Thematic Stages of Recovery in the Treatment of Bo

[Mel]

Thematic Stages of Recovery in the Treatment of Borderline Personality
Disorder



Borderline personality disorder is characterized by stereotypical repetitive, and maladaptive interpersonal interactions. Considerable controversy exists regarding preferred treatment and prognosis.
Patient-therapist interactions often result in traumatic reenactments and therapist burnout. Employing a case illustration and object relations theory, the author postulates that borderline patients have specific thematic questions that they are trying to resolve at sequential stages of their recovery. Each of the four thematic stages entails characteristic patient-therapist interactions, underlying conflicts, associated behaviors, and unique challenges and pitfalls that must be overcome in order to avoid traumatic reenactment and move forward in recovery.


As long as (the patient) is under
treatment he never escapes from this
compulsion to repeat; at last one
understands that it is his way of
remembering. . . .
Sigmund Freud, ". . . . Recollection,
Repetition, and Working
Through," 1914

INTRODUCTION


This paper presents a model based on object relations theory for conceptualizing stages of recovery for borderline personality disorder (BPD). Each of the four stages has a central thematic question that must be resolved before the patient progresses to the next stage. Two core conflicts underlie the four thematic questions and are manifested by characteristic behaviors and patient-therapist interactions at each stage of recovery. However, the paper does not focus on specific psychodynamic techniques, except as they highlight the description of a given stage.

This paper employs the more specific DSM-IV definition of BPD ( 1), rather than the traditional psychoanalytic concept of "borderline personality organization" ( 2, 3). Gunderson, who was instrumental in developing the DSM criteria ( 4), delineated borderline personality disorder as characterized by unstable interpersonal relationships, identity disturbance, suicide attempts, negative affects, impulsivity, and brief psychotic episodes.

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 ( 5). 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.


THE CASE OF JANUS


The case I am choosing to illustrate the stages is a divorced woman in her thirties. I chose the name Janus as a pseudonym. Janus was a Roman God of gates and beginnings, and had two faces. This seemed to describe the split self-image of borderline patients and their characteristic of always being on the threshold between recovery and total disaster.

Janus had an extensive past psychiatric history involving multiple episodes of suicide attempts, cutting behaviors, and high utilization of the medical and psychiatric healthcare system. This included six hospitalizations starting from age 23 triggered by suicide ideation/attempts, depression, psychosis, and/or dissociation.

Like many patients with BPD, Janus met criteria for several Axis I disorders at various times in her life. Her eating disorder involved a combination of weight loss, distorted body image, loss of menstruation, binge eating, purging, and diet pill abuse. She had three distinct psychotic episodes, mainly consisting of seeing and hearing demons in her home. Symptoms of obsessive compulsive disorder included obsessions of her house burning down and compulsive checking. Dissociative identity disorder was prominent over several years and involved five distinct personalities with specific ages and genders. Sitting with Janus was like sitting with a kaleidoscope. Lability of mood, thought, and behavior was most striking.

Not surprisingly, Janus had been tried on all the major classes of psychotropic medications. She did not like being on medications because it made her feel that she was crazy or mentally ill, something her family and husband had told her throughout her life.

The degree and extent of trauma in this person's history was quite remarkable and unusual. Janus reported sexual and physical abuse by her father and stepfather. There was also an insecure attachment to her mother, which led to separation anxiety as a child. A gang rape by a group of older teens occurred at age 12 near a playground. This appeared to be a turning point for Janus. Heavy drug and alcohol use started at age 13 and involvement with prostitution by age 16. She was told by her parents that she was "stupid" and "wicked." Janus married at age 18 when she became pregnant. The prostitution continued even into the early years of her marriage.

The pattern of trauma and dysfunction continued into Janus' adult life.
She stayed married to a husband who was physically, verbally, and sexually abusive. Occupational functioning included intermittent brief employment as waitress or factory worker. She was considered wild and fun to be with, and would be passed around to her husband's friends.
After entering a detox center in 1992, her substance use was more intermittent, but still involved heavy use of alcohol and cocaine.

With the help of social workers, Orders of Protection were issued and she made multiple attempts to leave her highly abusive marriage. But, she would always eventually remind herself that she provoked a lot of her husband's attacks and how lucky she was to have someone willing to stay married to her.

