“While the language of psychiatry has remained deeply rooted in a medical frame of reference, our concept of psychopathology or mental disorder is no longer a traditional medical concept. Rather, as Thorpe (1960) has pointed out, we conceptualize mental disorder as a hypothetical construct of dynamic interaction among biological, psychological, and social factors.”
Stella Chess and Hassibi Mahin, 1978
History
Clinicians such as Kety and Rosenthal at one time approached borderline behavior as a psychosis, calling it “borderline schizopa.” Others, such as Kernberg, Masterson, Gunderson, and Singer, approached it from the perspective that it was a neurotic character disorder (Webb, 1981).
At the time, “borderline personality disorder” described the condition of the patient less than it did the confusion of the psychiatrist concerning the nature of the presenting problem (Masterson, 1972).
In the early 1950s, personality disorder was identified as one of three psychopathologies included in borderline behavior. Campbell (1981) defined personality disorder as:
“… patterns of relating to the environment that are so rigid, fixed, and immutable as to limit severely the likelihood of effective functioning or satisfying interpersonal relationships. They are deeply ingrained, chronic, and habitual patterns of reaction that are maladaptive in that they are relatively inflexible; they limit the optimal use of potentialities and often provide the very counter-reactions from the environment that the subject seeks to avoid.”
Therefore, clients who exhibit borderline personality disorder often have stable contact with reality, but exhibit psychotic symptoms under stress (Goldstein, 1980).
Now that the DSM III (1980) has included “borderline personality disorder” as a diagnostic category, some of the confusion has been cleared up. (The previous concept of “borderline schizophrenia” is now called “schizotypal personality disorder.”)
The diagnostic criteria for borderline personality disorder includes eight characteristics of current and long-term individual functioning, five of which need be exhibited in order to make the diagnosis. These characteristics are:
- Impulsivity or unpredictability in at least two areas that are potentially self-damaging, e.g. spending, sex, gambling, substance use, shoplifting, overeating, physically self-damaging acts
- A pattern of unstable and intense interpersonal relationships, e.g. marked shifts of attitude idealization, devaluation, manipulation (consistently using others for one’s own ends)
- Inappropriate, intense anger or lack of control of anger, e.g. frequent displays of temper, constant anger
- Identity disturbance manifested by uncertainty about several issues relating to identity such as self-image, gender identity, long-term goals or career choice, friendship patterns, values, and loyalties
- Affective instability: marked shifts from normal mood to depression, irritability, or anxiety, usually lasting from a few hours and only rarely more than a few days with a return to normal mood
- Intolerance of being alone, e.g. frantic efforts to avoid being alone, depressed when alone
- Physically self-damaging acts, e.g. suicidal gestures, self-mutilation, recurrent accidents, or physical fights
- Chronic feelings of emptiness or boredom
It is important to remember that for persons under the age of eighteen, “identity disorder” is the appropriate diagnosis when the symptoms of borderline personality are observed.
Masterson felt that borderline syndrome was not a specific personality disorder, but was a symptom of personality organization. This view is shared by the DSM III. Masterson claimed that the principle psychopathology was a failure in the pre-oedipal stage of development, leading to a pathologic defense mechanism. Individuals were diagnosed as borderline when evidence was found of this developmental arrest in an individual’s functioning.
This subject has generated a great diversity of thought. Michael Stone (1980), Thomas Szasz, and others feel that there is greater etiological significance in genetic and constitutional factors. Today the role of constitutional factors is supported by Masterson (1981):
This view (his developmental theory) as originally stated remains unchanged as one of the possible etiological agents; however, it now requires the following addition: Contributions to the etiology may come from either or both sides of the mother-child equation … from both nature and nurture. Examples of the former would be minimal brain damage or developmental lags or disharmonies.
What Causes Borderline Syndrome?
In Masterson’s view, the child during the rapprochement stage needs his mother to be appropriately supportive, to be reassuring, and to provide a loving environment that encourages him to individuate. This “emotional refueling” is the reassurance the child needs to overcome the natural anxiety he feels when individuating. The child looks towards the father to provide a tangible “other than mother” presence (Masterson, 1972). The original mother/child symbiotic unit attachment is stronger than the secondary support received from the father, however, as the mother is more important in this process.
