Abstract
We all share in common our clinical experience with personality-disordered patients, and we note certain of their attributes. To a significant extent these patients are lost in terms of knowing who they are: they feel a dark aloneness; feel a grim sense of worthlessness; feel no warmth for themselves; and do not feel like a whole person with a genuine place with others. We could ascribe these attributes to their being deficient in five capacities basic to human stability, even viability. Because they are required for maintaining the self, I refer to them as self-maintenance capacities. They include (1) the capacity for self-realness, the experiential (not merely cognitive) knowledge that one’s qualities, and the relationships between oneself and others, exist as real, that is, as actual; (2) the capacity for self-security, the ability to provide oneself an ongoing experience of being secure, which is the heritage of having developed with secure, warm holding; (3) the capacity for self-worth, the experiential knowledge of one’s self-worth; (4) the capacity to experience love for oneself; and (5) the capacity to know one’s identity experientially. To boil this down, people need to experience that they are real, secure from aloneness, worthwhile, and deserving of their love, and that they possess an identity.
The major difference between neurotic and personality-disordered patients is that neurotic patients have the capacities to provide themselves these basic-self experiences. Personality-disordered patients do not. The aim of treatment with the latter, then, is to help them develop these capacities. Though I have listed these self-maintenance capacities as if they occur as distinct phenomena, in the clinical situation they do not present so neatly. They overlap and intertwine. I have listed them separately simply to help us think about them.
The self-maintenance capacities seem to occur in a more or less developmental hierarchy. For example, people cannot develop a sense of security without first experientially knowing that their bodily and mental qualities exist as real. Similarly, they cannot experience self-worth unless they experience themselves as both real and secure. Attaining self-love depends on having the first three capacities in place, and all of these capacities are required for a stable sense of identity.
I want to clarify what I mean by “real” and “reality.” The word real carries many meanings in science and philosophy, and in psychoanalysis as well. But for therapeutic purposes we need to think about a sense of self-realness in clinical terms, ones that respect the need of human beings to be “certain” about what is real in themselves and what is real in their world. Their mental orientation, and their sanity, depend on it. We could say that their “certainty” takes two forms. One form is perception, which I will speak of as a “cognitive” sense of realness. Another form of realness is what people feel to be true about themselves and their world. I’ll call this “experiential” reality. So what I call “self-realness” includes both cognitive perceptions of reality and felt experiences of it. These two forms of self-realness are actually subjective in nature. But there is also an “objective” reality, one that is consensually perceived and agreed upon. A vital part of treatment is helping patients know the difference between this objective reality on one hand and their cognitive and experiential senses of reality on the other. One of our hopes for treatment is that we can help patients achieve a high degree of congruence between their cognitive and experiential realities and objective reality.
Before presenting clinical cases, I would like to offer some comments about treatment. Most patients come for treatment with a mixture of neurosis and personality disorder. Some may be predominantly neurotic, while others may be predominantly personality-disordered.
A major difference between neurosis and personality disorder is that the first involves intrapsychic conflict for the most part. Although personality disorder too involves intrapsychic conflict, the insufficiency of self-maintenance capacities is of primary importance. Whereas neurotic patients need help in recovering unconscious conflicts, personality-disordered patients first need help with deficits in their self-maintenance capacities. When neurotic patients gain the insights they need, they can complete their internal selves out of their own inner resources. That is, neurotic patients can draw from the healthy qualities of themselves to replace what has been neurotic. But personality-disordered patients have no internal resources from which to draw self-maintenance capacities. They must rely on the analyst, and others, to develop these capacities.
A second difference between these two types of patients is that neurotic defenses center on repression, whereas personality-disordered defenses center on denial/disavowal. We are all used to discerning which type of defense a patient is using, and then determining which type of defense analysis applies. Repression calls for free association. But free association is useless when a patient is using denial. What is denied or disavowed is not unconscious. It is barricaded from awareness by rigid suppression. It’s as if the patient has shoved the bureau, chairs, and bed up against the door so no one can get in and nothing can escape. Of primary importance in working with denial is providing safety for the patient. We try to help the patient feel it’s safe to open the door, at least a crack.
Our knowing and bearing a patient’s feelings is fundamental to our work, whether it serves the purpose of support or serves the analytic process itself. Patients will not freely provide associations or even conscious content unless they know the analyst will understand it. Support, in general, has a bad name. It is usually taken to mean our providing a patient caring and advice that is received passively. This is indeed done with patients who are otherwise untreatable. But it is not done in genuine analytic work, whether conducted on the couch or face-to-face. Here support is a complex matter, and it is essential for treatment in that it is the means through which patients are able to feel safe enough to work effectively with the analyst.
