Abstract
This article presents the treatment of a female patient with borderline personality disorder which draws on the principles of Margret Mahler’s object relations theory. Common characteristics of this disorder include fear of abandonment, unstable relationships, lack of identity, impulsiveness, pervasive emptiness, excessive anger, and the inability to regulate emotions. These symptoms are rooted in the dynamic, ambivalent, and prevailing struggle between the merger and individualization during the rapprochement subphase. Psychotherapy that utilizes transference within the treatment helps the patient to increase awareness of how she participates in a dyadic relationship based on early internalizations. The unconscious reenactment of early object relations is understood by uncovering defenses (splitting, projection, and projective identification) that play out in the therapist/patient relationship. This offers the patient the opportunity to integrate parts of the self and other, and hold ambivalent feelings without splitting or distorting. Consequently the therapeutic relationship is the vehicle for change.
1 Theoretical and Research Basis for Treatment
According to data from a subsample of participants in a national survey on mental disorders, about 1.6% of adults in the United States have borderline personality disorder (BPD) in a given year (Lenzenweger, Lane, Loranger, & Kessler, 2007). In all, 15% of psychiatric inpatients have a diagnosis of BPD (American Psychiatric Association [APA], 2000). According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000), to be diagnosed with BPD, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
Extreme reactions (including, depression, rage, or panic) to abandonment, whether real or perceived A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love to extreme dislike or anger Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, plans and/or goals for the future (such as school or career choices) Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating Recurring suicidal behaviors or threats or self-harming behavior, such as cutting Intense and highly changeable moods, with each episode lasting from a few hours to a few days Chronic feelings of emptiness and/or boredom Inappropriate, intense anger or problems controlling anger Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality. (National Institute on Mental Health, 2012)
2 Case Introduction
To maintain confidentiality, all demographic information was altered. “Betty” (not actual name) is a 45-year-old divorced African American female who is 5′10″, of average weight, dressed casually in a loosely fitting Afro-centric outfit with bold jewelry. Betty is a PhD psychologist who just completed her postdoctoral work with inpatient HIV-infected African American women. She is currently unemployed. She lives in an apartment with her 16-year-old son. Betty’s mood is depressed; her affect is labile, shifting from anger to sadness to elation. Her interview behavior was cooperative. Her style of speech is impressionistic and abstract. The patient is well above-average intelligence. Betty is articulate and creative (she sculpts in clay and makes masks). She seems genuinely concerned about the consequences of her rage and wants to improve her life.
3 Presenting Complaints
Betty requested couples counseling because of arguments and emotional turmoil with Alex, her long-term boyfriend. They have been in a “secret” relationship for the past 11 years during which time Alex was married twice and had three children. Betty reported that Alex, a Caucasian government worker, is now in the process of divorcing his second wife, a marriage that was depicted as a “War of the Roses.” Betty characterized Alex’s wife as “a crazy, erratic bitch” who is vindictive. Betty claims that Alex now wants a committed relationship with her, which is “terrifying.” She reports feeling “angry, anxious, and depressed,” stating in her first interview, “Why does he want me now? I’m not going to be his Nigger girl!” Nevertheless she expressed a strong desire to examine this relationship conjointly because she wanted “to make it work.” Betty also reports experiencing the following for a period of 1 month: sleep disturbance (insomnia), increased appetite, indecisiveness, irritability, low self-esteem, feelings of hopelessness, worthlessness, extreme anxiety, and “uncontrollable rage.” Betty has no history of suicidality. She admits to passive suicidal ideation but denies intent. Initially, Betty denied any alcoholic consumption. She later admitted that she has a “stiff vodka and O.J.” at night to calm her before bedtime and smokes marijuana occasionally.
Betty felt she was “doing all the work in this relationship. I don’t want to be Alex’s therapist.” When asked about treatment goals, Betty stated that she would like to improve communications within the relationship as well as redefine and establish more mutuality in the relationship. Betty requested that I provide individual treatment for her and Alex concurrent with conjoint therapy. I supported her comprehensive treatment concept but declined (with explanation) to personally provide all three treatments. At Betty’s insistence, I agreed to see Betty and Alex conjointly. Referrals were offered for individual treatment. I met with the couple two times, focusing mainly on assessment. By our third session, Betty became very anxious, stating, “I know my needs are not going to be met here, you like Alex better than me. He’s charming and everyone thinks he’s nicer!” Since the triadic relationship of conjoint treatment seemed so intolerable to her, individual treatment with Betty was finally agreed on, and referrals for Alex were later requested and given.
4 History
Betty was born and raised in the projects of a major East Coast city in a predominately African American neighborhood. She was raised a Baptist but no longer practices nor has any inclination toward religion. She lived with both parents until she was almost 2 years old, when Betty’s parents divorced. At that time, Betty’s mother was pregnant with her brother Bobby who was born shortly after her father left the home. Thereafter, she had two brief (1-day) contacts with her father at ages 10 and 23. She lived with her mother and her brother until she was able to leave home to go to college at age 17. No extended family was involved in her caretaking. Betty speaks very little about her affiliation with her brother while growing up other than to state, “We didn’t get along . . . I was a parentified child and was responsible for Bobby’s behavior.” Her brother now lives in another state, and they currently have minimal contact.
