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Persons with BPD interact in stereotypical, repetitive, and maladaptive patterns with other people, including their therapists. These interactions are accompanied by intense countertransferential reactions and often result in traumatic reenactments or chronic dysfunction. Unpleasant interactions and marginal outcomes have led many observers to conclude that BPD is untreatable and is best managed by brief, intermittent interventions of acute episodes. The present paper attempts to challenge this perception and suggests that recovery is possible, albeit difficult, and involves successful identification and negotiation of the four sequential stages.
Two Core Conflicts Of Borderline Personality Disorder
Stage I. "Can I Be Safe Here?" Establishing the Treatment Alliance: The conflict of divergent wishes plays out strongly between the patient and therapist in the first stage of recovery. The central thematic question, "can I be safe here?" has three components: Will the therapist provide the kind of nurturance and support that I so desperately want and need, or will he/she be cold, humiliating, or rejecting? Will the therapist support my independent decision-making, or will he/she take away my autonomy and sense of self through infantilizing and smothering? Will the therapist be able to contain my neediness and rage, and maintain appropriate boundaries, or will I end up destroying either myself or him/her?
The patient-therapist relationship during Stage 1 is analogous to Searles' first two phases in the treatment of schizophrenia. Searles described patients moving from "out of contact" to an "ambivalent symbiosis" characterized by testing of the therapist. Each component question regarding safety is usually unconscious, but gets acted out in the patient-therapist relationship.
Winnicott was very interested in the transition that infants make from a state of merger with mother to separation and autonomy. He felt that inanimate objects, such as teddy bears or blankets, could serve as symbolic representations of mother during this transition period and called them transitional objects. The transitional object has qualities of being comforting and soothing like mother on the one hand, but separate or "not me" on the other hand. This provides a useful metaphor for the ideal stance of therapist as transitional object, partially gratifying dependency wishes by a warm and soothing manner, while also supporting independent decision-making. This stance can be difficult to maintain, however, and the testing of safety concerns often feels intrusive, aggressive, or controlling. An essential quality of the transitional object is its ability to survive the patient's neediness and rage without collusion, retaliation or abandonment. A mutual sense of safety is created by setting limits on behaviors that can lead to intensely negative countertransference responses and by the therapist acknowledging those responses within himself/herself when they occur. Establishing clear roles and parameters also helps prevent boundary violations derived from complicit unconscious gratifications.
The development of a fairly stable idealizing maternal transference (therapist as soothing and safe presence) marks the end of Stage I. In Searles' terminology, the patient-therapist relationship has moved to "full symbiosis" and the therapist has the feeling of a "Good Mother". The patient is engaged in the treatment process and is experiencing moderately decreased symptoms in all domains. There is an increased awareness of feelings of guilt and anger, and some ability to connect feelings with actions. The duration of Stage I is highly variable, but can last anywhere from a few months to a year.
Stage II. "Do I Have a Right To Be Angry?" Helpless Victim Versus Guilty Perpetrator : This question represents a universal response to severe trauma and underlies the second core conflict of borderline personality disorder. Alternative ways that this question can be posed include, "was I unloved, beaten, neglected, or abandoned because my parents were hateful, or am I so evil as to be unlovable or even provoked attacks because of my bad behavior? Am I to blame or are they? Are my wants, needs, and opinions legitimate, or am I just a crazy person?" These questions are derived from an essentially different kind of conflict from that of diverging wishes, and instead are best described by metaphors of dissociative splitting of self and others into good and bad objects.
In his work with traumatized and delinquent children, Fairbairn noted that they were unable to cognitively process traumatic experiences and needed to maintain an idealized image or fantasy of their parents as safe and loving, i.e. as a "good object." Traumatized children are prone to sacrifice their self-esteem in an attempt to maintain an unconscious fantasy of the idealized parent, i.e. the child becomes the "bad object" so as to maintain the fantasy of the parents as the "good object". Among adults undergoing trauma, such as kidnap victims, this process of taking on excessive responsibility for the traumatic actions of one's perpetrator has been labeled Stockholm Syndrome. In order to regain self-esteem, the negative self-image can become projected or repressed, but is nevertheless manifested by chronic dysphoria, suicidality, and self-destructiveness. Self-image and patterns of interactions become split between innocent victim versus guilty perpetrator. In the victim role the patient can appear helpless, passive and dependent, or enraged and self-righteous. In the perpetrator role, the patient is depressed, guilt-ridden, suicidal, or self-destructive.
Stage II tends to be a prolonged stage of treatment as patients repeatedly engage and disengage in traumatic relationships in an attempt to answer the question of whether they are victim or perpetrator. Self-destructive behaviors, dissociation, and suicide wishes become more clearly linked to traumatic experiences. It is easy for therapists to feel discouraged as their patients reenter traumatic relationships.
