Borderline Personality Disorder · Psychopathology: Theory and Practice Borderline Personality Disorder The term - Borderline Personality Disorder - has a long history, dating back

Psychopathology: Theory and Practice

Borderline Personality Disorder

The term - Borderline Personality Disorder - has a long history, dating back

to 1938 and Adolf Stern's definitive paper (although it has recently been

supplanted in the psychiatric field by the term Emotionally Unstable

Personality Disorder). In this lecture, Marcus West will be tracing some of

the ways the concept has been understood in both psychiatric and analytic

fields, particularly focusing on Kernberg's and Fonagy's conceptualisations

and contemporary attachment and trauma theories, which have afforded

us further, and now widely accepted, ways of looking at the phenomena.

West will explore the overlap between borderline and narcissistic

organisations and ways of functioning, before focusing on the powerful and

profoundly distressing clinical phenomena as they occur in the consulting

room, understood primarily as sometimes near-unbearable (for both

patient and analyst) co-constructions in the analytic relationship of early

relational trauma. The clinical challenges, as well as the opportunities,

opened up by these co-constructions will be explored using, amongst

other things, a developed understanding of Jung's concept of the traumatic

complex.

Marcus WestNovember 7th 2019; 19.30 - 21.30

The October Gallery, 24 Old Gloucester Street, London WC1N 3AL

Psychopathology: Theory and Practice

Borderline Personality Disorder

Plan for the talk

• Main aim: To make the phenomena understandable, give a sense of the difficulties and challenges and how to address them

• An overview of how the different psychopathologies fit together

• The history of the borderline concept, concentrating on Stern, Kernberg and Fonagy

• How this is related to trauma and early relational trauma in particular - calling on Jung’s concept of the traumatic complex

• How the analyst is deeply involved in the process too - the co-construction of the relationship, the particular pressures, idealisation, the analyst’s role / process / development

• Working through - both the ‘borderline’ dynamics and the underlying, primitive narcissistic defences

• Current treatment modalities

Overview of theoretical constructs:

Narcissism & Borderline

How do the concepts fit together?

Narcissism - broad and narrow definitions

• Narcissistic personality organisation

• Bollas: ‘oblates the difference between self and other’ (2000 p. 8);

• “I am right, you must change” - the fight response

• Schizoid personality organisation

• Bollas: “the mind becomes the fundamental object of dependence … (they)

dread emotional experience” (p. 10);

• “I am good, don’t challenge me”; the flight response

• Borderline personality organisation

• Bollas: “seeks out turbulence, turning molehills into mountains and escalating

irritations into global states of rage” (p. 9);

• ‘frozen’ to bad experience; “you must pick up the pieces or you don’t care”

• Hysterical personality organisation

• Bollas: “(they) suspend the self’s idiom in order to fulfil the primary object’s

desire” (p. 12);

• the collapse response: “You don’t want me to be - care for my baby self”

Broad & narrow definitions of narcissism &

borderline

• Broad definition of narcissism: all these personality organisations

are forms of narcissistic defence as they are attempts to defend

the self against narcissistic wounding

• vs. Narrow definition: the narcissistic personality organisation

(the classical understanding of narcissism)

• Broad definition of borderline:‘where ego-functioning and relating

are disrupted and there is a preponderance of primary process

functioning’ ‒ or impaired reflective function and mentalization in

Fonagy's (1991) terms

• vs. Narrow definition: the borderline personality organisation

Borderline personality organisation

The clinical picture

Destructiveness, self-destructiveness and self-harm

• Why does someone behave so self-destructively and against their apparent best interests? Why are they bitter, full of rage, dissatisfied, unappreciative and so difficult to help? Why do they have angry outbursts and blame others, continually getting into trouble? Why can’t they contain themselves? Why do they attempt to harm themselves though cutting, drugs or alcohol

Hopeless, despairing and depressed

• Why do they remain convinced that there’s no hope, no pleasure or meaning in life and that it is not worth living? Why do they want to kill themselves so persistently? … and what’s going on in the dynamics around it?