Betty describes her father as a “narcissistic sociopath, a compulsive gambler, and a thief.” Betty arrives at this characterization of her father via accounts told by family and friends. Her mother worked as a piece worker for a clothing factory during the week and as a seamstress at home on weekends. She initially portrayed her mother as “a good mother” but later in treatment admitted that her mother was “a distant, ambitious, isolated woman with poor social skills.” Betty remembers standing at the screen door crying as her mother left for work. Betty stated that her mother would never look back or try to console her. One time Betty remembers being disobedient just before mother left for work. “Just for that, I am leaving and never coming back,” her mother snapped and left for work. Betty’s uncontrollable cries were ignored by her mother and the babysitter. When Betty tells these stories, she does so to validate her reality of maternal neglect and abandonment. Betty reports that as a child, she experienced this as rejection, neglect, and abandonment.
Anecdotally, Betty recalled a weekend when her mother was working from home. Betty states
My mother never stopped sewing . . . she worked 7 days a week. One time when I was 7 years old, my mother dozed off at the sewing machine. The heavy industrial sewing machine that she [mother] used pulled her hand through. Mom pulled her hand out, wrapped a scrap piece of fabric around it, and never stopped working.
Developmental and Structural Considerations
Betty has been unable to provide a clear picture of her developmental history. She has consciously and unconsciously resisted giving what she calls her “trauma history” until recently. The following is a collation of Betty’s historical pages that are slowly unfolding.
Her mother returned to work shortly after Betty was born. Betty was left in the care of a babysitter until she was approximately 9 months old. She was left then with a variety of other sitters until she mastered her toilet training (age not known) and was then placed in a day care. As mentioned earlier, Betty was approximately 2 years old when her brother was born and her father left the home. At age 6, Betty remembers being touched on the vagina and buttocks by her landlord while in his care. She reports being digitally penetrated by her swimming instructor at age 8 during a swimming lesson. Betty tearfully reported that she has not disclosed this to anyone prior to treatment. She now wonders if these were single episodes.
Betty was a successful student with a small circle of friends. At age 14, she was sexually assaulted by a 17-year-old boy who pulled her into an abandoned building and ejaculated between her legs (no penetration). Betty told no one, commenting, “Who would I tell?” In junior high school, Betty’s academic performance dropped but not markedly.
As with Betty’s earliest object relationships, she developed a series of brief relationships that quickly ended. Although compliant at home, Betty was rebellious outside of the home. At 16, Betty began alcohol binges that usually culminated in sexual encounters with friends and strangers. Betty reports this went unnoticed by her mother, who was engrossed in her work: “I was responsible for raising myself.” During this period, Betty began self-mutilating behaviors such as scratching her inner thighs with her nails, particularly after a casual sexual encounter. It is not uncommon for females who experience sexual abuse to use self-mutilating behaviors (scratching, burning, and cutting) to cope with the pain of the abuse. Betty finished high school and was accepted with a scholarship to a reputable university in Massachusetts. She did not complete the 1st year due to failing grades, which she attributes to racial insensitivity on the part of the school and her political activism in the Black civil rights movement. In the 1 year interim before attending another college, she became actively involved with the Black Panthers, who gave her an “identity” and a sense of “affiliation and empowerment.” She changed schools two more times before graduating from a lesser known private college. Betty was unable to obtain another scholarship, so she relied on loans. She had difficulty meeting deadlines and getting to class on time, which she attributed to “sex, drugs, and rock and roll.”
At 23 years, Betty married. Her marriage lasted for 9 years, and Betty reports that her husband, an African American man, was “reliable but boring and narcissistic.” She worked at a government agency, where she met Alex and began dating him just prior to her divorce. Alex, her present partner, is currently in psychotherapy for his “sexual addiction” and relational problems.
Regarding the 11 years Betty has been with Alex, she remarks that they had the “illusion of a relationship.” She explained, “It was extremely sexual and my fantasy created the rest.” Betty’s current socioeconomic status (SES) is best characterized as middle class. She lives with her son in a two-bedroom condominium in a racially mixed community. Alex stays with them most weekend nights. She has little trust of African American men and states that she has learned “how to deal with White folk.” Betty states that she has one female friend but “relies on no one for emotional support.”
Parenting issues have emerged during crisis situations. She presents herself as an overpowering but competent mother. Betty is beginning to see her parenting style much like that of her own mother, particularly when she demands autonomy, compliance, and emotional restraint from Tom, her son. Tom is 16 years old and is now investigating various colleges to attend. His independence is beginning to prompt feelings of loss and abandonment for Betty.
Betty obtained her master’s degree while married and returned to school again at age 36 for a PhD in clinical psychology. She has been eligible to sit for her licensure exam for the past 2 years but reports without any apparent concern, “I keep missing the deadline, I just can’t do it.” She also reports that she is ambivalent about career goals.
5 Assessment
DSM-IV Diagnosis
AXIS I: 296.23 Major Depression, single episode, moderate;
R/O 309.81 Posttraumatic Stress Disorder, delayed onset;
AXIS II: Borderline Personality Disorder with narcissistic traits;
AXIS III: None;
AXIS IV: Psychological stressors: difficulty with her significant other, employment, and interpersonal relationships, severity: 5—severe; and
AXIS V: Current GAF: 55.
