explain a person’s emotional problems, and that medication should be the first line of treatment – may fade and then collapse.

The vested interests of psychiatry will inevitably resist these changes because of the threat they pose – to making billions of dollars for drug companies, sustaining psychiatrists’ high incomes, and maintaining the fiction of psychiatrists as authorities who can diagnose emotional “disorders”. As Macchiavelli implied, the old order profits from defining reality in a way that benefits it, and some people may have trouble even considering that emotional problems could be understood in a radically different way.

Nevertheless, it is my hope that people will be open to the following idea: that promoting hope and restoring meaning for those suffering from the symptoms associated with “Borderline Personality Disorder” might be better achieved in many cases without labeling people as BPD. If some people still find benefit from being labeled as borderline, then so much the better. People ought to be free to use what works for them. But if other people are helped more by a “formulation”-like approach, one which connects their symptoms to their personal history and life circumstances without labeling them as having an “illness”, then perhaps we should shift our mental health practices in this direction. There might be still other approaches that work better for some people than formulation.

These ideas, some of which may seem confusing, relate to the arguments I have repeatedly made in previous articles: that BPD is an invalid and unreliable diagnosis, that no biological or genetic basis has been found for BPD, and that the medical model approach with its emphasis on medication is not useful for many people. For more information, the reader is again referred to the articles linked to above and their links to other websites.

The Idea of a Borderline Spectrum

However, part of me remains sympathetic to the idea of a borderline spectrum of emotional problems, which does not mean that BPD is a literal psychiatric illness. Instead, it means that people with similar-appearing emotional struggles as adults can be understood as using similar psychological defenses (e.g. splitting and projection), resulting from related histories of neglect and/or abuse. In this model, people and their problems are understood as existing along a continuum of functioning and symptom severity, and they are not understood to have the same “disorder”.

This spectrum-based model may have some value in allowing people to relate their emotional problems to other people’s (similar) problems in a meaningful way, and in allowing treatments to be developed for similar-appearing emotional problems that might be called part of a “borderline” spectrum. However, this idea conflicts with some of what I have written earlier about the lack of validity of the borderline concept per se. As can be seen from the trouble I’m having writing about it, it can be quite tricky to discuss emotional problems without using labels!

To conclude, it is fascinating how the words we choose to describe emotional problems, along with the theoretical models we base them on, are such powerful influences on our thinking and feeling about what is possible for us. I would be interested in what others think about what makes hope realistic, about formulation as an alternative approach to diagnosis, about the (lack of) validity of the medical model of BPD, and about the idea of “borderline” symptoms as occurring along a spectrum. Please feel free to share your views in the comments!

#16 – An Eastern Approach to Recovery: Lao Tzu, Sun Tzu, and BPD

Below are five quotes from the ancient Chinese philosopher Lao Tzu, author of the Tao Te Ching.

Please consider them first for their beauty and their applicability to any human being. I will then suggest ways in which they relate to the person recovering from Borderline Personality Disorder.

1. “Being deeply loved by someone gives you strength, while loving someone deeply gives you courage.”

2. “At the center of your being you have the answer; you know who you are and you know what you want.”

3. “The snow goose need not bathe to make itself white. Neither need you do anything but be yourself.”

4. “If you do not change direction, you may end up where you heading.”

5. “Those who have knowledge, don’t predict. Those who predict, don’t have knowledge.”

Lao Tzu was probably an amalgam of several Chinese philosophers from the early centuries BC. As a symbolic figure, he is regarded as the father of the religious and philosophical movement called Taoism.

A statue of Lao Tzu in China

A statue of Lao Tzu in China

Some fundamental ideas of Taoism include: feeling contentedly at one with the “Dao”, which is an unseen, transcendent force flowing through all things; reaching a state of freedom from earthly desires called “wu wei”, which can be translated as “flowing with the moment” or “not acting”; and a return to nature. Taoism’s emphasis on inner peace make it an interesting philosophy for people with borderline issues who need to develop self-comforting capacity.

tangyin5a

A Taoist painting illustrating Taoism’s focus on nature and personal contentment

During the arduous years of getting better from BPD, I encouraged myself using quotes like these. They helped create a sense of purpose and motivation. I’ll discuss the quotes above one by one:

1. “Being deeply loved by someone gives you strength, while loving someone deeply gives you courage.”

This first quote implies the reason why borderlines feel emotionally weak. They do not feel truly loved, nor can they trust other people deeply. Being dependent on and vulnerable toward another human being is the most crucial experience a borderline needs to grow emotionally. It is trust in another person that leads to feeling deeply loved. This was described in the phase of “Therapeutic Symbiosis”, in article #10 on this blog.