Not getting better

• Why don't they get better? Why don't they just get on with their lives and 'get over it’? Why don’t they respond to reason and interpretation or behave reasonably? Why do they remain so regressed for so long?

Issues in therapy

• Why do they say that “you don’t care” when you have bent over backwards to help? Why are they furious when you can’t offer a changed session time, so that you dread having to bring it up? Why do you feel at the same time concerned, despairing, furious, and at your wits’ end?

Some elements of the clinical picture

The borderline concept

Adolf Stern (1938) - 10 main features:

1. “narcissism” due to a “deficiency of spontaneous maternal affection” which thus led to

“affective narcissistic malnutrition”

2. “psychic bleeding”- complete psychic collapse when the individual encounters pain

and trauma

3. “inordinate hypersensitivity”

4. “rigid personality” - he described both psychic and bodily rigidity

5. “negative therapeutic reactions”

6. “constitutionally rooted feelings of inferiority deeply embedded in the personality”

7. “masochism and self-pity”

8. “a deep, organic insecurity and anxiety” which leads to “extreme and clinging

dependency”

9. the use of projection, for example, a paranoid experience of a hostile environment

10. “difficulties in reality testing”, particularly in personal relationships.

Borderline Personality Disorder - DSM V (2011)

Significant impairments in personality functioning manifest by:

• 1. Impairments in self functioning (a or b):

a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often

associated with excessive self- criticism; chronic feelings of emptiness; dissociative

states under stress.

b. Self-direction: Instability in goals, aspirations, values, or career plans.

• AND

• 2. Impairments in interpersonal functioning (a or b):

a. Empathy: Compromised ability to recognize the feelings and needs of others

associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted);

perceptions of others selectively biased toward negative attributes or vulnerabilities.

b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust,

neediness, and anxious preoccupation with real or imagined abandonment; close

relationships often viewed in extremes of idealization and devaluation and alternating

between over involvement and withdrawal.

Pathological personality traits in the following domains:

• 1. Negative Affectivity, characterized by:

a. Emotional lability: Unstable emotional experiences and frequent mood

changes; emotions that are easily aroused, intense, and/or out of proportion to

events and circumstances.

b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often

in reaction to interpersonal stresses; worry about the negative effects of past

unpleasant experiences and future negative possibilities; feeling fearful,

apprehensive, or threatened by uncertainty; fears of falling apart or losing

control.

c. Separation insecurity: Fears of rejection by – and/or separation from –

significant others, associated with fears of excessive dependency and

complete loss of autonomy

d. Depressivity: Frequent feelings of being down, miserable, and/or

hopeless; difficulty recovering from such moods; pessimism about the future;

pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal

behavior.

Pathological personality traits in the following domains:

• 2. Disinhibition, characterized by:

a. Impulsivity: Acting on the spur of the moment in response to

immediate stimuli; acting on a momentary basis without a plan or

consideration of outcomes; difficulty establishing or following plans; a

sense of urgency and self-harming behavior under emotional distress

b. Risk taking: Engagement in dangerous, risky, and potentially self-

damaging activities, unnecessarily and without regard to consequences;

lack of concern for one‟s limitations and denial of the reality of personal

danger.

• 3. Antagonism, characterized by:

Hostility: Persistent or frequent angry feelings; anger or irritability in

response to minor slights and insults.

Otto Kernberg (1975)

• ‘Identity diffusion’ and a ‘characteristic ego pathology’:

• ‘ego weakness’ – lack of anxiety tolerance, impulse

control, capacity for enjoyment or creative

achievement

• ‘identity diffusion’: ‘a psychological structure

composed of multiple split-off object relations,

positive and negative, each reflecting a dyadic unit of

a self-representation, an object-representation and a

dominant affect linking them’ (2008, p. 603)

• splitting, idealization, projection, projective

identification, denial & omnipotence

Trauma related models

• 87 % of subjects with borderline personality disorder

had histories of severe childhood abuse and/or neglect

starting prior to age 7

• “borderline personality disorder significantly overlaps

with what Herman has termed complex post-traumatic

stress disorder (complex PTSD)”