DSM rationale
Betty has been seen by a physician, and there are not any organic causes that may have befuddled the diagnosis. Betty clearly meets the criteria for a major depressive episode: depressed mood, sleep disturbance (insomnia), increased appetite, indecisiveness, irritability, suicidal ideation, feelings of hopelessness and worthlessness. She has been experiencing these symptoms daily for a month without any periods of relief. There is no reporting of previous episodes or indication of psychosis.
A diagnosis of BPD was given because of Betty’s distorted reality, which is exaggerated and unrealistic because of extreme forms of projection and splitting. Also because of her dangerous behaviors (self-mutilating, thigh scratching, which stopped in her early 20s), extreme reactions to real or perceived abandonment, pattern of stormy relationships, emptiness and/or boredom, and problems controlling anger.
DSM differential diagnosis
The symptoms of posttraumatic stress disorder (PTSD) as found in the DSM-IV (APA, 2000) TR can clinically resemble BPD. BPD symptoms, such as affect regulation, severe mood swings, anxiety intolerance, and uncontrollable anger, are characteristic of both disorders. About one half of all the cases of BPD in the United States have an etiology of severe complex trauma (Kuritárné, 2005). Until diagnosticians receive more guidance, discernment of a PTSD diagnosis must be differentially considered. This is not to exclude the possibility that both diagnoses may be appropriate.
Betty demonstrates traits of narcissistic personality disorder (NPD). However, she is more impulsive and self-destructive, and less stable than a person with NPD. Narcissistic traits, which Betty displayed, are grandiosity, a sense of entitlement, and interpersonal exploitiveness. BPD preempts the diagnosis of identity disorder.
Psychodynamic assessment
Using an object relations framework, borderline conflicts are differentiated by the defense mechanisms that guard against the abandonment depression. Kernberg (1976) argued the excessive aggression that some children experience heightens their fear of destroying “good” self- and object-representations. When such intense conflict results, they must use splitting as a major defense. Due to Betty’s arrested psychological development, her identity remains diffused, leaving her without a clear foundation of who she is. For example, Betty is neither in nor out of the relationship with Alex. Betty’s inconsistent sense of self leaves her conflicted about being overly dependent on Alex, and at the same time resisting aggressive urges toward him. Professionally, she has a PhD in psychology but is unconcerned about obtaining her license. Even her racial identity fluctuates in the way she defines herself within a social context. This internal separation of the self adversely affects other ego functions, such as the capacity to neutralize anger, impulse control, and anxiety tolerance.
Betty struggles with the developmental tasks of the late practicing and early rapprochement subphase. She defensively fends off fears of object loss and to a lesser extent, loss of the love of the object. Betty was prematurely cut off from maternal responses to her dependency needs due to mother’s work and the birth of Bobby at this critical point of recognition of separateness. Well before the achievement of object constancy, Betty came to rely on her own maturing, autonomous apparatuses in lieu of an available mother. Blanck and Blanck (1974) described such premature ego development as “an unevenness in development characterized by pseudo-self-sufficiency in which part of the ego replaces the symbiotic partner,” and in which there is a “concomitant absence of object cathexis” (p. 340).
Psychodynamic differential diagnosis
Betty’s long-standing relationship with a married man initially alerted me to consider unresolved oedipal conflicts. Nevertheless, Betty’s lack of object constancy and her profound dependency needs (oral) and attempts at controlling others (anal) clearly placed Betty at a preoedipal developmental level. Betty’s anxieties vacillated between the loss of the object and loss of the love of the object. A keener understanding of her relationship with Alex was required to assess if this was merely a temporal regression to a preoedipal state. Betty has proclaimed herself, “The Queen of Fantasy.” When asked how she felt about Alex’s wife, Betty claimed,
She didn’t exist. I had Alex on weekends and that was all I wanted. During the week he was whoever I wanted him to be. I created him. In my fantasy he had no wife or children. I was in complete control. I never felt competitive . . . I had him.
Nevertheless, this is not delusional; Betty acknowledges this is fantasy and a style of coping. Over the course of the treatment, I came to believe that by utilizing primitive defenses, most importantly denial, Betty was able to relate to Alex dyadically. She pervasively operated at a borderline level of functioning, and her denial, splitting, projective identification, and distorted sense of reality were in keeping with a borderline diagnosis.
Alex’s marriage served to modulate Betty’s ambitendencies. Betty was able to get her intense hunger for love, intimacy, and comfort gratified through the blissful experience of merger (like when her mom would work from home on weekends). However, this is an anxious and dangerous dependency. She therefore established a relationship that naturally retreats so that the anticipation of an all-consuming love will be averted; she will not be swallowed up or completely lose her own sense of shaky individuality. She can live richly, but within a world of fantasy, safe from the dangers of conventional relationships. This is consistent with Betty’s preoedipal dynamics. I believe the pathology is best viewed as primarily preoedipal and not as the result of regression from an oedipal state.
6 Case Conceptualization
Betty’s object relationships can be best understood theoretically from Erikson’s and Mahler’s theoretical perspective of development. Betty’s history of abuse and emotional abandonment sheds light on her ongoing problems with intimacy, safety, boundaries, rage, emptiness, and depression.