According to Masterson, what goes wrong during this period is that the mother withdraws her support from the child when he attempts to individuate. The mother can’t tolerate the child’s curiosity and assertiveness, and withdraws support from the child in order to maintain the closeness she felt during symbiosis. Rewarding the child with her emotional availability when he clings and acts regressively, and punishing him by withdrawing support when he acts independently has the effect of splitting the child’s self-image. When support is consistently denied the child in the individuation stage, the result is arrested growth.
A good example of this shown in the case excerpts at the end of this paper. As in many similar cases, the mother’s behavior is motivated by the desire to recreate the symbiotic tie she had with her mother. This is supported by clinical findings that “90 percent of … borderline patients have borderline mothers” (Masterson, tape). There are other reasons, of course, why the mother might be unavailable to the child, including depression, psychosis, and absence.
Within the split object world of the child, interactions with the mother are represented intrapsychically. The “good” mother is the “rewarding object part unit” that offers approval for regressive, clinging behavior; the “bad” mother is the “withdrawing object part unit” that criticizes the child’s efforts towards autonomy.
Symptoms
It is genetically appropriate for the child to individuate. The dilemma occurs when the mother withdraws her love. This dilemma produces in the child six clinical features that Masterson calls “abandonment depression.” It consists of: 1) homicidal rage. 2) suicidal depression. 3) panic. 4) hopelessness and helplessness. 5) emptiness and void. 6) guilt.
Split ego functioning: pathologic ego, reality ego
When given consistent nurturing, the child reacts by unifying the self and the object. Abandonment depression results in the interruption of the child’s drive towards unification. His images of self and object remain split, and his ego fails to make the transformation from the pathologic ego (which operates in accordance to the pleasure principle) to the reality ego (which operates in accordance to the reality principle). The pathologic ego then becomes dominant (Masterson, tape).
Pathologic defense mechanisms
Masterson believes that the pathologic ego protects itself against abandonment by the use of defense mechanisms, such as: splitting, clinging, acting out, denial, avoidance, projection, and projective identification. These important clinical features of the borderline syndrome represent the child’s reaction to the developmental conflict. I will discuss each of these in turn.
Splitting
This term was introduced by Kernberg, who defined it as the major defense mechanism for the borderline individual. It is the defensive separation of the “all good” images from the “all bad” images (Edward et al, 1981). The borderline, therefore, thinks in terms of black or white. An example of this would be a person who one day praises the therapist (for the first time in years) for the good progress they have been making, and the next week becomes angry with him over a minor irritation. The borderline oftentimes picks a fight as:
… a defense against libidinal wishes that had been stirred up by his acknowledgement of something positive in the therapist. The turning of the therapist into a “bad” object served as a defense against those urges which threatened to lead to feared closeness.
Splitting can sometimes be viewed as representing a developmental arrest as well as a defensive maneuver.
Clinging
Clinging is the mechanism used by the borderline to avoid separation anxiety and abandonment depression. An example of this would be when a person stays in a crippling and self-destructive situation because of the anxiety produced by changing.
Acting Out
Acting out is the result of displacing the unresolved anger the borderline feels towards his mother onto himself and significant others. Examples of this behavior are substance abuse, stealing, short-term sexual relationships, unkempt appearance, etc. This is seen in a clinical situation when the client, through transference, vents his rage upon the therapist.
Denial
Because the borderline harbors the desire to reunite with his mother or father, he must contain his feelings of abandonment depression via the mechanism of denial. This sacrifices the borderline’s ability to function in the real world. An example of this is when the borderline idealizes his parents, denying the reality of the way his parents treated him.
Avoidance
Fears of reliving the separation process that occurred in the borderline’s childhood cause the borderline to attempt to avoid situations that could lead to separation anxiety. An example of this is the borderline person who avoids relationships because of fears of engulfment and abandonment.