• Confirmed by Battle et al. (2004) in a study of 600

adults with personality disorder showing ‘a clear link

with childhood maltreatment’

Herman, Perry and van der Kolk ‘Childhood trauma in borderline personality

disorder’ (1989)

Peter Fonagy - developing views on borderline phenomena

• Fonagy (1991): the difficulty in thinking about oneself or

others - the person cannot bear to think about what is in

the mind of the other - e.g., too painfully negative, critical,

hateful, uncaring, or murderous

• Fonagy, Gergely, Jurist, & Target (2002): early attachment

patterns & the parents' inability to think about their child as

an individual in their own right - their ability to mentalize

• relates specifically to disturbances of borderline

psychology

Liotti, disorganised attachment & borderline functioning

“The attachment and defence systems normally operate in harmony as exemplified in flight from the source of fear to find refuge in proximity to the attachment figure. However, where the caregiver is at the same time the source and the solution of the infant's fear, there is a clash” (Liotti, 2004a,b)

• To flee or to attach? - the disorganised attachment pattern - "fright without solution" (Liotti, 2007, p. 129)

• disorganised attachment - “severe dissociation, splitting among ego states, and fragmentation of the self” - borderline functioning (ibid., p. 130)

Outline understanding of ‘borderline’ states of mind

Behaviour linked to early traumatic experiences that are embodied in trauma-related complexes (experiences that were unbearable for the psyche at that time)

We all have complexes, however:

when we can mostly get round them and behave in a creative, functional way but are sometimes taken over and affected -neurotic states of mind

when the complexes dominate the ego-complex and disrupt the development of the ego - borderline states of mind

typically when the person’s fundamental expression of need and distress was aversive to the parents

Integrating trauma, relational & analytic

theory and practice

• The bad history of trauma and analytic theory

• van der Kolk - “repetition compulsion”

• Freud's seduction theory

• Ferenczi

• Klein

• Jung

Trauma theory (in brief)

and early relational trauma

Understanding Freud's & Klein's responses

• empathy alone does not work - confirming the position of

'victim'

• contemporary trauma theory & lack of coherent memory of

the trauma

• counter-reactions to traumatic experience embedded /

implicit relatedness vs. innate destructiveness

• analyst becomes frustrated, blames the patient, or deems

them unanalysable

The lost / murdered child metaphor

- not intentional nor ‘resistance’

• Freud: the negative therapeutic reaction - 'not

getting better' - due to the patient's attempt to prove

their superiority over their analyst (1923b), or

masochism (1924c), or the death instinct (1937c)

• the person is staying true to (and is bound to) their

core, traumatic experience

• the person is not going to ‘get better’ until the

traumatic experience (the lost / murdered child)

has been thoroughly recognised, addressed and

worked through

Trauma theory - origins

• Charcot at Salpêtrière Hospital in Paris : ‘nervous shocks’ underlie hysteria [dissociative, conversion, somatisation, bpd, ptsd]

• Janet: traumatic event - vehement emotion - dissociation - memory traces remain in the form of 'fixed ideas' {woman with curious jump}

• dissociated elements not integrated with personality, individuals 'attached' to the trauma, personalities cannot enlarge

• the mind works in two ways:

• a: ‘to preserve & reproduce the past’

• b. directed toward ‘synthesis & creation’ (integration)

Vietnam, feminist perspective & trauma theory

• PTSD & sexual abuse

• PTSD - disturbing recurrent flashbacks, avoidance or numbing of

memories of the event, and hyperarousal, which persist for more than

a month after the traumatic event, resulting in “significant distress or

impairment of major domains of life activity” (DSM)

• Complex PTSD (Herman), developmental trauma (van der Kolk)

• Herman, Perry & van der Kolk (1989)

• Fonagy (1991)

• Bowlby and relational psychoanalysis

• Adverse Childhood Experiences Study

Adverse Childhood Experience Study - 17,421 individuals

Adverse Childhood Experience Study - 17,421 individuals

1. physical abuse

2. sexual abuse

3. emotional abuse

4. physical neglect

5. emotional neglect

6. parents divorced

7. mentally ill

8. addicted

9. in prison

10. mother treated violently

• Those with a score of 4 points or more:

