What Is It To Be A Borderline?
Bar-El J., M. D., and Gil Ts. E., B. Sc., M. A.
Acre community Mental Health Clinic, Fligelman ('Mazra') Psychiatric Hospital, Israel
(הרצאה שניתנה בכנס הבין לאומי הראשון לפסיכיאטריה דינמית, פירנצה, איטליה, אוקטובר 2012)
Since its introduction to the psychiatric lexicon, the Borderline syndrome had won an enormous amount of clinical, theoretical, and scientific literature, an amount which indicates, actually, our difficulty to comprehend the phenomenon. We would like to raise and discuss some questions, without pretending an ability to answer them. Is a Borderline a solid structure of personality, as the structural school proposes, or is it a flowing phenomenon which emanates in the therapeutic interface, as some inter-subjective authors suggest? Is it a neuro-socio-emotional phenomenon, which evolves from lack of appropriate relatedness of significant others in a crucial age to a neurologically harmed infant? Or maybe it is a chronic form of complex post-traumatic stress disorder, which hypothetically originates principally from a sexual abuse in childhood? Is the Borderline phenomenon represents a defect in object relations and use of primitive and maladjusted mechanisms of coping, or maybe the borderline is a manifestation of a distortion in cognitive processes which lead to misinterpretation of reality through use of idiosyncratic mental constructs? And while this list of theoretical explanations is not exhaustive or mutually exclusive, we may proceed further to the paramount issue of treatment. Parallel to the aforementioned survey of explanatory approaches to the phenomenon of borderline, there are numerous approaches to treatment, so far none has proved to be significantly superior to others, and most likely each invests in various aspects of the syndrome. We will present our own research as well as clinical material in order to highlight some of the intricate issues abovementioned and some of the complexities of the Borderline phenomenon.
Opening – Clinical Vignettes.
Zina was in her late forties when she attended psychotherapy. She had psychological problems since her early childhood. As a child, she was treated in children developmental unit. As an adolescent she was hospitalized in an adolescent psychiatric ward, and diagnosed as suffering from affective disorder, which won her a national security allowance. As an adult she was not hospitalized again. She worked in some unprofessional works, e.g., secretarial, but at the time of her attendance to psychotherapy she was unemployed. She was unmarried. During her life she had many relations with men, some of them more durable and meaningful for her, but most of them were occasional and of erotic color. She was a known character in the small town were she lived, wandering during the day and chatting with by-passers. She had aggressive relations with her neighbors and actually, in spite of having many acquaintances, she was a lonely woman. In therapy she told the therapist that she slept with almost all of her former doctors. She persisted in individual psychotherapy for rather a long time, though she was provocative and testing the treatment limits. When asked to participate in a therapeutic group she very soon quarreled with most of the other group members and was expelled from the group.
Eddy was eighteen years old when he attended psychotherapy, and it was after he was discharged from two consecutive hospitalizations in an adolescent psychiatric ward due to eating disorder, self harms, and suicidality. Eddy was a good looking young man, but he was sure that he is fat, ugly, and stupid, and no one would agree to go out with him. In reality, he tried to make relations with many girls, but never succeeded, obviously not because lack of attractiveness but because behaviors which could be understood as self defeating. In addition, he had hesitations concerning his sexual identity, phantazysing about men and sometimes having real sexual relations with them. He was intelligent and diligent and engaged in many activities, like learning, exercising, playing guitar, and many more, but with no apparent consistent line of ambition. When commencing psychotherapy he reported what could have been concluded as a light form of dissociative identity disorder, which declined along treatment. His mood seemed to be stable, and he attended the treatment regularly, expressing much neediness and reliance on it. When he was referred to a therapeutic group he participated there willingly and positively and was perceived as the 'star' of the group. Even though, and besides many things that he was involved in and the many people in his life, he was still feeling lonely, having no close relationships.
Gizel was at her late twenties when she attended psychotherapy, for the first time in her life. In the first session she presented her mother as 'mentally sick'; It was concluded that the mother was probably not mentally ill and probably never treated, but she was disturbed, aggressive and obsessive, and Gizel's childhood was highly dyed with surviving the grave role her mother played in he life. Her father, on the other hand, was portrayed as weak. Shortly after Gizel was born her mother vanished for some vague reason, and Gizel had been taken care by her siblings. When she grew to adolescence she discovered she was pretty and males found her to be highly attractive. Since then she slept with many men, most of them she felt exploited and humiliated. Some time before she applied for treatment she get married. Her husband was intelligent and good looking, however apparently with schizoid-like traits. After her marriage Gizel continued to meet men, with no reservation from her husband. She learned for a degree in Humanities but had no profession. She worked in some unprofessional jobs, unable to succeed to sustain with. She become depressed and even threatened with suicide, which drove her to seek psychological treatment.
What is common to those three people? From a layman point of view, very little. From our view, pretty much. But in order to infer the underlying structure which lies underneath the variable surface, one should indulge in high level of research and theory. A vast amount of literature had been published about the subject, and it is difficult to propose something original. However, we would like to raise a very modest contribution, trying to discuss the phenomenon from the point of view of the Borderline patient, as much as we could empathize with.
