The Borderline Disorder of the Self
by James F. Masterson, M.D.
Borderline Personality Disorder (BPD) is due to a developmental arrest of the self and the ego in the pre-oedipal stage approximately between the ages of two to three. I have called the key psychodynamic theme that results, The Disorders of the Self Triad: Self-activation leads to separation anxiety and abandonment depression which leads to self destructive defenses. This dynamic is precipitated by real later life situations that require self assertion and autonomous functioning or by events that involve separation.
These events interrupt the defenses, the patient begins to experience the abandonment depression and then defends by giving up self assertion and activating self destructive defenses whose symptoms can vary from obesity to anorexia, from clinging to others to distancing from others, from sexual promiscuity to the avoidance of sex, from alcoholism to drug addiction.
There are three clinical types based on the patient’s capacity to function: lower level, mid level, and high level. There are also three types of therapy: shorter term, intensive analytic psychotherapy, and counseling. (The word shorter is used to distinguish this therapy from "short-term" therapy, which usually lasts a matter of weeks.)
Counseling is appropriate for the lower level patient who cannot tolerate the therapist’s being neutral and therefore is not a candidate for psychotherapy. When counseling, the therapist can advise, direct, support, give medications, etc.
Confrontive and analytic therapy are appropriate for mid and high level borderline patients. The essence of the psychotherapy with mid to high level patients is the therapist’s identification of the clinical vicissitudes of the Disorder of the Self triad, and then bringing them to the patient’s attention through the use of the therapeutic technique of confrontation.
There are two definitions of confrontation: the first is the eyeball to eyeball type we used to conduct with the Russians during the cold war which required a lot of aggression. Obviously, this is not the type I mean. I am referring to the second definition, bringing to the center of the patient’s attention firmly and empathetically the denied maladaptive self-destructive aspect of the defenses.
Shorter term confrontive therapy, which is the most common form of therapy, consists of once or twice a week sessions that usually last anywhere from 6 to 18 months. The goal of shorter term therapy is not to work through the abandonment depression but to repair the defects in ego functioning and improve self-activation. The ego defects and the primitive defenses all interfere with reality perception. In this case, the ego of the borderline is perforated with holes. The therapist’s task is to plus the holes and thus provide the patient with a more complete and solid perception of reality. The therapist’s confrontive remarks about the self destructive way the patient perceives and handles real life situations provide an alternative view of reality that the patient eventually internalizes. Shorter term therapy often results in dramatic improvement in the way patients function in daily life and conduct their relationships, and the patient usually wants to terminate therapy when the immediate problems that brought him into therapy clear up.
The patient’s self image and self assertion improve, along with his or her perception of reality, but the impaired real self is not fully overcome and the abandonment depression is still present. However, the patient can now meet it with a new sense of vigor, optimism, and control. Instead of resorting to his or her old self destructive defenses, the patient now calls on the capacity for self assertion to contain the depression. Each patient finds his or her own unique style. For example, the patient who was anorexic or bulimic turns to jogging to deal with periods of stress, or a patient who had been alcoholic finds that playing a musical instrument helps to contain feelings during stressful times. Should a severe separation stress occur, a patient may have to return for additional treatment which, however, takes much less time to restore functioning.
Intensive analytic psychotherapy, a longer term treatment with sessions at least three times a week for three to five years or longer, has as its primary goal to remove the defenses against the abandonment depression and to reactivate the real self in order to bring on the abandonment depression in full force for the purpose of working it through in the close therapeutic relationship. The preliminary objective is to create the therapeutic alliance and transference and remove the pathologic defenses that prevent the depression. This is followed by interpretation of the past through memories, dreams, and fantasies. As the patient goes deeper and deeper, the abandonment depression occurs, and brings with it the genetic historical memories with affects.
At the beginning of therapy, the patient will resist allying his emotions with the therapist because it means giving up his usual method of avoiding painful feelings of separation anxiety and abandonment depression. At this point he is inclined to rely upon the familiar strategy, which he thinks works, rather than one still unknown and untested. But the more he invests in the therapist, the more he will give up these old defenses and turn to therapy to work through these feelings of abandonment.
First, however, he must "test" the therapist with his habitual self destructive strategies to answer two vital questions: Is the therapist competent? Can he trust her? Thus the first phase of therapy is the testing phase.
It is necessary for the therapist to patiently and consistently confront the patient with the genuine destructiveness of his behavior and of his distorted perception that a real therapeutic alliance or involvement in therapy is equivalent to the painful state of being engulfed or abandoned, which up until now has been the patient’s experience when activating the real self. At the same time, the therapist must demonstrate, by actual dealings with the patient, the necessity and value of trusting the therapeutic relationship.
A host of therapeutic values and actions contribute to achieving this objective: The therapist’s thoughtful concern for the patient’s welfare, the accuracy of the confrontations, the therapist’s reliability, and the refusal to exploit the patient or to permit the patient to manipulate. Only when the therapeutic alliance is established will the patient be willing to give up his lifelong dependence on the false self’s ploys for emotional security. This is a momentous turning point in the therapy for the person with Borderline Personality Disorder, as it means the transference acting out is being converted into a therapeutic alliance and transference, and that the patient is passing into the second or "working through" phase of therapy, where it now becomes possible to work through, attenuate, and overcome the depression.