Projection
Projection occurs when the borderline becomes terrified in a relationship because he feels that at the onset of intimacy, the other person will reject and abandon him. He therefore must break off the relationship before that happens. An example of this would be the client who, after showing signs of improvement, regresses because he is convinced the therapist will end the relationship as soon as the client is cured.
Projective Identification
Kernberg believes projective identification is used by the borderline because his ego boundaries are weak, and therefore he projects his feelings onto the person he identifies with. The result is that the aggressive urges are maintained and his fear of these urges is increased. The borderline deals with this by trying to control or attack the other person before the other person can attack him (Edward et al, 1981).
Relationship between the split object part units and the pathologic ego
To relieve feelings of abandonment depression, the borderline’s rewarding part unit is activated by his pathologic ego. This is viewed as being ego-syntonic. This alliance promotes the denial of separateness, and encourages the ideation of reunion fantasies. Thus the borderline generates for himself feelings of being loved.
The borderline still maintains feelings of abandonment depression, however. These feelings are internalized, and the aggression is discharged by means of symptoms, inhibitions, and destructive acts as shown in the section on defense mechanisms.
When instances of separation, loss, or growth are experienced by the borderline, the withdrawing part unit is stimulated. At this point the borderline is trapped. His pathologic ego relates to these experiences as ego-dystonic, and there is an attempt to project the resulting feelings of abandonment depression onto another person. When the feelings have been successfully projected, the pathologic ego then moves to reactivate the rewarding part unit.
Treatment
Both analytic and supportive approaches are recommended in the treatment of individual borderline clients (DSM III, 1980). I feel it is helpful for the MFCC to understand these approaches when dealing with a borderline family member.
Masterson’s initial therapeutic objective is to confront the client’s behavior to show him how self-destructive it is. He feels a supportive confrontational therapeutic technique can engender transference on the part of some clients. Transference helps the client internalize the therapist as a “good” object. Once the client establishes a positive reality ego alliance with the therapist, the client’s emotional investment is shifted away from his pathologic ego/rewarding part unit alliance. One indication that this has been accomplished is when the client makes his old behavior “ego alien” by giving it a disparaging nickname (Masterson, 1972).
The second therapeutic objective is to help the client differentiate between and understand his “good” and “bad” self- and object representations. This understanding promotes the coalescence of the representations into integrated units. This is accomplished via a “circular working-through process” (Masterson, 1972): Confronting the client with the destructive nature of his scripting leads towards self-mastery and growth. This activates the client’s withdrawing part unit with its accompanying feelings of abandonment depression. Because of the therapeutic alliance with the clinician, the client is able to face these painful feelings. The success the client feels as a part of the therapeutic alliance activates his rewarding part unit, which enables him to again confront the next level of scripting.
With each turn of the circle, memories of the withdrawing mother come back to the client in reverse order. The expression of the encapsulated rage and depression associated with the withdrawing part unit and “bad” self-representation help the client remove the emotional roadblock that prevents him from higher functioning. At this point, the client has begun to give up the splitting defense and is moving to complete the work of separating and individuating.
Professional Insights and Development
It is my feeling that the MFCC training background is not best suited to work in individual therapy with the borderline disorder. If you find yourself doing individual therapy with the borderline, I believe you should refer him to a mental health professional who is trained intrapsychically in diagnosis and treatment in dealing with the borderline client. However, one must be prepared to work with borderline clients as part of family therapy. A good example of this is the work I did with a family with a borderline mother.
This case enhanced my skills in supportive therapy techniques, using clinical process in dealing with the mother’s and child’s feelings, re-parenting techniques in helping the mother more effectively relate to this child, using a confrontational approach in which a containment technique can be utilized when a borderline is flooded with emotions, and using family therapy strategies, which will be described below.
It also helped me to examine Masterson’s view that the borderline personality type is caused by a developmental failure in the mother/child relationship. In Masterson’s later works, he puts forth the theory that the borderline syndrome can be both nature and nurture (Masterson, 1981). There seems to be considerable research to support the idea that the basic temperament of the individual plays a major part in many pathological syndromes (Haley, 1976).