Borderline think differently.
In a research study in this population, we learned about their Mental Constructs and the different identifications inside their inner mental apparatus as well as in their relationships with significant ones using the Net method. In our study, the Borderline subjects were asked to choose an adjective which would best describethe characteristic of their physical body, and of their social, ideal one, of their mother, father, most close person and most disliked person.
When revising the data, we were surprised, since all the subjects chose pairs of non logical couples of adjectives, which were not related to each other in reality, so we concluded that this polarity was idiosyncratic.
One of the most frequent misinterpretations we met in that research population and which is consistent with the clinical experience is the common misunderstanding of being either authoritarian or a good person.
In rare cases– or maybe not so rare?– psychiatrists judge them to display mild disturbances in thought, a finding which make borderline bitter about – in their own judgment their thinking is highly reasonable: it is only other people who fail to understand them, or they claim that they had changed their mind, which is clearly human.
Borderline feel differently.
Very often they are described as capricious. They may express uncontrolled bursts of emotions – either positive (love, excitement, admiration) or of negative nature (anger, rage, disdain) without attempting at being reasoned or consistent. They are often perceived as theatrical, as playing roles (including emotional and sentimental ones) but superficially, with no depth. They may be perceived as flat and shallow, and typically as lack of warmth or authenticity. Therapists view them as having low tolerance to their feelings, unable to sublimate them; therefore they act them out or show psychiatric symptoms. The Object Relation School saw their instinct of aggression as their major drive, whose vicissitudes are being expressed in their twisted and struggling personality.
The Human Structural School of Gunter Ammon understood them as lacking sufficient amount of healthy narcissism and healthy aggression, without enough capacity of making adequate plans for their future, maintaining and accomplishing them. He also emphasized the lack of validation of their feelings by the primary group, so lacking later the internalization of this capacity by themself. Recent developments in theorizing Borderline proposed to view them as suffering from some kind of affective disorders. A neuro-socio-emotional research concluded that their principal defect is in affect regulation. If we make a comparison to people who for some reason are defective in their heath regulation mechanism we may approximate the Borderline whose feelings swing so rapidly. Since the Borderline’s sensations and emotions are not validated by his or her surrounding (as will be discussed later) he or she finds it difficult to tag his or her own inner experience. Consequently, his or her inner world become confused. However, inside, so we infer, there exist an almost constant feeling of insult, one which is not reasoned (or only rationalized), very often unconscious (often denied), and whose developmental origins hide far away in a highly distant and hardly accessible past.
Borderline judge reality differently.
As far as we know the term ‘Borderline’ had been originally proposed with purpose to delineate their being in between neurotics, whose judgment is principally unimpaired, and psychotics, whose judgment is clearly disturbed. Borderline people characteristically make their own judgment, which may deviate to some degree and they either forcefully defend it against any interference, or abandon it absentmindedly. They are often misleading in judging other people’s intentions, motives, or even overt statements. This is probably what is meant to by the currently popular term of metallization, or mindfulness – the difficulty the Borderline experience in trying to view himself, others, or the world, as well as others view them. Sometimes they charge their views with projections from their inner world, eventually they execute what might be seen as arbitrary inferences, and than go further in developing them into intricate but unestablished theories. Because all of these features, they may be portrayed as fickle minded or incendiary.
Borderline behave differently.
Their potential abilities are often normal or even higher; therefore they may execute impressing acts of planning, striving, or performing. However their acts may be seen as undoable or unsustainable, and perceived as capricious or impulsive. Their life moves from a disaster to a disaster or from a crisis to its resolution, one which may be discovered as temporary or false, leading to the next crisis. Their rigorous performance, on one hand, their egocentricity, on the other, and their impulsivity, on the third, makes them susceptible to delinquency. And indeed, criminals get often the description of being Borderline. That finding is interpreted as a sign for weakness of their superego.
Borderline relate differently.
Some Borderlines may be displayed as schizoids; but most of them are highly involved with people. In this connection, Miller de Paiva understands the Schizoid Personality disorder as a subtype of the Borderline Spectrum, specifically the introverted one.
But in general, it seems that their life is an unending stage where the drama of their life is acted on with other people as secondary actors. Their relations seem, therefore, to be intensive but unstable. They tend to switch between extremes, or what had been referred to in psychoanalytic literature as the mechanism of split. Sometimes the same people may serve different and even reversed roles – the same girl may be adored at one time as perfect, and detested as a monster at other time. For that reason they find it difficult to have stable, endurable and gratifying relations with close people. Traditionally they had been described as suffering from maladapted object relations, which derived from distortions in internalization of representations of significant others in formative developmental phases. Approaches that emanate from psychoanalytic and attachment theories suggested that the Borderline dynamics are organized around fear of abandonment. That hypothesized fear cause many of the observable symptoms, e.g., anxiety, some of their traits, e.g., avoidance or dependency, and their interpersonal behaviors – e.g. terminating connections before they would be threatened of being abandoned. From the point of view of the Borderline his relatedness is invalidated: what he thinks, feels, senses, wishes, is not being reflected through his or her surrounding’s responses. This surrounding is perceived as disappointing, frustrating, and annoying – shortly, bad surrounding, and therefore one that deserves being acted out back. This upsetting surrounding is being reactivated again and again through growth, each time re-verifying what the Borderline has already known – that his or her inner world is not validated by surrounding, therefore he or she should keep on searching for another surrounding.
