Borderline Personality Disorder

An extract from a recent teaching I gave on the subject

Why did I give this man a pound? (Masterson, 1976).

 If I gave them a pound because I felt sorry for them, they are Borderline. If I’m scared, they’ll be angry if I don’t, they are Narcissistic. If they needed one but didn’t ask for it, they are Schizoid. If they charmed it out of me, they may be a Psychopath!

Okay, this seems to smack of labels and diagnosis, doesn’t it, so firstly, the disclaimer: there is no ‘Borderline’, although this is the way I will refer to someone with its traits here for ease of reference. We are each unique and complex human beings, and all disorders are ‘melodies’ playing a similar tune (Greenberg, 1999). As complex humans, none will play exactly the same melody. Being Borderline was a healthy original adaptation to an unhealthy situation, usually trauma and abuse.

To explain some of the terms. Narcissists can come into therapy because they have lost a significant ‘supply’ or validating other; a narcissistic wound such as ageing or loss of status. They tend to be occupied with self-esteem or the possibility of being shamed. A person with a Schizoid personality (this has some crossover with an Avoidant Attachment style, which you may be more familiar with) or traits will have issues around trust or safety.

Borderlines are more preoccupied with love and nurturing and will present with problems with intimacy and relationships -- primarily whether others are going to abandon or engulf them with their needs.

Saying someone is Borderline or a Person With Borderline Personality Disorder (pwBpd) or Adaptation – the terminology has segued from Character Disorders to Personality Disorders to Disorders of the Self in the last 30 years -- is a way of categorising these clients so we, as therapists, can look up and find the resources in how to help treat them better. It can hurt to be categorised, and it is not meant to do this.  

Who and When?

The term was first coined in the 1930s. It was not clearly defined until the 1970s and then in DSM-III, which is the diagnostic manual therapists refer to, in 1980. Many Borderlines or pwBpd Biare co-morbid or co-exist with Narcissism -- they can exhibit up to 25 per cent or more of narcissistic traits.

In addition, a person with Borderline disorder co-exists with PTSD (90 per cent also fulfil the criteria for Bpd), substance abuse (50 per cent of substance abusers fit, as do those with eating disorders), alcoholism, Dissociative Disorder, Body Dysmorphic Disorder, Multi Personality Disorder, ADHD, Bipolar, OCD, phobias and more.

They consume a greater percentage of mental health services than those with other diagnoses (25 per cent of all patients seeking psychiatric care are diagnosed with the disorder); 70 per cent commit suicide. Yes, it is this high.  

Identifying and understanding a person with Borderline Personality Disorder

They have usually suffered terrible early emotional abandonment or abuse, which is not always intentional – they may have had a mother who was bereaved or hospitalised and unavailable for parenting. The pwBpd’s underlying fear is that they are unlovable; that they were treated badly or uncared for because there is something wrong with them. 

Underdeveloped sense of self

A person with Borderline Personality Disorder lacks the supplies to become separate and autonomous, and they are fearful of abandonment. They have been left with many unfulfilled emotional needs. They’ve had to suppress the development of their true self and may have unintegrated, contradictory views of self and others.

Kernberg and Masterson (1976) called these part-selves or part-object representations ie they react to only a part of you at a time: you will be seen as the good, nurturing mother (all-good part-object representation), or the abandoning or engulfing mother (all-bad part-object representation). 

Engulfment and Abandonment Fears

Passionate, charismatic, fun, creative and more – they are often fantastic and compelling company. They can feel childlike or like big toddlers – it is the ‘I hate you, don’t leave me!’ stage we see in teenagers, too; impulsive and emotional.

Often drawn to caretakers, they imagine they will love and care for them unconditionally, or less so, to those who replay their original drama, such as Narcissists or abusers. They will often exhibit clinging or distancing behaviour and focus on intense one-to-one relationships (Greenberg, 1989b).  

Splitting

Their lack of whole object relations and object constancy (Mahler, Pine and Bergman, 1975) limits their ability to see themselves and others in a realistic way and leads to splitting – a psychological defence that involves keeping contradictory views of the self or other separate.

This is so they don’t become overwhelmed with negative affect destroying the positive, and vice versa. Others are therefore seen as All Good or All Bad or as a Good or Bad Parent, with nothing grey in-between. They ‘split’ to preserve their good feelings about their mother: if she is abandoning, then she is all-bad, so therefore I am all-bad.  

Rage / Pleasing

They can experience an immense inner rage. They will unleash this on those they feel safe with. They can be overly pleasing or under-assertive with everyone else. If they do rage, they cannot feel emotionally connected to that person or maintain a positive emotional tie to them. This then leads to turning or retroflecting their rage onto themselves and hating themselves or, in lower-functioning Borderlines, hurting themselves.  

Ego syntonic

They believe that a particular way of behaving, no matter how dysfunctional, is inextricably part of their self: ‘I go out, drink until I’m sick, abruptly finish with the woman I love, drink wine for breakfast, everyone does.’

There is no ‘Before and After’. Some clients or people will have upsetting events they felt differently about themselves before and after, this type of person won’t – they have felt the same way since childhood. 

Inability to self-regulate

Their caretakers weren’t available to soothe them, and / or the Borderline is usually emotionally rewarded for not separating from his or her parents, or has been punished by the withdrawal of love for trying to do so. Parent: ‘I’ll take care of your emotional needs, your self-esteem and your self-image and for that you’ll give me acknowledgement, affirmation and approval’ (Klein R, 1995).