Case Excerpts
In this section I will describe through the case excerpts my learning experience in doing co-therapy with Dr. Don Fleming, who is the expert evaluator of each of these clinical cases. In each of these case excerpts, I will make observations of Dr. Fleming’s work, of my own work, of my professional and my personal reactions, and about what I’ve learned from the experience.
There are four clinical characteristics I am using to demonstrate my development:
- Family therapy techniques
- Clinical self-awareness
- Counter-transference
- Building a trusting relationship with the client
Will we use material in the case excerpts from throughout the therapy. In the case excerpts we will describe:
- The steps we used to re-parent Jane
- Building a trusting relationship with the client
- Helping the mother separate from the child to let her daughter go to pre-school
- How we worked with the mother’s intense emotional reaction to her daughter’s autonomy and independence.
- My development while working with a client who was very fragile emotionally and could easily feel wounded by what was said to her
- My counter-transference
- My clinical self-awareness
In the early sessions with the family our goal was to develop a trusting relationship with the mother.
Case Background
This is a case of a 35-year-old divorced mother, Jane, diagnosed as being a high-functioning borderline personality type, as defined in the DSM III, including these five clinical features:
- Inappropriate, intense anger or lack of control of anger
- Affective instability: marked shifts from normal mood to depression, irritability, or anxiety, usually lasting from a few hours and only rarely more than a few days with a return to normal mood
- Intolerance of being alone. Wants someone around but will not be intimate. Mostly feels empty and bored.
- A pattern of unstable and intense interpersonal relationships.
- Chronic feelings of emptiness or boredom
Jane was referred to us by her pediatrician with a presenting problem of separation anxiety from her daughter, Mary, age four. Jane presented to us that she wanted her daughter to be in pre-school but she felt afraid to entrust her daughter to any pre-school. Jane had many intellectual rationales why these schools were inadequate, some of which were based on her training at the Bank School of Child Development.
As we looked at Jane’s background, we found she had been verbally abused by her mother and abandoned by her father, who left the household when Jane was five years old. Jane grew up with few friends, in a background of a socially and emotionally isolated family.
Jane was married at the age of 26 father for five years. Mary was one year old at the time of the divorce. Jane’s ex-husband has not made contact with her or Mary since the divorce.
Jane and Mary live an isolated life. Since the divorce, Jane has not developed any social contacts. Mary has been the center of Jane’s life, but Jane now sees that they both need outside contact, and that Mary needs to be placed in a pre-school. Jane loves her daughter, and wants the best for her. Due to her basic fears and lack of trust, Jane has a great deal of difficulty implementing these goals.
Jane needed to feel accepted and understood by us. Jane also had to develop a sense of trust in the treatment team before she would even consider allowing us to tell her what was best for her child, and yet she was the type of person who would easily mistrust the therapy and therapist if she felt at all threatened by the interaction. It was a challenge to maintain a therapeutic alliance with this client, but we were able to do so using a variety of clinical techniques.
When she started with us in treatment, Jane would complain about her ex-husband because she had many unresolved feelings of anger and pain concerning that relationship. She expressed her sense of loneliness and isolation by dwelling on the fact that there was no one in the world she could trust; she and her child had only each other. Jane’s belief that most pre-schools would not be adequate for her child’s needs was based on her deep-seated fears of separating from her child.
Case Excerpt 1
At first, Jane was allowed to ventilate her anger and anxiety. After a short period of time Dr. Fleming and I felt it was time to re-focus the therapy on helping Jane resolve the presenting problems.
I commented to Jane that I could hear how much she cared about her daughter and that she felt very concerned about her daughter’s welfare. I then turned to the child and said, “Mommy really cares about you, and feels worried about you. Mommy really wants to find a school that will be good and lots of fun for you. So we’re going to help Mommy see that there are some good schools out there, and I know Mommy really wants that for you.”
I noticed that Jane liked that I was talking to her daughter in a warm and supportive manner. I also got my beginning message across to the mother that there were some good schools available. Through my clinical self-awareness, I was able to see that the way to begin building a trusting relationship with the mother through the procedure of talking through the child.