Her mother returned to work shortly after Betty was born. Betty was left in the care of a babysitter until she was approximately 9 months old (trust vs. mistrust). According to Mahler, the child begins to “hatch” during this time. The child becomes increasingly interested in the outside world while using mother as a home base. If responsiveness by the mother or primary caretaker is not optimal during this time then the differentiation may be characterized by fear rather than curiosity (subphase (Mahler, Pine, & Bergman, 1975).
By age 2 (autonomy vs. shame), Betty was forced into premature ego development because of maternal unavailability due to work, the arrival of the second baby, and the abandonment by her father during a critical developmental period. This occurred during what Mahler describes as the rapprochement subphase, marked by needs for individuation as well as reassurance before the achievement of libidinal object constancy (Mahler, 1972). Thus, within the first 2 years of life, Betty experienced prolonged separations from her mother, permanent loss of her father, and a succession of unsatisfactory and unstable child care situations, thus generating Betty’s lack of trust and fears of attachment and abandonment. Her subsequent relationships in life have consequently taken on a transient, shallow, indiscriminate, and ungratifying pattern.
Betty’s mother wanted her to become independent as soon as she began to explore her separateness. This can provoke a fear of object loss. The child, experiencing premature pressure to grow up, may engage in a reaction formation against the recognition of her deeper needs while continuing to have a weakened core. In later life, separations or, paradoxically, successes may reawaken memory traces of being abandoned and produce a sense of profound anxiety or loneliness (Mahler, 1972).
Betty reconstructs a history confirming the problematic separation-individuation hypothesis. Betty’s incapacity for intimate relationships with therapists, partners, or friends may be a result of the faulty resolution of Mahler’s rapprochement subphase of the separation-individuation phase of development. Mahler used the term ambitendency to describe the push-pull of compelling needs for closeness and autonomy that characterize this subphase (Mahler, 1975). Betty’s repeated terminations and reentry into treatment reflect the ambitendency experienced by Betty as a toddler. Betty’s anxiety with respect to her dependence on an unresponsive maternal object seems to occur when Betty realizes she is not all powerful (autonomy) or the center of the universe (being cared for).
In retrospect, another way to conceptualize this case would have been through the lens of trauma theory. According to trauma theory, most if not all the features (identity diffusion, self-regulation, and problematic interpersonal relations) of BPD are a consequence of early sexual abuse and severe repeated childhood trauma. According to a study by McLean and Gallop (2003), individuals with early onset of sexual abuse were significantly more likely to be diagnosed later with both PTSD and BPD than those with late onset. This may be because the abuse interferes with the developmental process. The similarities in symptomatology give support to conceptualizing this case from either theory. However, because this case was formulated from an object relations point of view, I will proceed to demonstrate the usefulness of Mahler’s work during Betty’s treatment.
As I look back over my conceptualization of Betty, I am aware that although I have attempted to stay close to the developmental and clinical data, it is a scant approximation of a complex woman. She is often contradictory and extreme. By the very virtue of Betty’s characterological use of splitting, it is difficult to paint an integrated picture of her.
7 Course of Treatment and Assessment of Progress
The 1st year of treatment was turbulent. Despite Betty’s pain and despair, she had difficulty engaging in the early phase of the treatment process. Betty characteristically resisted any kind of ongoing relationship that would carry danger of harm or the inevitable danger of loss. Lack of trust and a reservoir of rage were further impediments to the establishment of a therapeutic alliance.
Betty’s lack of object constancy was apparent when she would experience closeness within the therapeutic relationship. This experience would result in missed appointments or create disruptions that would provide distance. She would often attack my competence. She would alternately proclaim that she feared she would destroy me or I would destroy her. Her rage is toxic in that it destroys the very relationships she angrily depicts as ungratifying, leaving her with no gratification at all. A pivotal point for Betty came 1 year into the treatment when I interpreted her anger not as an emotion but as a defense to establish distance and thereby protect herself from the intimacy that she so feared. Control of the relatedness and separateness was of paramount importance. Conversely, when Betty’s anger/rage produced too much distance, she would feel abandoned, whether she initiated the separateness or not. After one of Betty’s breakups with Alex, she commented, “I kicked Alex out this weekend. I’m feeling so depressed and abandoned.”
She tends to see herself and others in a one-dimensional way, which is consistent with the splitting tendency characteristic of people with this diagnosis. One misattuned response and she will categorize me as “all bad.” A historical perspective cannot be maintained, and past performance has no reality. Betty also splits off her undesirable aggressive traits. To rid herself of unacceptable hostility, she protects herself by projecting. In treatment, it is common for Betty to project her destructive feelings onto me, whom she will then devalue (all bad). I become the enemy who must be controlled.
When Betty gets more deeply depressed, she would arrive to session with immaculate makeup and dressed as if she were going to a job interview. The more split she feels, the greater her need to have the appearance of competency—no doubt an internalization of her mother’s expectation of little Betty to prematurely be self-sufficient and competent to care for her brother early on. This is another example of Betty’s “pseudo-self-sufficiency” which Blanck and Blanck (1974) described earlier. Betty also associated feelings of depression and low self-esteem with high level of accomplishment, possibly due to early associations of object loss with respect to autonomy and independence during the individuation-separation process. Betty will in fact come close to accomplishing desired goals and then sabotage success or loose motivation, for example, inability to obtain professional licensure or accept career opportunities that are offered. Autonomous behavior and mastery restimulate Betty’s archaic experiences of abandonment, and the old sadness returns.