Borderlines are confused about their identity.
In order, probably, to build a solid identity they may elicit impressive statements about themselves and about the world, but consistently with their characteristic inconsistency they may alter those statements, reverse or abandon them at all. They may cohabit contradictory statements which for them are not necessarily mutually exclusive (see their thinking above), and thereby preserve a complex and apparently unattainable view of themselves, others, and existence in general. Some of their self-destructive behaviors may represent strives to check their limits. They may report feelings of emptiness or of worthlessness. These feelings, when not reported directly, can be reached to when the patient is being investigated what feelings come to his or her awareness when he or she does not feel or does allow his or her feelings to be expressed either verbally or behaviorally. This hypothesized emptiness or worthlessness dictates many of the Borderline behaviors and traits whose purpose is to manufacture an experience of identity or at least to avoid an experience of not having one.
In this sense, the Dialectic Behavioral Therapy developed by Masha Lineham, which claims for high therapeutic efficiency, includes the concepts of non judgmental validity, metallization, psycho education and development of coping skills. It also includes long term personal and group therapy, with the necessity of a positive relation between patient and therapist as a condition for the treatment to succeed.
All of the above makes sense, in terms of all the above mentioned.
Abuse and Borderline.
Last decade’s professional literature had proposed a closed connection between being a Borderline and a history of childhood abuse which is, mainly, but not exclusively, sexual abuse. Empirically this association is still debatable. It seems that etiology of Borderline is complex and may include abuse among other causes; some of them may interact together, probably amplifies or compensate each other. However, from the point of view of the Borderline he or she is traumatized. It is not important for him or her, as a patient, and probably for his or her therapist, as well, whether this trauma did occur exactly the way the Borderline recalls and express, whether it is overstated, or maybe even invented. The significance rests in the Borderline’s subjective experience. That experience is not only remembered – sometimes highly vividly, other times as a vague scene – but it is reconstructed repeatedly in the Borderline’s life, sometimes also in the transference. For the Borderline, therefore, the trauma is not reminiscence but a continuous ingredient of current living. It comprises part of their ongoing suffering and sense of hurt.
Borderline make different relations with their therapists.
Issues of transference and counter-transference were always at the heart of psychotherapy with the Borderline. Therapists typically did not like Borderline patients (although, in what may seen as a mechanism of reaction formation, they turned them to be a ‘challenge’), and inclined to blame their ‘Borderlinity’ in the failure of the treatment. They were perceived as ‘difficult’ or ‘impossible’ patients, and lot of professional thinking had been invested in findings bypass for the special obstacles they make in their treatments. From the point of view of the Borderline patient it seems, first of all, that the therapist does not like him, alas, the very experience that is so familiar for the patient since his or her childhood! When the therapist makes most efforts to stay with the patient, to show him or her understanding and empathy, the patient may perceive him as faking or artificial. When the therapist tries to alter some of the patient’s maladaptive behaviours, the patient perceive him as coercing. The Borderline patient regularly feels that the therapist should be tested and retested again and again in order to prove his authenticity, his ability to genuinely comprehend the patient ‘from within’, and his distinctiveness from the patient’s original authority figures. This subtle tango of a couple who need to dance together but who does not trust each other and who look at their common situation in so different manners composes the delicate art of psychotherapy with the Borderline.
Finally, when taking all these constituents of the Borderline, it firstly must be stressed that they are not a list of symptoms or traits. They are all manifestations of a single personality, though complex and dynamic in its nature. As we have noted in the introductory illustrations, the Borderline has many faces and revelations. They differ when comparing different persons whom we would entitle as Borderline, and they may be changing within a single person. What we observe when interacting with a Borderline is a person who, in his or her inner experience, is a sufferer. He or she suffers as being a victim of an abuse which becomes an enduring part of his or her life, including, often, the treatment itself. He or she is misunderstood by his or her surrounding, while simultaneously being told he or she misinterprets reality. His or her feelings are mostly negative and if positive are typically not durable. Often he or she is active, and sometimes even attains success; but very soon he or she experiences blow, defeats, or failures. The Borderline search actively for identity but characteristically is confused. And when he or she turns to seek love, friendship, or support, he typically fails to attain them the way he or she needs.
We do not have the space to discuss therapeutic approaches that derive from our view of the Borderline phenomenon. We will live it to another lecture. However we would like to summarize with a prudently optimistic belief that while treatment of Borderline is a difficult, lengthy, and often frustrating task, an empathic therapist who is devoted to understand his or her patient inner compound experience may reach satisfying accomplishments with his or her Borderline patient.