• 50% had learning or behavioural problems at school

• 66% of women, 35% of men - later life depression

• Alcoholism 7 times more likely than score of zero

• Those with score of 6 points or more:

• 4,600 % more likely to have IV drug use

• 15% chance of currently suffering one of the 10

leading causes of death: pulmonary disease, heart

disease, liver disease, obesity, diabetes, stroke …

• 50% more likely to have cancer

• 4 times more likely to have emphysema

The Hidden Epidemic

• Reduce depression by over 50%

• Reduce alcoholism by 66%

• Reduce suicide, IV drug use & domestic violence by 75%

• Improve workplace performance +++

• Vastly decrease the need for imprisonment

The Hidden Epidemic

The Adverse Childhood Experience Study (Felitti)

“(the researchers) realised they had stumbled upon the gravest and most costly public health issue in the United States: child abuse. (They) calculated that its overall costs exceeded those of cancer and heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters. It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration.”

“When the Surgeon General’s report on smoking and health was published in 1964, it unleashed a decades-long legal and medical campaign that has changed daily life and long-term health prospects for millions. The number of American smokers fell from 42 percent of adults in 1965 to 19 percent in 2010, and it is estimated that nearly 800,000 deaths from lung cancer were prevented between 1975 and 2000.”

“The Adverse Childhood Experience Study, however, has had no such effect. Follow-up studies have appeared … only now (these effected children) receive high doses of psychotropic agents, which makes them more tractable but which also impairs their ability to feel pleasure and curiosity, to grow and develop emotionally and intellectually, and to become contributing members of society.”

Bessel van der Kolk, The Body Keeps the Score, p. 148

Trauma theory

• Definition of trauma = that which the psyche cannot cope with at that

moment in time - can't integrate with ego-functioning

"Janet proposed that intense arousal ("vehement emotion") seems to

interfere with proper information processing and the storage of

information in narrative (explicit) memory ... (so that) memories of trauma

may have no verbal (explicit) component whatsoever. Instead, the

memories may have been organised on an implicit or perceptual level,

without any accompanying narrative about what happened" (van der Kolk

1996b, p. 286-7)

• Disruption of ego-functioning: no coherent narrative - trauma

“disrupts individuals' capacity to perceive, represent, integrate, and

act on internal and external stimuli”(van der Kolk, McFarlane & Weisaeth 1996, p. x)

• vs. resistance & intention

Dissociated traumatic elements & the

disruption of ego-functioning

Traditional psychoanalytic view:

• "the borderline feels that his or her core object is to be found only through

turbulent states of mind. Unconsciously, therefore, the borderline

character seeks out turbulence, turning molehills into mountains,

and escalating irritations into global states of rage" (Bollas, 2000, p. 9)

• Vs. powerful affective-somatic reactions - flashbacks - form core

elements of the transference e.gs. being kept waiting, non-

responsiveness, asking questions, irritating the other

• regression and dissociation - the disruption of ego-functioning = dissociated

from everyday, well-adapted functioning

• subjectively, experiences feel more powerful, more intense, more terrible,

more certain, more spontaneous / impulsive, more true, more real …

The triune brain & the polyvagal theory

Narcissism - broad and narrow definitions

• Narcissistic personality organisation

• Bollas: ‘oblates the difference between self and other’ (2000 p. 8);

• “I am right, you must change” - the fight response

• Schizoid personality organisation

• Bollas: “the mind becomes the fundamental object of dependence … (they)

dread emotional experience” (p. 10);

• “I am good, don’t challenge me”; the flight response

• Borderline personality organisation

• Bollas: “seeks out turbulence, turning molehills into mountains and escalating

irritations into global states of rage” (p. 9);

• ‘frozen’ to bad experience; “you must pick up the pieces or you don’t care”