Any change in my demeanor or mood would create confusion and anxiety for Betty. This is another example of her inability for object constancy. At such time, she comments that she feels as though I am “a different person,” and this also ignites feelings of abandonment in her. She would use projective identification to defend against this vulnerability. Should I identify with her projection, she felt safer and more in control because she got to define me. The reparative work of the early treatment was founded on the building of trust and safety. The efficacy of this approach was confirmed nearly 1 year into treatment by her comment, “You are the only person that I have any sense of consistency with.”
Nevertheless, only months after Betty made that comment, Betty’s trust was disrupted by my acceptance to a 3-month training program that was out of state. This meant a hiatus in her treatment. Betty’s immediate reaction appeared reserved and calm. By the next morning, I began receiving rageful messages on my voice mail threatening to sue me and my supervisor if the entire year’s fees were not reimbursed. Her anger was relentless for 2 weeks. This was a major hurdle in the treatment and in Betty’s developmental progress. Although difficult, I tried to remain constant, empathic, and whole, despite Betty’s efforts to see me split.
The following occurred 5 weeks prior to my departure and illustrates how our interaction went at that time. I had planned on giving Betty 8 weeks to prepare her for an interruption of treatment. Betty found herself in a crisis at that time, which left only 6 weeks for this process. The following session transpired 2 weeks after I gave Betty the news of my educational plans. This was the week that Betty left numerous hostile phone messages, complained to my supervisor, and threatened to sue me for malpractice. Betty experiences this abandonment as annihilation. Without the ability to contain or soothe herself, Betty erupts with the terror that she feels. Betty came to session with a gift wrapped in white tissue paper. Betty decorated the tissue paper by dipping her feet in paint and stepping on the paper creating a colorful pattern of her footprints. I opened the box to find an athletic supporter with a hard cup (the type athletes wear during games to protect their genitals). Without any desire to camouflage her desire to see me castrated Betty started the session. I attempted to conceal my intense intimidation and anger.
How dare you make plans like this without consulting me! I am fucking furious. This is totally unprofessional and you will pay for this. I told you how vulnerable I felt in the beginning of this . . . in fact I told you that I feared that you would reveal yourself as crazy. You are suppose to help me learn how to develop healthy relationships . . . you are just another mental health hazard . . . I don’t need to pay for a repetition compulsion . . . you fucking asshole.
You sound very hurt and angry . . . I would like to understand your feelings better.
I am feeling quite exposed now that you reveal that you have been taking steps to terminate therapy in four sessions . . . we never discussed a time-limited relationship . . . I was moving closer to you . . . you should have told me.
[Defensively] I just recently found out myself. . .
[Interrupting and yelling] You should have told me about your possible plans . . . I don’t care if they were uncertain . . . This feels like another major abandonment . . . it feels overtly hostile . . . I feel victimized [Pause].
[I take a breath about to speak]
I don’t want to hear about an “interruption in treatment” . . . this is a termination . . . I don’t do telephone therapy . . . I don’t do telephone relationships. This is not negotiable . . . I don’t want some of my needs met . . . This is termination baby! [Betty leaps out of her chair pointing her finger in my chest] And don’t expect me to pay for this session either. You have ripped me off as much as you are going to.
Betty, you must sit down . . . if you don’t we will have to end the session. [Betty sits and gathers her purse as if she is preparing to leave] I do want to hear what you have to say. I am fully committed to continue treatment with you [I stop speaking as Betty covers her ears with her hands].
I’m not listening [stares intensely—long pause]. I don’t want a relationship that has so many conditions. If you retreat into a self-protective stance, you will lose. I’ll use whatever I have to get you. I have no intention of taking care of you out of some sort of guilt. You can’t treat me . . . your countertransference is too strong. Why don’t you admit that you are angry with me? Why do you keep seeing me . . . I know you don’t want to.
If I was angry would that help relieve your anger? [Pause]. When have you felt like this before?
[Maintains an angry glare with tearful eyes] Why can’t you admit that you are angry . . . I know that you are. You are furious with me. You are protecting yourself . . . [Folds her arms and resumes an angry stare].
It’s true I have felt angry. Can you tell me how that makes you feel?
[Posture melts and face looks sad] You punished the honest me that so much wanted you to stay with me and not leave . . . to do more important things than take care of me. [Almost to herself] This pain is so familiar. It still hurts (crying).
I am so angry with your mother.
[Inaudible—crying].
It must have been very painful for you to see her leave for work. You wanted so much for her to love and nurture you. Now . . . like mom . . . I’m going off to do “important things” and you feel left to fend for yourself—way before you felt ready. I am very sorry.
I wanted you to hurt like I hurt.
So I could better understand your pain? To reestablish a connection?
[Seemingly calmer] Possibly.
I understand that you have been very injured and that my leaving for school reopens old wounds. It must have been very painful and frightening; can we talk a little about that?