I can attest that feeling loved as a person was the critical ingredient that helped me become non-borderline. It was a feeling I first reached in psychotherapy and secondarily with several trusted friends.

After one feels loved for oneself, one can then love others, and this gives courage. Loving someone else deeply makes one feel that one is truly alive, that nothing can stop you. It lessens the fears of failure, aging, dying, and unfulfilled potential.

2. “At the center of your being you have the answer; you know who you are and you know what you want.”

This is a lovely quote, but again not something that borderlines start with – they don’t know who they are. But at the center of their being, they have the answer – their innate desire to get better, to be loved, and to feel fully human.

This again relates to quote #1. Love, trust and dependence on other people is the simple answer to the question: What allows a healthy child, or adult borderline, to grow and become emotionally healthy? Finding the answer to this question allows borderlines to develop a personal identity, to know who they are and what they want.

After my abusive childhood, the awareness dawned on me that I fiercely desired to be loved and cared for. Following this desire led me to attend psychotherapy and support groups, to make new friends, and to take risks. These resources allowed me to grow into an individual with an identity, to know who I am and what I want. It’s really true what Lao Tzu said – in my heart I always knew what I needed to get better. The challenge was taking the risks, fighting through fears, and overcoming psychic defenses to reach human help and love.

3. “The snow goose need not bathe to make itself white. Neither need you do anything but be yourself.”

This quote is attractive in the simple self-acceptance it implies. In my late teens and early 20s I hated myself. On the one hand, I felt pressured to achieve in academics, sports, and work so that others would like me. On the other, I believed my personality and appearance to be unlikeable and unattractive, and so never felt genuine or spontaneous. Instead, I was always trying to mold myself into what other people wanted.

How different I am today! I’m not afraid to say what I think, and don’t adapt myself for anybody. I am what I am, and if people don’t like that, too bad. I take delight in being myself.

This quote represents the ultimate ideal of self-acceptance that human beings, including borderlines, can aspire to. Like the snow goose which is naturally white, you don’t have to do anything to be yourself. Again, to approach this ideal, borderlines need the experience of being loved and accepted by an outside person, so that they can adopt the same attitudes toward themselves.

In article #15 on Gerald Adler, and in article #10 on Seinfeld’s four phases, it was discussed how self-acceptance – based on internalizing and believing the positive support of another person – is crucial to becoming non-borderline and developing genuine psychological stability.

4. “If you do not change direction, you may end up where you heading.”

This obvious but humorous quote really strikes home. It reminds me of the old-timers in my 12-step group who used to say, “If nothing changes, nothing changes,” and “Doing the same thing over again and expecting a different result is the definition of insanity.” Hard experience has taught me that transforming oneself  – while very doable – requires a lot of work and time, plus a willingness to take risks and try new things. Radically changing one’s emotional status quo is not comfortable, but it’s much better than stagnantly staying in an unhappy place. This was discussed more in post #14, about how risk-taking promotes recovery in BPD.

5. “Those who have knowledge, don’t predict. Those who predict, don’t have knowledge.”

This is true wisdom! A wise person understands how complex, ambiguous, subjective, and unpredictable the world is. Therefore, they don’t try to predict exactly what will happen to themselves or others.

While it can be fascinating to make predictions, such predictions, especially about mental illness, ultimately demonstrate a lack of knowledge. If prognosticators appreciated how people are extremely “complex” systems (influenced by many unpredictable sources of input) rather than “linear” systems (influenced by a limited number of clearly known variables), they would show more restraint.

I learned much about this subject from reading Dan Gardner’s book Future Babble. Two of his points stand out. First, the statistical study of past predictions made in various fields, including economics, politics, sociology, medicine, etc. indicate that the more certain someone is about a given prediction, the more likely they are wrong. Gardner thus warns the reader against trusting people who seem very sure of their predictions. He argues that those who think about a range of possible outcomes and speak in terms of ambiguity and uncertainty are more likely to be correct.

Second, Gardner showed how astonishingly quickly predictions can go wrong if even one factor inside the complex system unexpectedly changes. For example, with the weather, if the moisture level, cloud cover, wind direction, or one of dozens of other factors shift slightly, the whole outcome can totally diverge from the original prediction.

This is why human life courses are so difficult to predict over the long term. Human beings are not balls rolling down a hill whose paths can be precisely laid out! 🙂 They are complex systems like the weather, subject to millions of influences that we cannot map out in advance.