[Mel]

EARLY TREATMENT WITH JANUS


Janus' first experience with psychotherapy was with a "Christian"
counselor on a twice per week basis over a five-year period. Janus'
condition did not progress with treatment and she continued to require frequent visits to the emergency department and psychiatric hospitalizations. Unfortunately, there were very poor boundaries in Janus' relationship with her therapist and sessions in the latter years were characterized by infantile behaviors, including playing with toys on the floor of the therapist's office and cuddling in her lap with a baby bottle. The therapist was not only the idealized mother in their mutual fantasy, but both patient and therapist were also trying to recreate that in reality. The inevitable result was traumatic reenactment of childhood rejection, abandonment, and boundary violations ( 6).

Janus' regression ended with an episode of psychosis and subsequent hospitalization. During the hospitalization, the therapist terminated treatment with Janus and I offered to provide weekly psychodynamic psychotherapy after discharge.

The patient's clinical condition was very marginal at the beginning of our psychotherapy. In addition to severe dissociative symptoms, Janus had nearly constant suicide ideation and repeated self-mutilation.

The content of our early sessions focussed on two main areas. One area concerned our relationship with one another. Janus was generally suspicious of my intentions and our treatment alliance was fragile. In addition, she wanted more frequent sessions and was angry that I limited telephone calls to twice a week.

The other area concerned conflicting feelings towards her former therapist. For the most part, the theme was "I can't believe what I did to her!" On occasion, however, she would question whether her former therapist's behaviors during sessions were appropriate and express outrage at being abandoned. These feelings could be summed up as, "am I to blame, or is she?"


TWO CORE CONFLICTS OF BORDERLINE PERSONALITY DISORDER


These two content areas in the early psychotherapy of Janus reflect the two core conflicts of borderline personality disorder:

1. Strong divergent wishes of dependency versus autonomy
2. Split self-images of helpless victim versus guilty perpetrator
Both conflicts are evident in each stage of recovery, however, the first is more prominent towards the beginning and end of treatment, and the second conflict predominates in the middle stages.

Moreover, the two conflicts are fundamentally different in nature and are explained by different sets of metaphors. The first is what Kris (
7) has called a divergent conflict and represents two opposing and mutually exclusive wishes. Attachment theory presumes that human beings have an essential need for bonding or attachment to an attentive and nurturing mother ( 8). As infants, patients with BPD have insecure attachments with their mothers. As a result, borderline patients with BPD are unable to self-soothe and avidly seek idealized mother figures through pathological dependency ( 9). The internalized image of a soothing mother provides the sense of security that allows infants to separate from mother, take some risks, find out their strengths, and develop a sense of self ( 10). Because of their insecure attachment, borderlines have been inhibited in the pursuit towards individuation.
Consequently, they feel torn between strong, divergent and conflicting wishes for dependency and for autonomy. The corresponding fears are of aloneness, rejection, and abandonment on the one hand, and of smothering, infantilizing, and merger on the other ( 11).


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:

1. 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?
2. Will the therapist support my independent decision-making, or
will he/she take away my autonomy and sense of self through infantilizing and smothering?
3. 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 ( 12).
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.

Early in her treatment with me, Janus brought in a self-portrait. The center of the drawing was described as a needy little girl who sucked other parts of herself into a black hole. Another part of her was labeled as being dead. Yet another part she could describe as cheerful, shy, and a hard worker. This drawing illustrates Janus' fears of destroying autonomous and adult parts of her self through her infantile and unquenchable neediness.

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 ( 13). 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. Janus would sometimes call me at night threatening suicide, but refusing emergency evaluation. I found myself in an impossible dilemma of being perceived as uncaring if I didn't intervene with forcing an evaluation and controlling if I did. In this situation, Janus was unconsciously enacting in the therapy relationship her conflicts regarding dependency and autonomy ( 14).

An essential quality of the transitional object is its ability to survive the patient's neediness and rage without collusion, retaliation or abandonment ( 15). Over the course of treatment with Janus, there were intermittent behaviors that threatened to destroy our relationship.
A partial list included verbal hostility, frequent telephone calls, and noncompliance with medication recommendations. 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 ( 16). Establishing clear roles and parameters also helps prevent boundary violations derived from complicit unconscious gratifications ( 17) as occurred between Janus and her former therapist.

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" ( 12). 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 I took about 9 months for Janus. She was no longer cutting herself by the end of this stage. Maladaptive behaviors, including compulsions, purging, and drinking were much more intermittent. ED utilization was decreased. The next stage of treatment more directly tackles the second core conflict driving BPD.


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 ( 18) 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" ( 19).
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 ( 20).

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 ( 21). 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 ( 12).
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.