A crucial part of support is that the patient experiences that he or she matters to the analyst, that is, that the analyst cares about him or her as the person he or she is. Patients must also know that their meaning to the analyst is strictly about themselves, that they are in no danger of the analyst’s using them for his or her own purposes. That is, the patient is cared about with no strings attached. Another part of providing supportive safety is the analyst’s capacity to endure the patient’s feelings with equanimity, no matter how intense they are.
When patients are predominantly neurotic, but also personality-disordered, they can use analysis on the couch once they have developed beyond whatever degree of personality disorder they began with. But treating personality disorder itself requires a face-to-face setup. Visual contact with the patient provides analysts nonverbal information on the basis of which they can develop a deeper experiential understanding of the patient. In addition, the face-to-face situation allows the patient to experience, nonverbally, the analyst’s thoughtful and empathic understanding of him. It also helps the patient see and experience that the analyst both knows him and is with him.
I will now offer three clinical accounts of treatment, each focused on one or two incapacities for self-maintenance.
Mark: Self-Realness, Self-Security
Mark’s difficulty was primarily neurotic, but treatment could not be completed until he was also helped to gain the capacities for self-realness and the security of not feeling alone. He had been through two lengthy and essentially classical analyses. They had helped, but he still felt a pervasive sense of depressive meaninglessness, even though he was a highly regarded professor, known for his leadership, his books, his wisdom, his teaching, and his warm personality.
Mark’s developmental history primarily involved his life with his mother. His father was a good man, but he and his son had little in common. The boy was smart and popular throughout childhood and adolescence. He always held positions of leadership and responsibility. His mother needed him to be who he was in the world because the meaning in her world depended on his importance. He devoted his life to maintaining her world; being himself in the actual world was hardly significant. His world was her world, and within himself it was only living in his mother’s world that mattered.
At first I thought Mark’s difficulties lay in some remaining repressed conflicts in regard to his mother, so I asked him to proceed free associatively. This got nowhere. Then it occurred to me to say that I thought he knew himself cognitively, but I wondered whether he felt, whether he experienced, being the self that he cognitively knew himself to be. His answer: “No, I do not.”
In regard to Mark, I want to consider one of the ways we need relationships with other people. In Waiting for Godot, Vladimir says, “We always find something, eh? . . . to give us the impression we exist?” (Beckett 1954). That is, we all need to experience the being of ourselves through the experience others have of us and relate to us. As George Berkeley (1710) wrote, “To be is to be perceived” (Esse est percipi). The experience others have of us conveys, verbally and nonverbally, who and what we are. In contrast to traditional views of neutrality, personality-disordered patients need us to provide this kind of input nearly all the time, even though they are impaired in their capacity to internalize it. It is this inability to internalize that prevents these patients from using others’ experience of them to develop the self-maintenance capacities they have lacked. When they observe that others really do experience them, these patients say, “I just can’t let it in,” or “It just doesn’t sink in,” or “I just can’t hold on to it.”
The question this raises is what threat the patient feels he must defend against, and what defense he uses. I first tried to help this patient gain insight into these questions through the use of free association and dream analysis. This effort proved fruitless. So the reasonable question was whether the defense was denial/disavowal. The usual way to discover that denial is operating is by helping the patient feel as emotionally safe as possible, and then encouraging him to recognize what was so threatening that he had to keep it out of mind. But with Mark this effort didn’t work either.
So the next question was why both efforts failed. This raised the possibility that the threat involved might have been so great that it called for an unusually rigid denial. If this was the case, it would be useful to ask the patient to focus attention on the brief moment when the defense most probably came into play: just before the patient found that “it just doesn’t sink in” or that he “just can’t keep hold of it.”
I began trying to do this by offering as much supportive safely as I could, and then asking the patient to try, when he could, to allow himself for just a moment to experience another person’s feeling experience of him. When he was able to allow this, I asked him then to notice a “nanosecond” of whatever happened just before the experience disappeared. Eventually and inevitably, patients like Mark notice that the “nanosecond” of feeling is one of fear. It is akin to signal anxiety, and, like signal anxiety, it arouses defenses, in this case defenses of denial. The fear signal alerts the patient about even greater threats were the patient to allow himself to internalize any of the feeling and self-maintenance capacities the analyst is offering. These greater threats are always discovered to be terrible fear, and/or great sadness, and/or intense hatred, and/or being overwhelmed.