Betty went on to discuss early issues of abandonment, her fears of destroying me, and how she had to act all grown-up and take care of herself and her brother. Betty began to recognize the early dependency wishes, which she had previously adamantly denied. Betty identified feelings of intense shame that she suffered. She could not live up to her idealized grown-up image of herself.
This illustrates a time when Betty intensely needed to disavow her rage about object loss. I rarely express my personal feelings in session. Nevertheless, once I composedly express my own feelings of anger (projective identification), Betty visibly calmed. Previously unmanageable feelings became more manageable and less terrifying than before. Thereafter, Betty was able to take back those feelings, now made more manageable, and hopefully take in some of my capacity to contain and stay with these difficult feelings. Kernberg, Selzer, Koenigsberg, Carr, and Applebaum (1989) stated,
One manifestation of omnipotent control is the borderline patient’s attempts to make the therapist an extension of herself. The patient’s rage toward the therapist for having a separate life, the confused and confusing identification as both a victim and victimizer, the demands to which the therapist has difficulty responding appropriately—all can combine to render the therapist ineffective and make the patient’s control complete. (p. 75)
Betty does not really want to destroy the object—only control it. This interpretation seemed compelling to Betty and me. It seemed to fit, and Betty worked with it productively. These unconscious dependency wishes and the anger toward the object with whom she could no longer control and who had ultimate power to meet or refuse to meet those needs are partly the conflict of the above session. Her anxiety and shame were stirred up with the emergence of the dependency needs, the rage at the power the needed object had over her, the fear of retaliation of that anger, and the anxiety of abandonment—all of which are central transferential issues that give insight to Betty’s struggles.
A series of enactments of old object relations and identifications emerged. At times, I was her mother, rejecting her dependency and encouraging her autonomy (my departure for training). She would feel powerless and victimized. But then she was her mother, detached, controlling, and victimizing. Either position was untenable for Betty and our alliance. In innumerable sessions and via innumerable routes, her current anger and attacking behavior was seen in relation to her retention and reliving of that old traumatizing internalized object relationship. On one hand, she wants to retaliate, and on the other hand, she wants to master the repetition of the old internalized object relationship. During her rageful enactments, Betty is usually beyond reproach; nevertheless, she has begun to acknowledge her defensive splitting retrospectively.
Sometimes I feel frightened and helpless when Betty attacks me. During these times and noticeable in the process recording above, I find it difficult to respond spontaneously. I refrain from interpretations and move toward safer clarification questions to slow down the process so I can assess both the transference and countertransference simultaneously. It is during these times that I rely most strongly on technique and supervisorial internalizations because I am fearful of making a countertransferential blunder. As I understand Betty better, it becomes easier to sort out projections, projective identification, and countertransference. Betty seems to recreate in me the attitude that her mother may have had. I wonder whether I am, like mother, not hearing or misunderstanding the child’s cries. As I contain my own anxiety during these times, I am better able to understand the projective identification as a reenactment by which Betty communicates unspeakable experiences or preverbal affects.
In the 2nd year of treatment, Betty was able to enter into the therapeutic process only after she realized that her intense rage would not destroy me and that I would interpret or contain her projections rather than identify with them.
The following narrative elucidates the thesis of this article and illustrates Betty’s progress after 2 years of treatment. Just a few weeks prior to this session, Betty again expressed her ambivalence about staying in treatment. Shortly after working through some of Betty’s resistance, the following process transpired.
I feel depressed and anxious . . . This is the toughest shit in the world. I had a dream last Wednesday that I want to share.
Do you mind if I take notes?
There was this . . . this very threatening Black man . . . I was on the ground and his face was large and above me. There were other Black men standing around. He orders one of these guys to take me out to the ocean and drown me. One of the guys started dunking my head under the water . . . It was cold . . . I knew I didn’t want to die . . . not this way. He whispered to me to just fake being dead . . . so I did and let my body go limp. He dragged me to shore and I laid there. Occasionally, I would forget and blurt something out and he would remind me to “play dead” or you will really have to die. Next thing I know I meet this old White bag lady, dressed in a baggy old dress. She tells me to follow her . . . so I do. Meanwhile I’m still limp . . . limping . . . even though I realize that I don’t need to any more. She invites me to get on this bus. I get on but I don’t have any money. She tells the bus driver, “It’s OK, she’s with me.” So we sit in the back of the bus and there is no one else on it. We start to pass through my old neighborhood, and she begins pointing things out. I am fascinated that she knows so much detail about my turf. Occasionally, I can’t see her . . . peripherally . . . she’s on the side of me. I start to see old landmarks. I decide to get off. She says, “You can’t leave yet, this is a journey . . . we have more to see.” Each time the bus stops, I want to leave . . . but I don’t . . . I find myself going limp from time to time . . . like I’m still afraid I’m going to die . . . even though I know it’s no longer necessary . . . It’s just the way I function. I woke up feeling anxious . . . It was quite powerful.
So this happened after our session last week?
Yes.