The following transcript illustrates how unconscious conflicts are enacted in relationships:

Janus: The person in the business office required all this I.D. before she would take my request seriously. I needed to prove to her that I was a legitimate person.

Therapist: Not really believing that you are a legitimate and competent person.

Janus: That's what I felt like. I don't think most people do see me that way. Even my friends sometimes say "God has one hand on Janus and one hand on the world."

Therapist: But you know, of course, your harshest critic?

Janus: Is moi?

Therapist: Yes, you can't believe your successes and competency either and that probably goes into why other people have a hard time taking you seriously.

Janus begins by describing a conflict with a person who is demeaning to her and then generalizes it to other relationships in her life. She is now in the helpless victim role. I provide an internalizing question to increase her awareness of the other side of her split self-image as a guilty perpetrator. The patient readily recognizes the internal conflict, stating "Is moi?"

In the following transcript, Janus starts out in the guilty perpetrator role with her sister, denigrating herself for being so jealous. She then switches into the victim role when talking about her mother and husband.
She is particularly angry with her mother for favoring her sister. I make an integrating comment, attempting to bring both sides of the conflict of helpless victim versus guilty perpetrator into consciousness.

Janus: I don't know why I'm so jealous of my sister and am thinking it's really immature of me. I just need to get over this and find my place in this world regardless of my sister and all her fan club. It's just that I don't like the fact people don't acknowledge all I've gone through, but give sympathy and assistance to her. It makes me mad. At a party my mother was telling me, 'it's so awful what (my sister) went through with her husband.' And I was like, "what about what I'm going through with my husband!" And then she spoke of how my husband is on the worship team at Church and 'maybe he's changed.' I just wanted to deck her.

Therapist: It's definitely a sensitive spot, because that's exactly what you are struggling with. Is my husband just this nice earnest guy who is trying to reform? Is it just my attitude that's the problem? Do I have any right to be angry and any value in myself? And so, it's a very sore spot.

Janus: I think I'm coming to terms with it though.

There is substantial improvement in many domains by the end of Stage II.
Anger, guilt and self-destructive behaviors greatly diminish. Some patients describe, "finding a voice," as they become able to appropriately assert themselves to resolve day-to-day conflicts and problems. Importantly, by becoming more aware of her conflicts, Janus was finally able to successfully remove herself from the highly traumatic relationship with her husband and obtain a divorce.

An important landmark in treatment was the development of empathy.
During the twin tower bombings, the patient was surprised to find tears on her face. She stated that it represented the first time she was able to cry for someone else, instead of for just herself. Even three weeks before that incident, she had stated in a session, "I feel like I exist for the first time in my life."


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 ( 22). 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.

The following is an excerpt of a dream from Stage III. The doll in Janus' childhood clearly had large symbolic meaning for her. The doll functioned as a transitional object in that it was part Janus and in part also symbolically represented the idealized mother. So when Janus became depressed after being raped near a playground at age 12, the doll also became depressed. The dream also highlights both the wish to become powerful and autonomous, as represented by the lady in the dream, and the fear of having to give up mother and be alone. Witness the lady's lack of warmth or connection.

[Mel]

I was with my mother and my Raggedy Ann doll in a room that was like an elevator. [My mother had made the doll for me when I was little and I always loved it. I loved the doll because it was so happy and had a huge smile. It felt like part of me. After I was raped at age 12, I tried so hard to get the doll's smile back, but I couldn't.] In the dream there was a lady with us who seemed cold and aloof She wanted to be powerful and somehow my behavior was affecting her power. She kept saying that 'you will never get out of this unless you let go of the doll and your Mom.' I pushed a button to not give her power so I could stay little and keep the doll. And she got angry and left.

Janus felt that the dream and the working through of its meaning was a turning point in her treatment. She realized that she could choose not to be that helpless and fragile little girl anymore and could be strong and move on with her life, despite the risk of becoming alone and detached.

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.

For Janus, the transference during this period was both highly idealized and eroticized. Identification was evident in the following dream.

I was going to school and wanted to become a member of the AMA. There was a committee in the school auditorium trying to discourage me. They stated that if you persist in this, everyone will find out about the horrible things you've done and you would get the death penalty.

As we explored the dream, the patient associated to our therapy relationship, fearing she was unworthy of me because of her past and that I would reject her because of this. The Stage III thematic question was, "am I worthwhile enough as a person for us to have a romantic relationship?"

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.

In the case of Janus, she was no longer content doing work under-the-table, but established a legitimate business and paid taxes, even though it jeopardized her Medicaid and Social Security income. By the end of this stage she no longer met DSM criteria for borderline personality disorder.