Some believe that their parent will die or go crazy if they separate from them. When they make a move towards self-actualisation, they act out in order not to feel unpleasant emotions, which may include: drinking, drugs, smoking, shopping, fighting, promiscuous sex and binge eating. 

How I help someone with borderline issues

One of the ways to start helping a person with Borderline issues is to identify, manage and begin to track themselves and notice these contradictions between their thoughts and feelings or behaviour.

Client: ‘My girlfriend was unavailable last weekend, so I went and got off with someone else. That’s their fault – she abandoned me. She asked me if I’d been unfaithful, and I told her and gave her what for, said she was ugly and useless. I didn’t mean it, though.’

‘Therapist: ‘Were you unfaithful?’

Client: ‘Yes, but it didn’t mean anything.’

Therapist: ‘So you told her you got off with someone else, how does that help you remain in a relationship with her?’

Another way is to help them connect the connection between their self-destructive acting out and what they are trying to avoid feeling. ‘When you do something good for yourself, you start to feel bad and then you go back to drinking as a way of avoiding the bad feelings?’

Sometimes, not always, they are hellbent on being a reproach to their failing caregivers as payback; retroflected rage. ‘Every injury to themselves is a symbolic injury to their hated parent’ (Masterson, 1981). They need help to recognise this to help give up their urge for revenge.

It can help to interrupt an enactment. ‘What were you thinking and feeling before you did this?’

Sometimes I help someone with Borderline issues to break down and identify what they are feeling in stages. ‘So, you picked a fight with your coworker, what do you think lead to that, and what does this mean for you both in the future?’

We have primary and then secondary emotional or feeling states, such ‘I feel shame, and then I get angry.’ They may need help with understanding these processes instead of attacking or abandoning themselves for them.

It can help to make the connection between what they say to themselves or attack themselves and how they feel. Often v concrete thinkers, explore for eg, ‘I am ugly and fat and never wear the right thing’ is linked to heightened anxiety or a depression.  

Separation and individuation

Punishment for separating from parents may have been extreme, so they need help to separate and individuate. Activating their real self may bring up more than fear and anxiety – this may appear in dreams about monsters, or images of a devouring mother. Some were brutally hit or abused, and these memories will appear in their dreams, nightmares and in sessions. With time, you can start confronting their attachment to an unhealthy caregiver they have had to see as good. Or if they are in a repeated abusive relationship: ‘Why did you say your partner was great, when he hit you last week?’

Encourage them to have and express their own desires, thoughts, needs, wishes and to follow their own path, to become inner directed. Help them not just find their no, but to discover their yes: ‘I do like doing drawing now I think about it.’ 

Safety

Talk to them about what was happening in their childhoods to really affirm what happened wasn’t their fault or down to them. 

Suicide

Encourage them to notice things they like about themselves or do well or to share good stuff with you in their lives. This is the Rapprochement stage of childhood (15 to 24 months) they missed ie basking in mum’s attention and approval, before we can go off and progress to independent humans.  

Future Thinking

Often impulsive, those with borderline adaptations often also need help thinking about the future consequence of their actions. ‘If you shout at work, how do you think this will affect your future there?’  

Bad

Often, if you are in a relationship with them or treating them, you will feel very inadequate, worthless, or out of control yourself. This is called Projective Identification (Ogden, 1982).

It is a form of communication but can feel very uncomfortable – your client wanting you to feel something they have split off in themselves and need to insert into you. Take time to reflect and try not to act out how you are feeling. Think about your response and what you are feeling because it is important information about their internal world. 

Sad

They are very depressed and feeling hopeless, telling you why you can’t help and arguing that suicide is the best way forward, which object relations theorists describe as projecting the depressed child part-self representation onto you. They need help to explore their despair and hopelessness – the strength of it. Borderlines are incredible survivors. Talk about this strength, currently being poured into how they can never improve their lives. They may need to play the other elements of their dreams in their minds – ie the other stronger parts. 

Confused

Who are they? They will often have many different personas or masks due to lack of self-identity. Sometimes they can change before your eyes in a session or dress very differently week to week. Try to help them identify these different identities inside them, so they can begin to integrate them.  

Idealisation and triangulation

It can be common for Borderline clients to see other therapists at the same time, or cycle through therapists and different types of treatment, searching for that person or object that will fulfil the painful void inside them. If you feel you are being placed on a pedestal, which can feel amazing or even subtle, you will be pushed off it at any time, without warning. Being aware of this will help you find a way to address it, and then to refer back to it when it happens. 

Bibliotherapy

Adler, G (1985). Borderline psychopathology and its treatment. New York: Jason Aronson

Greenberg, E (1989b). Healing the Borderline, The Gestalt Journal, 12(2)

Greenberg, E (1999). Love, admiration or safety: A system of Gestalt diagnosis of Borderline, Narcissistic and Schizoid adaptations that focuses on what is figure for the client. Studies in Gestalt Therapy, 8, 52-64

Kernberg O (1976). Object relations: Theory and clinical psychoanalysis. New York

Klein R (1995). The self in exile: A developmental, self and Object Relations approach to the schizoid disorder of the self. In JF Masterson and R Klein, Disorders of the self: New therapeutic horizons – The Masterson approach (Chapter 1-7, pp 3-142). New York: Bruner/Mazelel