I must say that working with people with Borderline Personalities has taught me more about psychotherapy than any other kind of clinical work because people with Borderline Personality Disorder need you to be good at listening, to be good at containing, to be good at setting boundaries, to be good at coping with very strong feelings, and to be good at working with complex transference and counter-transference issues. They also need you to have a great deal of patience. So, they're challenging but in very positive ways.
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So what is a Borderline Personality Disorder?
Well, let's look at the DSM-IV criteria. To make a diagnosis of Borderline Personality Disorder, they require "a pervasive pattern of instability of interpersonal relationships, [of] self-image, and [of] affects and marked impulsivity [beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the (diagnostic criteria - outlined later in this article)]"
Marked impulsivity is, in itself, another form of instability. So, what the DSM-IV is emphasising is a personality which is characterised by instability in all sorts of ways. And, instability certainly is a central feature of Borderline Personality Disorder.
There are various ways of understanding the Borderline Personality Disorder. Very few people today would still go with the historical psychoanalytic perspective which is that the Borderline Personality is on the borderline between psychosis and neurosis. In other words, that this kind of personality demonstrates many neurotic features and, under stress, slips into psychosis. In fact, most of those with a Borderline Personality Disorder do not go psychotic under stress and this is why we sometimes refer to them as being 'stably unstable.' They just stay predictably unstable in their self-image, in their mood, in their view of others, and so on.
The various more modern understandings of Borderline Personality Disorder emphasise different aspects of the problem. Most point to profound disturbances in the early mother-child relationship such that it leaves the person very damaged in terms of their relationships. I think that this aspect is fundamental. So, what happens is that part of the person is stuck emotionally at the stage of being a baby so, in that part of themselves, they easily feel very empty because they did not get enough of the reliable attention, closeness, warmth, and unconditional acceptance that is part of the normal experience of a good early mothering.
So, what happens later on is that they are left with this tremendous neediness for this reliable closeness, warmth, and unconditional acknowledgement and acceptance and this becomes particularly obvious in their close relationships. If the need is there and the person's partner is around, then the person will try to get the need met by the partner. So, they will want to be acknowledged, or held or listened to or made love to or whatever it is that will fill the hole. If the need is not met, then tremendous rage can ensue and anyone who has been in a relationship with someone with this difficulty will be able to tell you about this rage. It is like the rage of Kali (you know the Indian goddess who is black and who wears a garland of human heads). And when this rage comes out, one has one's head taken off in one way or another. To the person with the problem, they will usually experience it as being absolutely legitimate. The kind of response might be "All I asked for was acknowledgement, I don't think that was too much to ask" (as the ashtray comes flying past your ear).
It is often the case that the request was not such an unreasonable one - it's not unreasonable to ask for acknowledgement from one's partner, for example. Rather, it is the reaction to the request not being met that is so out of proportion for an adult. If the person was six weeks old and his or her needs were not being met, he or she would feel extremely distressed and this is what happens to six week old babies - they cry like hell if they are not happy. People with a borderline disposition also feel tremendous distress if their deep-seated needs are not being met and because a very young part of themselves is being evoked, the feelings are still those of the archetypal realm. Consequently, if you are their partner and you are not meeting their needs, they may (and often do) feel betrayed by you and it is out of this sense of betrayal that the rage emerges.
Now the picture I have painted is a bit of a distortion in the sense that the infant part of the person with a Borderline Personality Disorder is not the only part of that person. There are child, adolescent and adult parts too. In many cases, the adult parts realise the unreasonableness of the degree of emotion and they also realises how needy the neediness is and so they try to mask it. It is only when the person is overwhelmed with neediness or rage or some other very strong infantile feeling that they can't help but let those aspects out. At those times they become adult sized infants from an emotional point of view and they can hate themselves for it afterwards when they have time to reflect on it.
In people with Borderline Personality Disorders, the infantile aspects may be present to greater or lesser extents. The greater the degree to which they are present, the greater is the borderline pathology. The greater the borderline pathology, the more these people's feelings tend to fall into the archetypal realm. If they are in love with you, that love can be enormous and wonderful but, if they are disappointed in you, the disappointment can be shattering. So, they live in a world of great opposites and, from a psychoanalytic point of view, one of their main defences is splitting. So, everything is either wonderful or terrible and there tends to be very little middle ground, few shades of grey. This is often apparent in their thinking too. They will tend to assess say a friend as being either wonderful or awful not as having some good points and some bad (as all of us do in reality). Cognitive therapists call this dichotomous thinking or black and white thinking.