In both shorter term and intensive analytic therapy, the therapist establishes a therapeutic alliance and facilitates the emergence of the patient’s real self through the use of confrontation as illustrated in the following cases:
Penny came for therapy twice a week. In the early sessions, she dramatically elaborated on her panic, her symptoms, her fear of physical expression, and her inability to manage. I confronted her helplessness by saying, "Why do you feel so helpless?" This led her immediately to describe her feelings:
"I don’t think I can manage myself. My mother was my worst enemy. When I was lonesome in college and called home, she encouraged it. I was totally taken care of, overindulged. It makes it hard for me to manage myself. I never did anything completely for myself before I moved to the city. In high school I had no responsibility. This is the first job that I have had with any responsibility. I feel that now I have to show initiative and set my goals. My life has been so structured. I have never had to do it before. I never had to spend time alone. I think other people should plan for me."
After a few confrontive sessions, the acute symptomatology subsided: Penny became depressed and began to intellectualize about the difficulties between herself and her mother. For example, she would say, "I dislike the idea of being responsible and taking care of myself. I don’t think I can; it seems that I’ll break down. I can’t take the pressure. I’m an empty personality. I’d rather be an extension of someone else. I’ve always structured my life for someone else to do it for me. When I turn to my mother and she doesn’t do it, I get furious with her, then I get depressed."
At the time, Penny had a boyfriend to whom she clung for relief of anxiety and for support. "I’ve never been rewarded for being an individual. I am afraid of being depressed and alone. I never developed anything in myself on my own. I did well in college and had lots of interests, but they were all for everybody’s approval." I confronted this defense by asking her why she had so much difficulty managing on her own.
The next level of confrontation dealt with the lack of continuity between sessions caused by Penny’s avoiding thinking about them because they made her "feel bad." "I have to be on my own and independent, and then I get anxious and forget about it."
I confronted her about her appeals to her mother for reassurance, which encouraged her to stop calling her mother to manage feelings herself. Throughout these first three or four months of treatment, Penny described her symptoms and interpreted he situation intellectually but showed little genuine affect. She would become overwhelmed with guilt, depression, and anger when she spoke about her parents and would block out her thoughts in order to deal with the guilt. When I confronted her blocking she articulated the borderline dilemma by saying, "I don’t want to admit I’m competent or in control. I have to pretend I’m helpless. If I’m competent, I will be cutting mother off, or she will cut me off. I wouldn’t need her anymore. She’d have no duty to perform."
As Penny continued to delve deeper into the conflict with her mother, it was necessary to confront her denial of feelings in general, as well as her denial of anger and guilt about the mother. At one point, when she turned down her mother’s request to spend some time with her, she said, "Mother uses me as a tool for herself. She put in my head the one thing I can’t do is separate and that I would be punished for it. She was the original power. I was empty."
Following this, Penny had a nightmare that she was losing her mind and going crazy: she would not be able to speak or move her feet to walk. Throughout this time she was clinging to her boyfriend, and it became necessary to challenge and confront the clinging. I questioned why she needed him to provide her internal security, pointing out some of the destructive aspects of this behavior to the relationship. Throughout the first year of treatment, she attempted to deal with the sessions by intellectualization, denial, avoidance of individuation, blocking, and suppressing of affect, acting out in the transference, and clinging with the boyfriend. The confrontation of all these defenses gradually brought about a therapeutic alliance and transference and the real self began to emerge.
Fred, a nineteen year old college student, dropped out of school because of severe abandonment depression. "Life has no meaning for me. I can’t study or even think," he announced on beginning shorter term therapy.
The third of three children, Fred recalled his mother and father never being home or doing anything together. He obeyed his mother, who was domineering, never wrong, never able to admit faults or accept criticism. Father was a lawyer who worked all the time and was rarely home. Although "kind," he tended to avoid trouble or conflict with the mother, and his support for Fred (when Fred would submit to the mother’s demands) was never expressed with any genuine feeling.
In therapy, Fred projected the rewarding parental image (based not on the reality of how the father acted but on the father’s empty verbalizations) onto his father and the disapproving, withdrawing image onto me. Fred acted out by massive passivity in the sessions, expecting that I would take over for him and suggest topics, direct him, and give advice. He was often stonily silent, reenacting the passive role he played at home, where he would not confront the mother in order to receive the father’s love and support. He felt he had earned that support by his behavior. When I didn’t take over and direct him with his passivity, he would grow angry and accuse me of "not helping." He acted out his anger by missing or being late for sessions, by blocking, silence, and accusing me of not being interested in him, of being rigid, having a monotonous voice, or being bored. Our financial arrangement led to his criticizing doctors in general for being greedy and interested only in money. If my attention lagged or I accepted a phone call or was late, he would burst out in rage.
As the intensity of this projection mounted, Fred would attempt to get revenge on his father for his failure by acting out against me and the therapy. I emphasized for him the reality of the arrangements necessary to provide a framework for therapy. I couldn’t always be available, regular hours had to be kept, I had to charge a fee to make a living but this fact did not preclude my genuine interest in his problems. Whenever I pointed out the reality of these considerations, I met deep silence. Fred was intensively acting out in the transference with me his profound disappointment and rage at the father for failing to fulfill his side of the unconscious contract beneath which lay the abandonment by the mother. There was little room for a therapeutic alliance.
Slowly, gradually over the course of the first ten months of therapy two times a week, my refusal either to reinforce his wishes to be taken care of or to reject him because of his projected anger, and my continual, firm reinforcement of the limits of reality began to establish a beachhead of therapeutic alliance. He stopped criticizing and attacking me, began to see me as a therapist, not his projection, and to start exploring and investigating the sources in his past of the very angry feelings he had previously projected onto me. His avoidance and passivity abated, and he became self assertive enough to return to school.
These two cases illustrate just two of the endless variety of defenses that the therapist must deal with when treating borderline patients. Appropriate management of these defenses leads to successful treatment.