The analyst works to help by being steadfast in his support as he tries to help the patient first to understand the signal fear and the purpose it serves. When this effort succeeds, the analyst can engage the patient in discovering what the signal portended, what would be so greatly frightening. With discovery, the analyst helps the patient to gradually tolerate and understand what he fears and why. Treatment can then proceed as a typical analytic process.
To return to Mark, he was unable to use my experience of him, or that of others. As with other such patients, I asked him to try to allow himself, at least briefly, to feel what another person is feeling about him and then observe what happens just before the feeling disappears. He soon reported having felt a friend’s obvious liking for him, but the feeling quickly vanished. Fortunately, he remembered the “nanosecond” of feeling just before the feelings of his friend’s feelings disappeared. I asked him to try to recall it. With a frightened look, he said, “I’m terrified.” When I asked why, he said, “I’ll lose my mother.” For a long time thereafter I continued to offer as much support as I could, while he persistently tried to manage his terror of losing his mother and at the same time allow himself to experience the experience that I and others had of him. In this process he gradually developed experiencing a felt reality of being himself. However, as he progressed, he realized more and more that, in contrast to his new self-experience, he was still living in the world he shared with his mother. The real world and his realness in it still lacked sufficient meaning. In addition, he felt terrifyingly insecure stepping out of the world he shared with his mother and into the real but alien world where he was unfamiliar to himself.
But he wanted to be his actual self more than he wanted to stay in his mother’s world. With patience on both our parts, he persistently tried to tolerate the insecure unfamiliarity of being his genuine self in his actual world. Slowly, in a working-through process, his fear was worn away; he “got used to” being himself, with his professional achievements, his family, and his friends. With this, he completed treatment.
Jean: Self-Worth, Self-Love
Jean, a middle-aged woman, was held in high regard for her academic achievements. She was loved by almost everyone. She had previously been treated in a twelve-year psychotherapy. Her sense of guilt and self-hatred had led to several attempts to kill herself, for which she was hospitalized. She was convinced it was an incontrovertible fact that she was unspeakably evil and that she infected everyone around her.
She resembled Mark in that she was unable to feel, experientially, the realness of her personal and professional attributes, nor could she feel secure in the warm regard of everyone who knew her. The first part of treatment was conducted much as it was with Mark, even though the extreme nature of Jean’s experience called for a more arduous effort. I’ll not review that first part of treatment. I’ll just mention that she made strides toward developing her capacities to experience self-realness and, to a considerable extent, self-security. This achievement provided the necessary grounding for her to address issues of self-worth and self-love. For Jean this work was especially important because self-worth and self-love were the only possible sources she could use to oppose her sense of being evil.
Jean’s illness was like that of many other personality-disordered patients in that it was extreme in depth and intensity. She required much more support than patients like Mark. Whenever I tried, carefully, to speak of the possibility of her being worthwhile or loved, she responded with torrents of self-hatred. She adamantly insisted she was evil and a danger to others. Because of her guilt and her belief that she would damage or destroy others, she felt it was imperative to kill herself. With continued support, and through free association, she recovered memories from her childhood. Her parents had abused her horrendously. She made sense of her parents’ evil behavior by believing that it was she who was evil, and that her evil had caused her parents’ abuse. Taking evil onto herself allowed her to hold on to a tenuous belief that her parents had some good in them. However, throughout her life she lived in fear of them, believing, even hallucinating, that they were coming after her. They invaded my consulting room, and sometimes I was seen as one of them.
I think a major predictor of therapeutic success is the patient’s devotion to the truth of objective reality, that is, valuing reality for the sake of reality itself. An additional factor is the patient’s capacity and devotion to thinking. Successful treatment depends on the patient’s having enough of these two qualities. They are needed if the patient is to bring the two forms of self-realness into harmony with objective reality. Jean’s valuing of objective reality was greater than that of any other patient I have worked with. When she had developed enough sense of relatedness and safely with me, I could appeal to these qualities by gently questioning the reality of her delusions and hallucinations. Whenever I did this, she fell into a silent thoughtfulness. She would go home and think some more, and then come back to tell me what she thought. With her love of what is objectively real, she eventually was able to dispense with her delusions and hallucinations, dispense with them altogether. They never recurred.
Jean’s belief that she was evil meant that feeling self-worth and self-love were impossible. She recoiled from compliments and never felt the love that others expressed toward her. She once showed me a present that a grateful student had given her. She put it down beside her chair and refused to talk about it. When I spoke about the student’s gratitude, she exploded, shouting “No,” while forcefully sweeping her arm over the present as if to shove it away. Her sense of evil forbade any thought that she could be deserving of gratitude.