The dichotomy applies in all realms and so it applies also to their sense of self. They tend either to be inflated: "The work I do is really special" or they tend to crash into a deflation: "I really am a useless piece of crap." In their view of other people, the same splitting applies. They tend to see important others as being really wonderful or special or incredible and, when they become disappointed the person swings to a very negative position in their view and becomes completely untrustworthy, a total shit, and so on. Consequently, in a relationship with someone with this pathology, you are on a roller-coaster ride. One minute you're useless and being criticised for all manner of wrong. Then you defend yourself. And, if through heated debate, your partner realises that fault lies also with him or her and then they crash into feelings of shame.
Remember, as a therapist, you're dealing with the same object relations. At the beginning of a therapy situation, someone with a Borderline Personality Disorder will only stick around if they have put you on a pedestal. An acceptable therapist is not an emotional possibility - you have to be special. Of course, the rule is that if you've been put on a pedestal, at some stage you have to fall off. In fact, negotiating that falling off is a very important part of the therapy because it allows the person to learn to deal with the reality of shades of grey.
At the start of the therapy, however (and here I'm really talking about the first one or two years) they will need you to be special in the way that a mother should be special for a young baby. They need you to be there for them, they need you to be loving, they need you to be reliable, and they need you to listen very carefully to their experiences and their needs. This careful listening is one of the most important aspects of all. If in doubt, just listen and reflect back their experience to them. That task, of course, is called mirroring by psychologists- and is one of the main tasks of mothers with infants. The infants get to know they exist and who they are by having themselves reflected back to themselves.
Remember, unconsciously, people with a Borderline Personality Disorder need the 'boundarylessness' of the early mother-child relationship and so by being convinced that you understand them profoundly, it becomes a situation for them where they think they are inside you. In fact, they do get inside your psyche. You will find yourself thinking about them a good deal and it is a common dictum amongst psychodynamic psychotherapists that, if you dream about a client, that client is likely to have a Borderline Personality Disorder.
Of course, the needs of the borderline client make limits of the therapy situation very difficult for both you and the client. They want to know that you really care (that they are not just another patient but someone special in your life) and so, it is often the case, that they will want to meet up outside of the therapy situation. It is also hard for them to accept that there are limits on the therapy time and restrictions in terms of contact with you outside of this time. None the less, these limits are very important both for you and your client.
Now, one of the most difficult feelings for those with this disorder is that of abandonment. It feels to them as if they have lost all life in themselves - that they have died inside and been cast into this dark nightmarish world of an abandonment depression. The alchemists called this world the nigredo and in dreams it emerges as death, dismemberment, darkness, and so on. This is a very difficult experience for anyone to tolerate so you can imagine how difficult it is for someone with a Borderline Personality Disorder where there is what analysts would call a very fragile ego.
Having a Borderline Personality Disorder in general is not easy. Everything feels unstable and is unstable. Part of the reason is that part of the personality is very young and very damaged. Another reason is that the personality has not yet fused properly. In normal personality development, somewhere between two and six we integrate a view of ourselves and the world as part of what Jungian analysts call the ego. And so we believe ourselves to be particular kinds of people - 'I'm a good little girl and I like to be helpful' or 'I'm a bit of a naughty girl and I like to have lots of fun' and so on. Our awareness of the aspects of ourselves that we don't like then slips into what Jung called the shadow. This is a healthy process.
In the case of those who are developing a Borderline Personality Disorder, this integration doesn't take place. So, what you get left with is a whole lot of complexes (sub-personalities or ego states) with the adult one or ones being quite fragile. So what happens is that the person keeps on slipping between the dominance of one complex and another. One minute, they may feel proud of their work and then they may get an indication that they have made a mistake and they may then flip into a state in which they are dominated by another complex in which they feel like the greatest failure that ever walked upon the earth.
This instability is usually reflected in all aspects of their being. For example, people with Borderline Personalities are often uncertain as to what it is that they want to do with their lives. Part of the problem is that different parts of themselves may want different things. One part may need to be creative, another may need security, another may be primarily interested in power and a fourth may have spiritual interest that clashes with all the rest. To compound it all, any of the parts can predominate at any time. So, for example, the part that is interested in spirituality may want to go on a retreat and get excited about it and book it and then, as it approaches, the part that is fearful of abandonment may dread the thought of going off on her own. These shifts around the personality can take place hundreds of times a day and so it is difficult living the life of someone with this disorder.
There is also a remarkable incidence of sexual abuse in the background of these people and many think that repeated traumas (including sexual abuse) are part of the cause of the disorder. I think that, in the case of many girls, it works like this. As an infant they did not have their needs met for a reliable, loving, unconditionally accepting mother. This left them with a life-long need to find this good mothering. In trying to find it as a child they may approach men who are very damaged in their own sexuality and who find the closeness and trust they can establish with them sexually exciting. These men then exploit the girl's need for love by satisfying their sexual needs with them. Part of the little girl is so desperate for this love that she goes along with it all but another part of them knows this is not OK and is traumatised by it all. People who have had this kind of experience as children tend to confuse sexuality and love and so as teenagers and adults, tend to try to get their needs for maternal love met through sexual relationships which often doesn't work. Of course, there are many more horrific scenarios than this where the child's desperate need for love leads them into situations where they are much more cruelly abused. If the abuse is very extreme, them Multiple Personality Disorder, rather than Borderline Personality Disorder will probably be the result.