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. For Janus, this included buying expensive clothes or equipment to feel "normal" and becoming a workaholic to generate more money. 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 ( 12) 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 ( 11) 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" ( 24). For Janus this fantasy was enacted through demands for a physical relationship with me. 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 ( 22). 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. As Janus began to bring up termination, she redeveloped panic attacks and increased cravings for alcohol.

As we discussed termination, my interactions with her often became devalued, hostile, and subject to projection. I.e. "You just want to get rid of me!" These attacks were essential for Janus to move from identification with the object to differentiation ( 11). They represented an attempt to destroy her idealized image of me so that she could see me (and herself) in a more realistic light and thereby progress in the separation/individuation process ( 15).

Self-image became more stable and cohesive. Greater self-acceptance led to increased toleration of others' mistakes and limitations. These changes created opportunities for improved social and occupational functioning. Janus discovered new ways of perceiving and interacting with the world, other than through the constricted and stereotyped lens of trauma and loss. By the end of treatment, Janus' score on the Dissociative Experiences Scale ( 25) was 22, compared to 64 at the beginning of therapy, reflecting less dissociation and better integration of the self. As Janus put it,

I feel like I've woken up and can see things I've never seen before.
There is a newfound clarity in my life . . . like Fall and fresh air. It feels so good. I think of the song, 'I can see clearly now the rain is gone. . . .'

During Stage IV, Janus developed a new way of relating to the world and loved that aspect of her existence, even though the responsibility of being a self-supporting single mother often felt overwhelming. Towards the end of treatment she stated, "I want to experience the fullness of life and not just look forward to the days when I meet with you. But you'll always be my guy and I'll carry you around with me in here (pointing to her heart)." Janus was no longer standing in the doorway, but had stepped into the adventure of living.


SUMMARY


Recovery from borderline personality disorder involves identification and resolution of two core conflicts. Recovery is a long-term process, however, and entails sequential stages that patients must work through.
Each stage has unique challenges and pitfalls that must be overcome in order to avoid traumatic reenactment. It is possible for some patients and their therapists to successfully negotiate the stages, even if pathology is on the severe end of the spectrum.


REFERENCES


(1) American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, D.C.: American Psychiatric Association.

(2) Stern, A. (1938). Psychoanalytic investigation of and therapy in the border line group of neuroses. Psychoanalytic Quarterly, 7, 467-489.

(3) Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15, 641-685.

(4) Gunderson, J. G. (1984). Borderline Personality Disorder.
Washington, D.C.: American Psychiatric Press.

(5) Paris, J. (2003). Personality Disorders Over Time. Washington, D.C.:
American Psychiatric Press.

(6.) van der Kolk, B. A., Hostetler, A., Herron, N., & Fisler, R. E.
(1994). Trauma and the development of borderline personality disorder.
Psychiatric Clinics of North America, 17, 715-730.

(7.) Kris, A. O. (1988). Some clinical applications of the distinction between divergent and convergent conflicts. International Journal of Psycho-Analysis, 69, 431-441.

(8.) Bowlby, J. (1969). Attachment and Loss, Vol I: Attachment. New
York: Basic Books.

(9.) Masterson, J. F., & Rinsley, D. B. (1975). The borderline syndrome:
the role of the mother in the genesis and psychic structure of the borderline personality. International Journal of PsychoAnalysis, 56, 163-177.

(10.) Stern, D. (1985). The Interpersonal World of the Infant. New York:
Basic Books.

(11.) Fairbairn, W. R. D. (1941). A revised psychopathology of the psychoses and psychoneuroses. International Journal of Psycho-Analysis, 22, 250-279.

(12.) Searles, H. F. (1961). Phases of patient-therapist interaction in the psychotherapy of chronic schizophrenia. British Journal of Medical Psychology, 34, 169-193.

(13.) Winnicott, D. W. (1953). Transitional objects and transitional phenomena; a study of the first not-me possession. International Journal of Psycho-Analysis, 34, 89-97.

(14.) Handley, R. B., & Swenson, C. R. (1989). Acting out of separation conflicts in borderline pathology. Bulletin of the Menninger Clinic, 53, 18-30.

(15.) Winnicott, D. W. (1969). The use of an object. International Journal of Psycho-Analysis, 50, 711-716.

(16.) Winnicott, D. W. (1949). Hate in the countertransference.
International Journal of Psycho-Analysis, 30, 69-74.