She believed it wouldn’t really matter to her husband if she died. Actually, he loved her very much. I questioned the accuracy of her belief, so she went home and asked him. He was shocked. She asked him to write a list about who she was, and she brought it in to review with me. It very realistically cited her values, her worth, how she showed her love for him, and how he loved her. She wanted to think about it, to examine whether it was accurate. I simply helped in her quest to grasp the realities of her husband’s list. This was the beginning of her considering the possibility that she was worthwhile and loved. But this development was followed by regression to her old state of being suicidal in her evilness and worthlessness.
Here I had to consider whether Jean was involved in a negative therapeutic reaction. Akhtar, in his dictionary (2009), describes four varieties of negative therapeutic reaction. One is based on unconscious guilt. But it was notable that Jean had stopped feeling guilty, and even in her regressed state she didn’t connect a sense of guilt with her evilness and worthlessness. She simply believed that evil and worthlessness were inherent in her. Akhtar describes the second form of negative therapeutic reaction as stemming from “problematic identifications,” as “with a parent who idealized a life of suffering.” This doesn’t fit with the characteristics of either of Jean’s parents. The third form is “separation-related issues” about becoming separate and independent of the mother. Jean had never been anything but glad to have her own life far distant from her mother’s, physically and psychologically. Fourth is envy of what the therapist possesses in his or her self that the patient cannot possess. Jean’s associations and nonverbal clues never suggested envy of me.
These observations led me to believe that Jean’s regression to her old suicidal state of feeling evil and worthless was similar to what I had observed with many other patients. Their regressive return to illness was motivated by fear. When patients make genuine steps in developing their self-maintenance capacities, they are confronted with the challenge of change. That is, successful treatment means finding themselves significantly no longer being who they were, and significantly being someone they hadn’t been before. They feel disconnected and nowhere. This state arouses a fear of the unfamiliar. They have become unfamiliar to themselves and unfamilar with the world they find themselves in, and this is deeply frightening. Many patients become so anxious that they seek refuge by regressing to their previous state of fear and pain in order to feel grounded as their familiar sick selves.
This regression rescues the patient from a frighteningly unfamiliar place by restoring him or her to the familiar place, the terra firma, of illness, miserable as it is. In this regression a patient can look as impaired as before treatment. Both patient and analyst may be in danger of believing that the treatment has been for naught. They may feel like giving up.
It’s helpful to know, however, that this kind of event is not an indication that the patient cannot progress. Instead it is simply a move back to the safety of being a familiar self. In this situation the analyst can interpret to patients that they are so anxious with feeling unfamiliar that they need to escape to the familiar place of illness. In my experience, patients feel encouraged by this interpretation and do their best to bear the unfamiliarity. They may regress repeatedly, but with support they keep on trying, until they get used to being who they now are. That is, they come to feel comfortable as their current genuine selves.
Now back to Jean. With every advance toward the self she was becoming, Jean took refuge in the terra firma of believing she was evil and being suicidal. As she was gaining self-realness, self-security, self-esteem, and self-love, she became all the more frightened. When I talked with her about the reason for her retreats, she recognized that she was terrified of being unfamiliar to herself and in a dangerously unfamiliar place. She spoke of herself as trying to cross a bridge over a deep valley. She made some progress, but she came to a place where she was in imminent danger of losing her grip and falling. She tried hard to stay on the bridge but had to retreat several times into her familiar state of illness. But Jean was determined. With support and encouragement, she tried and tried again to venture back onto the bridge. Finally she made it all the way across. That is, she was then comfortable with being her true self.
When her belief that she was evil was worn away, she associatively recovered a memory of being a very little girl who knew that the deepest part of her self was love, what she called “love supreme.” This had helped her stay alive as a child, and discovering it now helped her to love and be loved. There was no room left for being evil.
She wrote a poem that expressed her having gained all of the self-maintenance capacities:
Soothing the soul by love of the self The inner knowledge that the One True Self, is still worthy. No rhyme or reason. I call it Joyous Love— Where the loving soul Intervenes for the self and others. Without rhyme or reason, No trappings There is no single way Joyous love heals, Though the end, always the same—. A sense of oneness, sound and whole. Self-reverence restored, limbic pain abates, Wisdom comes, And self-love, Joyous Love, Rises like the heron High above the water For all to see.
Rick: Development of Personal Identity
I am presenting the next case to illustrate two things. One is the need for classical, albeit face-to-face, psychoanalysis in borderline patients before they can be helped to develop self-maintenance capacities. The other is to illustrate the development of personal identity. I will not repeat what I’ve already described for the development of the first four self-maintenance capacities.