I turned to Jane and said, “I can tell how delighted you feel when you watch your child play, and I can see that she means a great deal to you.” I then turned to the child and said, “Your Mommy looks like she loves you a lot.” It became apparent to me that one way to build trust with this mother was to validate the love and interest she felt for her daughter. After I said this to her daughter, the mother began to look at me warmly.
In the early sessions I learned one must focus on every opportunity to re-parent this mother, to look for and validate the mother’s intelligence, caring, and sensitivity for her child. By using the issue of the school as a part of the re-parenting technique, I was at the same time able to plant the seed that would lead to Jane considering alternative school choices.
Case Excerpt 2
In the early sessions, Jane repeatedly displayed impulsive, angry verbalizations either in the work we did together or in the sessions. She said angrily, “I went to the pre-school you suggested and the director would only spend ten minutes with me. I don’t think the teacher showed much interest in me either. And as far as I’m concerned, I don’t think the teacher knows very much about child development.” I said in a concerned tone, “I’m surprized, because this has not been our experience with this school.” Jane angrily replied, “You’re not listening to me. I told you the director and the teachers did not give me the time of day.” I then said, “I’m really concerned about how you feel….can we talk a little bit more about the school?” She looked daggers at me and said, “I can’t talk to you. What’s your background? You don’t even have children.”
I felt myself becoming irritated. This situation reminded me of times when my older sister used to routinely yell at me in a very abusive manner over minor situations. My clinical self-awareness helped me control my counter-transference. “Jane, I really feel badly that what I said made you feel I wasn’t listening to you. I hope I can show you that even though I don’t have children or the kind of background that you can feel comfortable with, I want you to know that I would really like to better understand your feelings.” Jane began to feel less annoyed and said, “Sometimes you don’t listen very well.”
My use of the supportive therapy technique of acknowledging her feelings helped Jane feel she was understood and that she could trust me. By responding in a caring way even when Jane expressed inappropriate anger and frustration, I was able to contribute to the re-parenting process (the infant who is allowed to rage and still feel loved).
In Masterson’s description of the borderline personality type he talks about the mother who withdraws her support of the infant. He believes that this consistent withdrawal produces arrested development in the child.(21) Jane provides an excellent example of this, as her mother was emotionally and psychologically abusive, and withheld love from Jane.
Case Excerpt 3
Jane walked into the session enraged at her four-year-old daughter. Earlier in the day, Mary had become lost in a store and had forgotten that in these situations she had been told to immediately go to a clerk and say she was lost. Instead, Jane found Mary an hour later crying in a corner of the store. In recounting this episode to us, Jane again started raging at the child, telling her how she could have been kidnapped and killed. Mary looked very frightened.
Dr. Fleming said, “Jane, we cannot let you keep saying these things to your daughter because you are scaring her, and we know you really care about your daughter.” Dr. Fleming then turned to the child and said supportively, “Your mommy doesn’t really want to scare you, but she feels really upset.” Shifting her anger to Dr. Fleming, Jane said, “I don’t care how scared she feels. She should not have left my side.” I noticed I started feeling angry at Jane. I felt protective of the child and wanted to rescue her from this painful situation.
I realized it was my wish that I would have had an adult to protect me from my older sister when she became angry and abusive. Instead, my mother rationalized my sister’s behavior because of her own discomfort of dealing with confrontation. With the recognition of my counter-transference feelings, I was able to act appropriately with the mother while I felt these protective feelings towards the child.
I confronted Jane by saying, “I know, Jane, no matter how angry you sound, you don’t want to hurt your daughter like this.” Dr. Fleming then said firmly, “The reason you are talking to your daughter like this is because you are so frightened about losing her. It terrified you and you expressed that terror by becoming enraged.”
Karasu (1985) talks about the value of a confrontational approach with certain well-functioning borderline clients. This approach may evoke tremendous acting out and angry behavior in the client, but it creates the potential for tremendous growth in interpersonal relationships, and a more adaptive defense mechanism.