Freud was the first to observe this pattern of traumatic reenactment and labeled it the repetition compulsion. Freud also pointed out that this tendency towards traumatic reenactment plays out in the patient-therapist relationship. It is common for therapists during the first two stages to experience countertransference feelings of helplessness, guilt, hopelessness, and frustration, and to have wishes to rescue, direct, or control the patient. The most common trap for therapists is to infantilize patients by assuming they are helpless and totally incompetent and by giving excessive advice or reassurance. The therapist thereby creates a traumatic reenactment of loss of autonomy. Patients react to this approach with either an infantile regression or a passive-aggressive rebellion, e.g. sabotaging efforts to gain employment.
Stage III "Am I Worthwhile?" Grieving the Loss of a Fantasy and Worries about Self Worth: New themes begin to emerge in this stage reflecting the patient's early successes at separating literally and intrapsychically from traumatic relationships. Sustaining fantasies begin to be challenged and worry about competency emerges as the patient becomes more autonomous.
Answering the question of whether I have a right to be angry poses another problem. For if the abuse or neglect I suffered as a child is not entirely my fault, it means that my parents weren't so great. I now have to give up my idealized fantasy of them as the perfect parents who never had a chance to show how much they really cared because I was so bad. Giving up this fantasy feels like a loss and there is a grieving process involved. At the same time, the fears of separation and individuation are still present. So the patient is in the process of separating both literally and intrapsychically on the one hand, and worrying about competency and ability to form new relationships on the other.
As the patient begins to realize his/her losses, doubt and uncertainty about the separation and individuation process begins to grow. Early in this stage patients can develop periods of deep depression and hopelessness as they grieve losses or become overwhelmed by new responsibilities. There are repeated attempts to reengage in the hope that "I am just imagining the problems in the relationship and I can turn things around by behaving differently." As the patient develops increased strength and autonomy, family members often try to undermine this success, either directly or indirectly.
As patients worry about their own competency or attractiveness, they may compensate by changing their idealized view of the therapist from a warm and nurturing maternal figure to a strong and moral, more paternal figure (23). This shift can be seen as a way to overcome fears of incompetence or unattractiveness by identification with an idealized image of the therapist. It allows the patient to internalize positive attributes of the therapist and thereby create an ego ideal upon which to base future goals, aspirations, and moral dilemmas.
As patients start to discover their unique attributes and internalize the idealized attributes of the therapist and others (forming an ego ideal), the nascent self becomes stronger and more integrated, with a sense of continuity and identity. A true sense of morality begins to form and the patient becomes conflicted about some of his/her impulsive or antisocial behaviors and starts to change them. The formation of a cohesive self and ego ideal marks the end of Stage III.
Stage IV. "Am I Ready to Leave?" Overcoming Barriers Towards Self-Acceptance end Long-Term Relationships : Successful negotiation of Stage IV is characterized by increasing realism in relationships, lifestyle, and expectations as the patient works towards self-acceptance and a new relatedness. However, Stage IV has its own serious challenges. Although the formation of the ego ideal contributes to a cohesive sense of self and discernment of right from wrong, it also creates a yardstick to measure imperfections. Self-expectations go from total incompetence in Stage III to impossibly high in Stage IV. This discrepancy between self-perception and a perfectionist ideal creates a sense of hopelessness. There may be frantic efforts to move towards the ego ideal. Because of high self-expectations, signs of progress and accomplishments do not provide the same feelings of elation and satisfaction that they did in Stage III. There is a sense of alienation commingled with resentment as patients perceive themselves as being different from all the "perfect" people around them.
At the same time that the patient is working towards self-acceptance, the nature of the therapist-patient relationship shifts to what Searles termed "resolution of symbiosis." This involves developing a more realistic perception of the therapist as a separate person with his/her own needs, limitations, and points of view. Fairbairn described the transition from identification with the object to differentiation from the object as a necessary stage of child development. Transitioning of the patient-therapist relationship from a state of relative symbiosis to self-other differentiation can be a long and painful process. It involves letting go of a sustaining fantasy that "once I have overcome my shortcomings I can have a more complete relationship (i.e. merger) with my (idealized) therapist". The patient may experience rage at perceived rejection, regression to more destructive behaviors, and a sense of loss as the limitations of the therapist-patient relationship are more fully realized. A goal of therapy during this stage is to help the patient mourn the limitations of self and others so that he/she can move towards realistic self-esteem and balanced relationships, acknowledging and accepting both strengths and limitations. An inherent aspect of working towards this goal includes discussion of termination. The patient may bring it up directly, or indirectly, e.g. difficulty finding time to schedule therapy sessions with the demands of a new job. The degree of anxiety experienced by patients regarding termination cannot be overstated.
Reflection Exercise #3