We took time to freely associate before moving to interpretation. We collaboratively interpreted the dream as representing Betty’s experience in treatment. The threatening Black men were the men who sexually molested and abused her in the past. They also represented me, who Betty fears will harm or destroy her. Similar to Freud’s “oceanic feeling,” the ocean was her mother—the mother of union, loss of self, and disappearance. However, the oceanic feeling is not a positive merger with omnipotence; indeed, Betty’s waters are cold with the power to engulf. Not speaking and going limp were Betty’s old defenses that she utilized to survive and which she now challenges. It also represented the trouble Betty has sometimes expressing herself verbally in treatment. The bus was the consulting room, and I was the old White woman who beckoned Betty to remain on this difficult journey of her past. Her inability to see me represented her curiosity about who I was as a person and her limited capacity to hold a constant image of me between sessions. I offered possible alternative interpretations, but the above meaning is what resonated authentic for Betty.
There is something about surviving a major fight that is reassuring. I haven’t quit and you haven’t quit me and that says you aren’t going to go anywhere. I thought you would be furious with me for acting out, but . . . I think you know me well enough that if I do act out . . . that we’ll deal with it. I won’t destroy you nor you me. Uhmmm . . . You frighten me less as you come closer. I’m still a mess but comfort comes with the notion that I can stay and I am not harmed. [Long pause—reflective] I have been feeling conspired by my dream life . . . feeling very overwhelmed. I wanted to control my own pace but my dreams are not allowing me to do that, once I began to talk about them . . . they came to life emotionally and it caught me by surprise. Part of what was so frightening was that once I began to telling you stuff [trauma history], things started to happen inside [of me] so quickly, and there was the fear that my dream life will give me more than I can manage. I decided if I’m going to have these kinds of dreams that I don’t want to do it alone. When I called you this week . . . I told you that I was frightened and didn’t know what to do . . . you suggested that I bring in the dreams [to the treatment] and we would look at them . . . and that was really uncomfortable.
Because?
That means you are available to help me . . . and that’s frightening. What I finally realized is . . . and have a hard time saying . . . I want you to be there so that I could do what I had to do in the dream without feeling unsafe. What I have been doing lately is putting you in my dreams . . . so I feel safer. Then I realized that I’m not alone. I don’t have to do this journey alone. I’m coming to realize that dependency is not totally a bad thing. [Chuckles almost jokingly to cover her embarrassment] That’s a new concept! [More seriously] I never thought like that before. I was so frightened to call you and admit that I was frightened. It is difficult for me to ask . . . not to be alone . . . it’s difficult to admit that.
It sounds like it is frightening to be alone with these feelings and frightening to ask for help so that you don’t have to be alone.
Yeah, that’s right.
When you called me about your dream, you were not only frightened. You said that you were angry because I was “colluding with your unconscious.”
I meant that our discussions were inspiring my dreams . . . and they were out of my control.
Do you feel angry that I am pushing you faster than you feel you can handle?
You push me, you push, you are demanding, uhmmm.
How do you feel pushed?
If I give you some material . . . a dream, or an actual event . . . you usually won’t pass on it, and in addition to a confrontation you provide an interpretation that kinda fits . . . that gives me some information at the moment that I can work with . . . and some I can’t work with, so that’s what I mean, and there’s a piece that takes me a while to get, so it winds up trickling [fingers flickering down like rain] . . . working that way. Does that make sense?
It kinda unravels during the week?
Well, it takes more than a week . . . actually . . . I have one take on the interpretation this week, another one next week, and another next month, and the meaning I get from it depends on what I am able to do with it . . . and it forces me to confront other stuff. I think part of my feeling comfortable . . . is that you do push. You provide just enough anxiety to . . . figure out what I’m uncomfortable about and how to work with it.
Is my pushing reminiscent for you in any way?
Betty proceeds to explain how her mother also pushed her. She differentiated that when I pushed, it was a result of attentiveness and interest in her. When her mother pushed her, it was toward an autonomy that was in service of her mother’s needs, not Betty’s. Betty recalled being severely punished for wanting attention when her mother was trying to work. For Betty, this awakened great sadness.
8 Complicating Factors
There were some challenges throughout the course of treatment. Betty understood psychological theory, terminology, and psychodynamic treatment. She also self-diagnosed herself as having a BPD early in treatment. Due to her clinical training as a PhD psychologist, she was very savvy about issues of countertransference and transference. Her intelligence and insight were her strengths; however, they could be used as weapons and/or defenses as well. When she was feeling vulnerable, Betty would try to disrupt my therapeutic position by questioning my unconscious motivations in hopes to gain control. To guard against derailment of the session, during those times, I was cautious about my wording and tone, which interfered with my ability to have an authentic presence during sessions. Also Betty’s attraction to unavailable White men introduced an element of seduction that Betty used consciously and unconsciously to both intimidate and pull me in.
9 Access and Barriers to Care
There were no issues regarding access and/or barriers to care.
10 Follow-Up
Paralleling the process in treatment, Betty has been better able to engage in a mutual relationship with Alex. They live together 5 to 6 days per week. Betty asserts that the relationship is less argumentative and more emotionally gratifying. They are beginning to make efforts to blend their families, which Betty formerly opposed vehemently.
Betty is more able to state her needs directly. She still has problems containing anxiety and has negotiated time-limited telephone contacts between sessions. She is better aware of the utility of her primitive defensive strategies (splitting, denial, dissociation, and projective identification) and makes efforts to understand her behavior in a less punitive manner. While impulsivity is still a problem, she is developing a capacity for self-observation. She now has a brief transitional space that allows her to catch herself before speaking or acting.