Another historical factor for those with a Borderline Personality Disorder is that, because their ego was so fragile and their feelings so strong, many experiences which might not traumatise others might have devastated someone who is on the way to developing a Borderline Personality Disorder. Take as an example, a boy of four who had had poor early mothering (with many abandonment experiences) and look at the situation where he was taken to school for the first time and left there by his mother. Now, many children find this difficult but most cope (and the incident doesn't get left as a trauma). What would tend to happen for our little boy is that he would have a catastrophic abandonment reaction and the incident would generate such strong feelings that he would be overwhelmed and the incident would then remain as part of a series of memories of traumatic abandonments. In many ways such a child would build up a whole library of traumatic memories - of abandonments, of betrayals, and of various abuses. Many, or all of these experiences may be the kinds of experiences we all go through - like going to school, like losing friends, like moving home, like having someone con us and so on. To our budding borderline personality, however, their emotional reaction to these events overwhelms their fragile egos and leaves further traumatic memories.
As I said, it is not easy to have a Borderline Personality Disorder and they experience themselves often as people who struggle in life. Often this struggle comes up in their dreams. There will be a symbol of things coming together - like a dream of a marriage and then there will be dreams of things falling apart again - divorces, disintegration, and so on. And, this is how it goes - struggling to get it together and then it all falls to pieces again.
People with a Borderline Personality Disorder also tend to carry a tremendous lot of shame that emerged out of their experiencing of not being loved. Because the degree of shame is great and because their ego is fragile, they tend to avoid shame at all costs because to experience it has catastrophic results. So, for example, if something went wrong they would tend to protect themselves from the shame by tending to blame others and this can be a very annoying aspect of living with someone with a Borderline Mobile Iv Therapy near me Personality Disorder. Say you are married to someone with such a problem. You will, at times, get stuck in the position of either having to accept unjust blame or having to go through the battle to get the blame back where it belongs with all the consequences that ensue because, if your partner then accepts the blame then he or she will probably collapse into a part of themselves that has an extremely negative view of themselves ('Why am I such a fuckup?') and they will be subsumed by shame and their mood may drop considerably as a result and so they may be depressed for days. This process is hard for both people involved.
A related problem occurs in therapy with those with a Borderline Personality. Sooner or later in the therapy, you are going to 'screw up' in their eyes and this is going to produce strong negative feelings - disappointment, anger, and so on. The thing to do in this situation is to listen carefully and reflect without getting defensive in any way even if you think that whatever you did was reasonable. Later on, when the crisis in the relationship has passed, then the incident can be worked through so that it can be understood in a more reasonable light. So, as an example, you may forget an appointment. It happens sometimes. Your client may feel abandoned and enraged as a result. If you listen to their feelings and apologise, then it will usually turn out OK. On the other hand, if you become defensive and say that you're only human and that you think their reaction is totally out of proportion and so on, then they will remain stuck in the conviction that you have done some terrible wrong and, if there have been other aspects of their experience of you which they didn't like, an official complaint may be the next step or they may even sue you. The deep seated motivation behind this would be the desire to see you hurt as much as they are hurting - as they see it - as a result of your actions. I would guess that the majority of official complaints against therapists come from those with Borderline Personality Disorders. To prevent this, in the vast majority of situations, all you have to do is hear the person out and apologise.
I think that the core aspect of the treatment of people with this difficulty is to have them have an experience of unconditional love and acceptance and you need to aim for this for at least the first year or two of the therapy so that they can have a corrective emotional experience. As they come to feel accepted and cared for, so they themselves will begin to question their reactions and this will open up the possibilities for honest discussion of the objective situation and that is the time to begin to see their reactions more realistically. They can do it then because the relationship between you and them bolsters the strength of their egos. The experience of being accepted and loved has to come first.
Over time in the therapy, the continuing sense of being held, listened to, cared for and so on, allows for a gradual integration of the various aspects of the personality. This just happens as a natural part of the process. In other words, given that you have set adequate boundaries (which are vital) and have an attitude of care and spend a lot of energy on careful listening and reflecting then the process of healing in the personality will unfold and, in this sense, you will be taught by your client as to how to do the work.
Remember that in all of this, the unconditional positive regard is not the same thing as colluding with the regressed part of the personality. So, for example, the reflections would mostly be in the form 'You are feeling devastated