Rick, a gay Hispanic, was a brilliant, academically successful young man with many friends. The oldest child in a large, poverty-stricken family, he represented to his mother her hope for higher status. When she was having more children, she sent him to stay, for months at a time, with an aunt who felt no warmth for him. He recalled those times as being on a frozen desert.
Rick came for treatment of depression. He was a lost young man. Though he knew cognitively that he attended a prestigious university and was well recognized and liked, and knew he was intelligent, he remained in a desert in terms of loving and being loved. His sense of identity was restricted to cognitive knowledge of himself.
Rick had a borderline personality disorder. My understanding of borderline psychology includes that BPD patients suffer from extreme deficits of self-maintenance capacities. Indeed, I think it is the severity of these deficits that defines the borderline. These patients need these capacities for their survival, but they cannot provide them to themselves. Their very survival is at stake, and they believe they are entitled to survive. I call this inevitable part of human nature our “entitlement to survive.” Being thus entitled, these patients demand, threaten, manipulate, and try to possess, as all of us would to save our lives and families.
They cannot in any way get nearly all of what they need from the analyst. Unconsciously and inevitably they hate and envy the analyst because he or she possesses what they need but cannot have. To fill their needs they seek to draw the analyst inside themselves, by ingesting and absorbing him or her. (Rick dreamed that he was eating meat from a can and discovered the pieces of meat were pieces of me. He was revolted and very distressed by this.) But hating, envy, eating, and absorbing—all of these mean destruction of the analyst, and this causes the terror that they will lose the analyst they need for their survival. It is this that accounts for the patient’s approach-and-avoidance behavior, which can look like splitting. But that concept doesn’t apply here. These borderline patients do not suffer from being overendowed with “aggressiveness.” Instead, the intensity of their “aggression” derives from the intensity of their unfulfilled requirements for survival.
Because of the dangers they present, the patient’s destructive feelings and urges must be kept unconscious, even though they are acted on in derivative ways. Because repression is involved here, treatment is by means of free association and interpretation. In spite of the turmoil of the situation, these patients can ultimately gain full insight and an effective working through. It takes a couple of years. The destructive urges will remain, consciously, but the analysis will have helped the patient feel safe with his envy, hatred, and oral urges. Perspective has tamed them, and the patient can continue with the next part of treatment.
Rick achieved this kind of insight and perspective. In the years that followed he developed self-maintenance capacities for experiencing his self-realness and freedom from aloneness. He also achieved self-worth and love for himself and for his world. Since I have described this kind of work with Mark and Jean, I’ll skip over it and proceed with describing Rick’s development of a sense of personal identity. (So far I have not mentioned, but now want to add, that all of the treatments I have described also involve transference analysis.)
Developing the other self-maintenance capacities is essential for developing a sense of identity. Each achievement of self-maintenance contributes to a growing sense of identity. Self-realness is the foundation, and this was true for Rick. Each of the other self-maintenance capacities—self-security, self-worth, and self-love—are built on that foundation. With these developmental achievements, Rick began feeling that in his own hands, he was in good hands. With this, he became more and more successful in his world. He became a professor, a liberal political activist, and a widely regarded true friend. A vital part of Rick’s development of identity was his sharing with me all the ways he was experiencing the self he was becoming. This served to bring an increasing valence of realness to being himself.
Finally he felt he was complete. He terminated treatment, became a professor at another university, and at a twenty-five-year follow-up had never regressed, despite having developed AIDS.
Summary
I have offered my understanding of the primary psychological problem for personality-disordered patients. They lack some or all of the self-maintenance capacities that are required for basic self-stability and survival. That is, they cannot sufficiently provide themselves the experience of being real, warmly secure, worthy, and self-loving, and of having a genuine identity. To the extent these capacities are lacking, patients must depend on others to provide them. Their primary defense is denial. One key to treatment is the analyst’s knowing in his own feelings the feelings that patients bring to him. I have also discussed the defenses patients use to prevent internalizing others’ experience of them, thus depriving themselves of the resources they need for experiencing their self-qualities. Treatment requires a face-to-face analytic situation. I have also described the difficulties presented to patients when they are making progress. They can become significantly unfamiliar with themselves, and this may induce temporary regressions.
Footnotes
Training and Supervising Analyst, Boston Psychoanalytic Society and Institute.
Plenary address, American Psychoanalytic Association, New York, January 2012.
Dan H. Buie