I have no respect for therapists who try to predict the outcome (via a “prognosis”) of people with Borderline Personality Disorder. Human emotional problems are way too complex to be medicalized like a physical disease. How someone does emotionally depends on literally millions of personal and environmental factors. Thus over the long term, we can only suggest factors that tend to promote success or hinder progress, while remaining humble about our lack of foreknowledge.

It is not only love and dependence, but aggression, cunning, and taking action that drive recovery from BPD.  With that in mind, I love reading a Chinese philosopher of a very different nature. Here are quotes from Sun Tzu, author of “The Art of War”:

1. “The general who wins a battle makes many calculations in his temple before the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat.”

2. “The reason the wise general conquers the enemy and his achievements surpass those of ordinary men is foreknowledge.”

3.  “If you know the enemy and know yourself you need not fear the results of a hundred battles.”

4. “What is of supreme importance in war is to attack the enemy’s strategy.”

5. “The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim.”

6. “Let your plans be as dark and impenetrable as night, and when you move, fall like a thunderbolt.”

Sun Tzu was a Chinese military general and philosopher living around 500 B.C. during a period of warring kingdoms. In this era, rivals groups fought constantly over territory, and survival was a zero-sum game in which hesitation, unpreparedness, and lack of knowledge proved deadly.

sun-tzu

An artist’s impression of Sun Tzu

Sun Tzu recorded many of his strategic military insights in “The Art of War.” His writing emphasized the psychology of how to wage war, especially how to outmaneuver one’s enemy by understanding his emotional strengths and weaknesses. Sun Tzu believed that both objective (e.g. the physical landscape; the resources of each side) and psychological (e.g. the enemy’s mindset) considerations needed to be taken into account when conducting a military campaign.

Sun Tzu emphasized that a military strategy was not a fixed, unchanging list of actions to be followed; rather, the reality of war dictated that conditions and thus strategy constantly evolved. This meant that leaders had to be ready for the unexpected situations that arose when their plans interacted with the enemy’s plans in unpredictable ways.

A battle from the Warring States period of ancient China

A battle from the Warring States period of ancient China

Sun Tzu’s viewpoint has Macchiavellian qualities, in that it promotes doing whatever is necessary to survive and triumph. This is familiar for me, since I often felt forced to do “whatever it took” to survive the emotional war I was fighting after being diagnosed with BPD. I was somewhat ruthless back then, and am still a bit that way, as described in article 12, “Cracking the Borderline Code.”

So, how can someone apply Sun Tzu’s quotes to fighting for recovery from Borderline Personality Disorder? Here are his quotes again:

1. “The general who wins a battle makes many calculations in his temple before the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat.”

As I recovered from BPD, this insight helped because it indicated that if I did not plan ahead, I was unlikely to prevail in the long multi-front war against BPD. I had studied many books about BPD, seeing which patients improved and which did not, analyzing which factors promoted recovery and which hindered it. I plotted out a rough plan to overcome Borderline Personality Disorder in an analogous way to how a general calculates a military strategy.

From my reading, I knew the primary goal was to develop dependent, supportive relationships in which I could be “reparented”. This process would develop the positive self-and-object units (see article #9, “A Fairbairnian Approach to BPD) and develop healthy ego functions to eradicate the borderline symptoms. I also knew that medication was ineffective at achieving these goals and so I stopped taking it, as indicated in article #13 on medication. Instead, I researched psychoanalytic-psychodynamic therapists and found one who had experience and success treating borderline conditions.

I started going regularly to therapy and continued for several years. To supplement this supportive relationship, I attended 12-step groups and developed friendships with people like Gareth, the older man who helped me work through my childhood trauma as described in Article #2. I was quite conscious about working to trust and depend on other people, because my research and experience indicated that it was only through building long-term positive relationships that I could recover.

So I had a long-term plan, and it worked. Today I enjoy my relationships, am successful in my work, and have no remaining borderline symptoms. Like the general in SunTzu’s quote, I made many calculations in the “temple” of my mind before beginning my battle against BPD in earnest, and they led to victory.

2. “The reason the wise general conquers the enemy and his achievements surpass those of ordinary men is foreknowledge.”

This quote is similar to the first. It could be viewed as a bit arrogant and presumptive to apply this to BPD. In truth, I did not know for sure that I would recover, or exactly how things would work on the journey.