• Hysterical personality organisation

• Bollas: “(they) suspend the self’s idiom in order to fulfil the primary object’s

desire” (p. 12);

• the collapse response: “You don’t want me to be - care for my baby self”

The window of tolerance

• Daniel Siegal (1999) due to hyper- and hypo-arousal - therapy needs to be conducted within the 'window of tolerance' to allow the individual to process the traumatic experience

• Ogden, Minton & Pain: 'therapists must consistently employ techniques facilitating interactive repair to keep clients' arousal within a window of tolerance' (2006, p. 61)

• recognising the somatic cues for when the trauma is being triggered e.g., critical parent (tension in shoulders, shortness of breath, increased heart rate) - response (measured deep breaths, maintaining eye contact, grounding in chair)

• other examples - grounding, not addressing the traumatic memories until the individual is ready - a steady sympathetic presence

Peter Levine & the polar bear‘incompleted action tendencies’ of fight, flight, freeze or collapse

'Long after the original traumatic events are over, many

individuals find themselves compelled to anticipate, orient to, and

react to stimuli that directly or indirectly resemble the original

traumatic experience or its context'. (2006, p. 65)

• Due to repeated triggering the

amygdala - the brain’s smoke

detector - in a state of high alert

• Orbitofrontal systems - deal with

self-control and rational thought -

less activated due to repeated

trauma

• Alexander McFarlane' study of

Australian combat veterans

• Difficulty with self-soothing and

inhibition of fear activation by

amygdala

The Impact of Trauma on the BrainCozolino (2002)

The Impact of Trauma on the BrainBessel van der Kolk - The Body Keeps the Score (2014)

Trauma triggered in brain scanner

van der Kolk et al. (1994)

Emotional / limbic system, centred on

the amygdala

Visual cortex -

associated with

visual flashbacks

Marked decrease in

Broca's area - speech

- speechless terror

Dorsolateral prefrontal cortex - links past, present & future & gives a sense of continuity -

goes OFFLINE - feel something will last forever

Thalamus - integrates bits of experience into a coherent story - goes OFFLINE

The midline structures of the brain - your deeper sense of yourself - CAN be accessed

(LeDoux)

+ve & -ve experiences never integrated in orbitofrontal systems

The Impact of Trauma on the BrainBessel van der Kolk - The Body Keeps the Score (2014)

DissociatedDorsolateral prefrontal cortex Thalamus

EMDR & Adaptive Information Processing

theory - Shapiro (2001)

• the cause of the current problem is unprocessed memories of

traumatic experiences - dysfunctionally stored memories

• this manifests in the present when associated situations and

experiences trigger responses similar to earlier experiences that

have been dysfunctionally stored

• it is maintained in the present because other memory networks where

information is stored which would enable more adaptive resolution of

the past experience are not being accessed

• the personal meaning of these memories, or ‘touchstone events’,

become the lens through which we view ourselves in the present

• EMDR & memory channels - free association - the trauma complex

Early relational trauma

The failure to repair mismatches & the

negative affective core - Ed Tronick

• Tronick and Gianino (1986): a “mismatch” causes distress

• infant or mother try to repair the mismatch

• infant successful in repairing the mismatches - they “experience

positive emotions and establish a positive affective core”

• sense of agency is enhanced, and they "internalize a pattern of

interaction that they bring to interactions with others"

• unsuccessful in repairing mismatches - feel helpless, focus

behaviour on self-regulation, limit their engagement with others,

and “establish a negative affective core” (p. 156).

Beebe & Lachmann - The Origins of Attachment(2013)

Studied infants at 4 months who would go on to be classified as having a disorganised attachement pattern at 1 year; they observed (2013, p. 63):

• mother greeting distressed infant with smile

• infant jerked their body while turning away in the chair -"could be considered a precursor of 'fight-flight' "

• mother poked and pushed her infant's face

• infant did not move at all, other than blink - "moments of freezing"

• after multiple maternal intrusions, looming, pulling infant's arm to orient him after he'd turned away

• infant collapsed like a ragdoll

Trauma & relational psychoanalysis‘In the Shadow of the Tsunami’ Bromberg (2011)