11 Treatment Implications of the Case
There is a dearth of outcome studies on the treatment of persons with BPD to guide clinicians. Besides psychodynamic treatment modalities, many other types of treatments are also popular with BPD. Other popular modalities include short-term hospitalization, residential treatment, long-term intensive psychotherapy, cognitive behavioral therapy, dialectic behavioral therapy, and schema-focused treatments. Treatment can be done one-on-one or in groups. It is difficult to decide which modality will work best for the patient and the therapist (http://www.nimh.nih.gov/health/publications/borderline-personality-disorder.shtml).
Currently, Marsha Linehan’s dialectical behavior therapy (DBT) has gotten considerable attention. Linehan’s research showed that DBT was helpful in reducing hospital time, self-injury (cutting, burning, suicidal gestures), and anger. However, a year after treatment terminated, the rates of self-injury by the DBT group were similar to those of the control group (Linehan, 2006). More outcome studies are needed to discern the efficacy of the different modes of treatment to find out what modality is effective for which symptoms. Until we have such studies, we must look to related literature for guidance. According to Winston (2000),
Ideas derived from psychoanalysis have received some empirical support and the central etiological role of childhood trauma has become apparent. Attachment, identity and the ability to make sense of feelings are increasingly seen as interlinked and all are adversely affected by abuse or neglect in childhood. (p. 212)
Considering that 87% of people with BPD have a history of childhood abuse and neglect, 40% to 71% have been sexually abused, and 25% to 71% have been physically abused (Ball & Links, 2009), it would make sense to look at treatment models that are more consistent with trauma disorders. There are abundant theoretical explanations correlating abusive and neglectful childhood experiences to problematic interpersonal relationships, poor boundaries, and inappropriate sexualization (Chu, 2011). Borderline individuals have trouble regulating emotions, which also appears to be linked to early trauma (Bradley, Jenei, & Westen, 2005), and sexual abuse is associated with self-injury for patients with BPD (Videbeck, 2010). This has led some researchers to connect BPD with PTSD.
The long-term psychological consequences of abuse depend on where the individual was developmentally when the abuse or neglect took place. The earlier the abuse takes place, the more detrimental the effects are likely to be (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006). Betty’s mother’s circumstances left her unable to attend to or protect Betty sufficiently during early pivotal developmental stages. Borderline individuals are typically preoccupied with their disturbing unresolved early relationships. This is probably because the child is cognitively and emotionally underdeveloped and thus unable to integrate or make sense of the early neglect or traumatic experiences (Buchheim et al., 2008).
Attachment theory is a close offspring of object relations theories. Research based on attachment theory is starting to clarify the relationship between childhood trauma and difficulties with interpersonal relationships later in life.
This finding is consistent with the observation that maltreated children have difficulty in expressing both negative and positive feelings. As well as contributing to problems in interpersonal relationships, the inability to think about feelings may combine with defective affect regulation to produce the impulsivity which is so characteristic of borderline patients. (Winston, 2000, p. 212)
12 Recommendations to Clinicians and Students
Psychoanalytic psychotherapy has long been used in the treatment of borderline patients but has never been subjected to formal evaluation. The available data suggest that only a minority of borderline patients benefit from psychoanalytic psychotherapy in its traditional form (Winston, 2000). A modified psychodynamic approach, which emphasizes current rather than past experiences and in which the therapist takes a more active role, may be more appropriate for the treatment of BPD (Levy, Clarkin, & Yeomans, 2006).
There are many schools of object relations theory, and although they share a common base, the theories vary on the subject of human development. The clinician should carefully choose a theoretical model that fits the clinician and the patient. Formerly, when treating people with a borderline diagnosis, I utilized a Kernbergian approach. This approach mandates more structure for the patient during the treatment for containment and boundaries. At one time, I believed it offered me a clearly delineated road map by which to treat. This approach was used with great success by my supervisor and colleagues. Nonetheless, because of the incongruence with my personal beliefs and style, it only created a more intense negative transference, a tumultuous countertransference, and a weakened therapeutic alliance. A strict unyielding structure seemed to lend itself to splitting rather than affective containment.
Conceptualizing Betty’s development from a Mahlerian perspective, I was able to provide constancy and the flexibility while negotiating limits that would also affirm Betty and assist her to live with more integrated feelings. Blancks’s treatment model focuses on ego deficits as well as separation-individuation issues with which Betty struggles. Blancks’s model seems more sensitive to and less assaultive of the patient’s defenses.
The provision of intentional gratification and emphasis on real object experiences are important reparative aspects of treatment. I have found this technically helpful while intervening in Betty’s treatment. Knowing how much support or gratification to provide to assist in building certain personality functions or structures is a difficult decision. I recommend soliciting consultation regarding the development of some criteria for when and how to provide real object experiences and measured gratification for the patient’s treatment. That said, there are many roads to reach a desired destination. Careful consideration, along with reliable supervision, can avoid cumbersome countertransference that can frustrate the treatment. A clinician needs to find the theory that is syntonic with his or her belief in healing; otherwise it can create an internal conflict for the clinician, which will cloud and confuse the treatment.