What Sun Tzu probably means is that the successful general is better informed than most people from the outset– in this case, about the terrain, the psychology of the enemy, the enemy’s positions, strengths, weaknesses, and how to engage him. He studiously prepares in order to know as much as possible about what is likely and how the enemy might act. It doesn’t mean the general is clairvoyant and can see the future, because as indicated in Lao Tzu’s quote about prediction, that is impossible. But the general plans for a range of scenarios and is as well-informed as possible.

As indicated in other posts, education about BPD and how it is effectively treated is crucial. To me, knowing a lot about BPD and how others recovered from it is the closest we can come to “foreknowledge” about what facing BPD will mean for us. I benefitted greatly from studying many books, talking to therapists, and reading websites and blogs about BPD. Educating oneself is in my opinion the “wise” thing to do with BPD and it provides a better chance of getting the results you want in recovery.

3.  “If you know the enemy and know yourself you need not fear the results of a hundred battles.”

This is another similar quote to the first two. It is of course simplistic to apply these quotes to a complex emotional condition, but it can be inspiring and motivating.  Knowing “BPD” means understanding how the condition works in depth. Borderline defenses like splitting and projection are initially powerful, tenacious, and deceptive mechanisms. It is useful to understand how they work, and I intend to write future posts on how splitting and projection/projective identification operate.

The early part of “knowing yourself” when dealing with BPD, in my experience, was understanding how defenses based on past trauma (“the enemy”) were constantly coloring how I viewed the external world. They tricked me into distrusting and rejecting other people’s help, since I misperceived everyone in my present day world as untrustworthy like my father.

With a better understanding of how my mind was working, I felt more confident in stopping my defenses from recreating past trauma in my present day life. Although I didn’t win every battle at first, I felt more confident about defeating BPD in the long term.

4. “What is of supreme importance in war is to attack the enemy’s strategy.”

This is more relatable to BPD than one might think. The “strategy” of defenses in BPD is that they cause a person to negatively distort the external world, tragically recreating their traumatic past into the present. It renders the borderline unable to take in support from other people in sufficient quantities to develop a healthy sense of self. In Article #15, Adler described the necessity of confronting psychic defenses which “block” the development of positive introjects, and in Article #10 Seinfeld analogously described how the bad internal object situation prevents the borderline from internalizing the therapist as a positive new person.

Although it’s a bit simplistic, and to repeat from the last quote, these defenses which “trick” the borderline into rejecting human help are “the enemy.” When I was borderline I had two selves – a “healthy” self which wanted to trust others and get better, and a “trauma” self which was emotionally frozen at the time of my physical abuse, distrusted others, and refused to believe that people cared.

I became able to track the operation of the “trauma” self and to reject its deceptive attempts to make me distrust others. I did this by understanding how splitting and projection pulled the wool over my eyes, so that I perceived emotionally only peopl’s negative aspects and refused to take in their good sides. I countered this tendency by putting myself in more and more “good” situations like therapy, 12-step groups, and with supportive family and friends.

Over time, I began to find more and more of the good in other people and in myself. Eventually others’ good intentions started to break through my resistance. I gradually learned that truly good people did exist, that it was safe to depend on others, that I was worthy of love, and so on. I attacked the strategy of the BPD defenses which were blocking my progress, and as Sun Tzu indicated, attacking the enemy’s strategy is paramount.

5. “The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim.”

I relate this quote to Article #14, “How Risk-Taking Promotes Recovery From BPD.” It’s a bit of a harsh description (poor victim!) but it emphasizes how good decision-making is decisive and timely. In the “Risk-Taking” article, I described how changing therapists, stopping medication, moving home temporarily after college, asking for help from Gareth, etc. were all situations in which I had to take decisive action. Over the years I’ve become more and more decisive about “pulling the trigger” on things that are in my best interest. The way the falcon quickly swoops down on its prey is a good metaphor for the way a tough decision must be made decisively to be effective.

There is only a very loose correlation between this quote and BPD, but effective decision-making is important when dealing with BPD or any other serious challenge.

6. “Let your plans be as dark and impenetrable as night, and when you move, fall like a thunderbolt.”

This quote doesn’t really relate to BPD. I just put it on here because it sounds cool! I’m a big fan of action movies, spy thriller novels, and adventure video games, and it’s too bad we don’t have Sun Tzu around to write snappy dialogue for them.

I hope this article gives the reader a different perspective on how to think about BPD reccovery. There are many useful approaches to healing from trauma, and we should not hesitate to use the insights from many  different people and cultures to help us.

The_Art_of_War-Tangut_script

Sun Tzu’s “The Art of War”