I said firmly to Jane, “I have seen you acting so loving to Mary, and I think she needs to know that you still love her even though you have been feeling angry.” I then turned to Mary. “I think if you go over to your mother she will give you a big hug.” Mary approached Jane, who was able to accept this overture and return the hug. It was my impression that the child’s overture to Jane made Jane feel given to. Caring behavior is often needed by the borderline personality type. This is another example of a re-parenting technique.
Masterson talks about how the client develops trust and internalizes the therapist as a positive object. The client is able to shift the bad part of himself and align the good part of himself with the therapist. This was demonstrated by Jane when she was able to accept Mary’s hug and return the overture.
These sessions were the next phase toward confronting the destructive part of the mother to produce moves towards her mastery and growth as a more integrated person. In this excerpt I feel:
- I demonstrated a growth in my abilities to become appropriately confrontative with this client.
- I recognized my counter-transference and didn’t let it interfere with the therapy.
- I made use of the mother’s positive transference as a way of motivating her positive behavior. By making the mother more aware of her impact on the child, I was able to help her use the good part of herself.
Family Therapy Techniques
Even though the case excerpts demonstrate some of the clinical characteristics, I would like to give three examples of family therapy techniques that I used in this case to demonstrate the development of my learning skills.
Example 1
Watzlawick talks about goal setting in family therapy, and how this helps the borderline client focus on specific goals, e.g., the step-by-step procedure used to get the mother to separate from her daughter, and to select a pre-school for her daughter to attend. He also talks about how goal setting helps to evaluate the progress of the therapy (Watzlawick et al, 1974).
The first step was to get Jane to call the school for an appointment. The second step was for Jane to call me back after she had made the appointment to inform me of the time, so that I could accompany her. The third step was to visit the school with the mother, to participate in the interview and evaluation of the school staff and facilities. Through this procedure, Jane was able to commit to signing Mary up for a pre-school program. I was able to see how effective this goal-setting procedure can be with a borderline person. It helped contain the mother from emotionally flooding with all her other anxieties, as we structured this task in a supportive and positive way. Jane felt a sense of mastery over a situation that had been very anxiety-provoking in the past.
Example 2
Another family therapy technique we used was Haley’s idea of families enacting their problems rather than talking about them. For example, we had the mother and child re-enact an argument they had before they came into the session. We told them we wanted them to solve it in front of us. By using the enactment technique we were able to point out to the mother the ways in which she was relating to her daughter that were not appropriate, and see her respond appropriately to the issue. We also were able to help this very bright four- year-old get her point across to her mother, and the mother was able to begin to listen to her daughter in a more understanding way. It was very revealing to me to see how an enactment technique sometimes was more effective with this mother and child than just talking about their problems together.
Example 3
In this case I had my first experience using a family therapy paradoxical maneuver. I felt somewhat uncomfortable using this technique because it appeared to reinforce the parent’s destructive actions towards the child. Dr. Fleming told me that sometimes the most effective way to break a family’s circular pattern is through the use of paradox.
As an example, a circular pattern began in this family when the mother became angry about something the child failed to do. The child responded by sulking, which caused the mother to get even madder. During one of these episodes Dr. Fleming used a paradoxical maneuver with the mother. “I think you ought to keep yelling at her because this shows how much you really love her.” After Dr. Fleming had used this type of maneuver several times, Jane stopped her inappropriate behavior with her daughter.
Even though the major part of the family work did not involve the use of paradoxical maneuvers, it was interesting to note that Slipp and Kressel (1978) suggest that to work paradoxically, all the strategies within the session must be paradoxical. In working on this case with Dr. Fleming, a limited number of paradoxical maneuvers seem to have been effective. But only, in my opinion, because we had already established a very strong and trusting relationship. This relationship enabled Jane to accept and utilize the paradoxes.
I know that my opinion would not be agreed to by many of the proponents of family therapy. However from my experience, I believe it is possible to use more than one therapeutic approach in dealing with a borderline client in a family therapy context.
Conclusion
Working in family therapy with a borderline mother was a profoundly emotional experience because it helped me grow professionally by challenging the use of myself with a borderline client who could easily transfer her feelings to me. I feel I came out of this experience with better skills to work with clients with severe mental disorders in a family context.
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