(17.) Langs, R.J. (1975). The therapeutic relationship and deviations in technique. International Journal of Psychoanalytic Psychotherapy, 4, 106-141.

(18.) Fairbairn, W. R. D. (1943). The repression and the return of bad objects (with special reference to the 'war neuroses'). British Journal of Medical Psychology, 19, 327-341.

(19.) Fairbairn, W. R. D. (1944). Endopsychic structure considered in terms of object-relationships. International Journal of Psycho-Analysis, 25, 70-96.

(20.) Favaro, A., Degortes, D., Colombo, G., & Santonastaso, P. (2000).
The effects of trauma among kidnap victims in Sardinia, Italy.
Psychological Medicine, 30, 975-980.

(21.) Freud, S. (1959). Further recommendations in the technique of psycho-analysis. Recollection, repetition and working through. In Collected Papers (Vol. 2, pp. 366-376). New York: Basic Books.

(22.) Searles, H. F. (1985). Separation and loss in psychoanalytic therapy with borderline patients: further remarks. American Journal of Psychoanalysis, 45, 9-34.

(23.) Seinfeld, J. (1993). Interpreting and holding: the paternal and maternal functions of the psychotherapist. Northvale, NJ: Jason Aronson.

(24.) Smith, S. (1977). The golden fantasy: a regressive reaction to separation anxiety. International Journal of Psychoanalysis, 58, 311-324.

(25.) Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727-735.

~~~~~~~~

By Robert J. Gregory, M.D., Associate Professor, Department of Psychiatry, SUNY Upstate Medical University. Mailing address: 750 East Adams Street, Syracuse, NY 13210

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Source: American Journal of Psychotherapy, 2004, Vol. 58 Issue 3, p335, 14p
Item: 16627068

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[seanyshow]

My God. I hate reading stuff like that, in fact I could only make it through the first two entries. In some ways it's good to know what's "wrong with me" and that there is treatment, but it scares me too. It frightens the life out of me to be honest.

[Mel]

Yes it can be very scary. It takes time.. Take your time reading information THere is a lot of information on these boards.

[lostlamb]

Hi,

I knew someone who had, or thought they had this disorder. I loved them and they treated me in a terrible way, and one which I had not experienced before. For my own peace of mind, I'd like to understand whether or not the person was able to realise, even eventually, the extent of their own behaviour. Would they have been concious of it at the time? To anyone rational (I suffer from depression but this doesn't affect my sense of right and wrong), his behaviour was beneath contempt and wholly unprovoked. My reasoning fell on deaf ears and the relationship ended. I had previously tried to help, but I'm wondering now whether treatment of this disorder includes either making up for your previous actions, or at the least, learning to accept they were wrong. Perhaps a therapist will manage to do this better then I did, but I'm interested in finding out to what extent these aspects are covered, and how the effects on other people can be minimalised during the treatment of the patient. If I understood the nature of disorder, I might feel less inclined to feel anger towards this person, rather than sympathy and acceptance. To what extent does this disorder generally affect behaviour, and how to tell the difference between a genuinely "ill" person, and one who is not. I'm at my wit's end trying to fathom it out, and would love to hear some thoughts.

Thanks,

I hope I've posted this in the right place xxx

[parsnip]

Hey, LostLamb.. your reply to this has had me thinking... thinking, thinking...it's all I seem to do. At least I am back at work now - part time, and that gives some structure to my life. Your post sounds so similar to what I went through with my previous girlfriend. The way I treated her was so mean - but I didn't know it at the time.. but the more I think of it... I know she loved me. I loved her too, as best as I could at the time. However I was self harming in a number of different ways due I guess to the fact I'm a bloke and couldn't deal with the stress I was under. Normally I am quite strong, but this last year I have been on a downward spiral of destruction which has affected my family and those close to me in so many ways.

It's been a couple of months now since I pulled the emotional rug from under the feet of my last girlfriend, and it would be counterproductive of me to conatct her and re-open the wounds that I have caused. I have been told that I have 'Borderline traits' yet have not been diagnosed officially - maybe I never will be - I'm having so much difficulty finding a psychiatrist in the UK, now that I have moved.

But Lost Lamb, if your ex is anything like me, he will be having sleepless nights thinking about what has happened in the past, feeling guilty, hating himself... still wandering around lost in his head.. and maybe not getting any better.

I hope he finds the help he needs, I hope I do too. And, lastly, I hope you find the understanding that whatever happened, however much you tried... it was not your fault. Don't feel bad.

Sorry for waffling.. it's just been on my mind.

Take care.

Jx