• Philip Bromberg: trauma is when self-invalidation or self-annihilation by another is inescapable, and the mind is flooded by powerful affects that disrupt the individual’s capacity to think

• these “precipitous psychological events ... disrupt the patterns of meaning that constitute the person's overarching experience of self”

(the normal multiplicity of self-states are unlinked so that the person's normal sense of self is disrupted)

• “the process of psychoanalysis is about helping patients reclaim their dissociated self-states”

Understanding & working with the traumatic

complex

Jung's word association experiments &

the complex

• 100 words: bread, table, war, ink, love, dog, head, faithful, water, stroke, lamp ...

• delayed, emotion-laded or peculiar responses

"A 'feeling-toned complex' ... is the image of a certain psychic situation which is strongly accentuated emotionally and is, moreover, incompatible with the habitual attitude of consciousness. ... [I]t has ... a relatively high degree of autonomy, so that it is subject to the control of the conscious mind to only a limited extent, and therefor behaves like an animated foreign body in the sphere of consciousness" (Jung 1934, para. 201)

The trauma was and remains unbearable

• Right from the start of therapy the patient is telling you, explicitly &/or

implicitly, what they find unbearable in the world and themselves … their

complexes … often it is they themselves that feel unbearable

• what is going to be your attitude to this?

• The patient is watching to see what you will do. Will you say:

• “you are not really like that?” or

• “the world is not really like that” or

• “I am not like that, and it won’t be like that here?”

• or will you help the person face the traumatic complexes and work them

through recognising that they will likely recur in some form in the analytic

relationship?

• Retraumatisation - violation - fury, hatred & murderousness

Idealisation

• idealisation - the wish for an ideal, conflict-free world where there

will be no possibility of re-traumatisation

• a universal(?), very powerful phenomenon inevitably and

understandably associated with trauma

“Acknowledging the impossibility of bringing this fantasy [of a

new and idealized, compensatory childhood] to realization

represents a betrayal of [the patient’s] most sacred inner self”

(Davies & Frawley, 1992a, p. 25)

• will the therapist try to be the ideal, good, rescuer?

• will describe later the immense difficulties this can cause …

Reconstruction, re-enactment &

the subtle effects of co-construction

• Reconstruction - contentious … ?

• Why are we so affected by our patients and drawn into these

dynamics?

• still unbearable - threat of re-traumatisation

• internal working models held in implicit memory deeply

embedded in the person’s personality

• intense negative transference, where the therapist is

experienced as cold, cruel, inhuman or sadistic

• We need to be drawn in in so far as we can then recognise the

dynamic

The complex - the site of the traumatic reaction -

‘contains’

1. Overpowering affective-somatic response - the

disruption of ego-functioning

“intense arousal interferes with proper information

processing and the storage of information in narrative

(explicit) memory”

“bad”, “useless”,

“unwanted”, “unlovable”,

shame

Dissociated from core self

2. Unbearable core traumatic experience - can't bear to be

who you are, but which you have to recognise you 'are' - self-

attack & envy

• the person is at odds with themselves, feels they are

wrong, can’t bear their feelings or responses, become

alienated from their core self and readily falls into envying

others, through either idealising others or denigrating

themselves or both

“bad”, “useless”,

“unwanted”, “unloved”,

shame

Primitive defensive reactions

3. primitive defensive reactions - fight, flight, freeze, collapse -not well-adapted

• combative, fight response

• avoidant, flight response

• despairing, frozen-to-the-bad response

• submissive, collapse, helpless response

• hypervigilant, anxious response

“bad”, “useless”,

“unwanted”, “unloved”,

shame

Conflict compromises identity & functioning

4. an (unconscious) talion response to the traumatiser/aggressor/abuser

• represents an identification with the aggressor, usually anathema, usually projected, binding the individual to the bad object

• (unconsciously) being themselves critical, shaming, bullying

• requires extreme sensitivity in interpreting this (eventually)

• the problem when people avoid identification with the aggressor -e.g., they 'need' to be more critical, selfish, blaming etc.

“bad”, “useless”,

“unwanted”, “unloved”,

shame

Trauma-related internal working models

5. Trauma-related internal working models are

embodied in the complex (Knox 1999)

• held in implicit / procedural memory

• “I am bad, unwanted, useless, and unloveable - the

world is critical and will reject me”, that is how

things work

“bad”, “useless”,

“unwanted”, “unloved”,

shame

Direct & reversed forms on different levels

- a pattern which can be applied in different ways

“I am bad - the world is critical and will reject me”

• objective level (current & historical)

• subjective level (interior)

• transference level (relational)

• archetypal level (this is the way things are / the way the world

works)

• direct & reversed forms - beyond the ‘victim’ position

• needs to be worked through on all levels

The analytic relationship

Bromberg (2011) The Shadow of the Tsunami

- the value of reliving

“the analytic relationship become[s] a place that supports

risk and safety simultaneously ‒ a relationship that allows

the painful reliving of early trauma, without the reliving

being just a blind repetition of the past.”

“It is optimally a relationship that I have described as ‘safe

but not too safe’… by which I mean that the analyst is

communicating both his ongoing concern for his patient's

affective safety and his commitment to the value of the

inevitably painful process of reliving.” (p. 16-17)

"The therapeutic effect comes from the doctor's efforts

to enter into the psyche of his patient, thus establishing

a psychologically adapted relationship. For the patient is

suffering precisely from the absence of such a

relationship"

Jung 1928 para 276

Accompanying the patient through ‘the

darkest places’

The defeat of the analyst's ego

• the analyst’s intellect and reason rendered powerless - addressing

primarily affective-somatic elements and implicit ‘ways of being with

others’ which cannot be worked through simply by being named

• not ejecting what seems destructive or ill-adapted

• finding the kernel of truth in what is being said - probably a

reconstruction

• e.g. "You are a block of wood and are not interested in related to me"

('depressed mother dynamic')

• desperate attempts to relate vs. recognising the wound?

• patient's/child's failure to repair the mother the core traumatic

experience being reconstructed

The underlying narcissistic defences

• Working through:

• both the trauma related ‘borderline’ dynamics

• and the underlying, primitive narcissistic defences against

overwhelming suffering:

1. Avoid and evacuate suffering 2. Control 3. Distance

oneself from relationship or from one’s own reactions

• Anne Alvarez, working with autistic patients: a point when

early ways of relating, once necessary defences, no longer

necessary in the same way - become simply ways of

relating, sometimes in the absence of knowing other ways

of being (1999, ch. 5 esp. pgs. 73-4).

Michael

/ Bryony

grateful for their

permission

Some particular pressures

The reconstruction of the inhuman

• The patient needs to constellate the bad, inhuman object in

order to work through the early relational trauma

• dyadically expanded states of consciousness (Tronick)

• however good you are it doesn’t work through the trauma

… (my failed analyses …)

• Casement: “an analytic good object … is that which can

tolerate being used to represent the worst in the patient’s

experience” (2001, p. 384)

• but when those are inhuman?

The masochisto-sadistic dynamic

• out of the moral defence - drawn to / resonates to situations

of suffering

• the punishment of the other is justified by the individual's

woundedness and re-wounding - the victim becomes the

aggressor

• underlies splitting - not just good and bad

• Shabila - murderous feelings toward me

• political / cultural consequences

The moral defence

• the wound to the core self feels so bad that it feels

morally wrong - "this must not be allowed to happen

under any circumstances!" - "you are bad”

• when the analyst re-wounds, they cause moral

outrage

• Shabila - arriving early

• addressing the wound compassionately

• vs. Fairbairn's moral defence: "I am bad" - keeps the

object, upon whom the child depends, good

The analyst’s personal journey

The earlier and more profound the early relational trauma, the more the

trauma will need to be fully constellated and lived through in the analytic

relationship by both patient and analyst

• the analyst thus has to accompany the patient into and through

‘the darkest places’

The process of the analysis goes at the pace at which analyst and

patient can bear to experience and embody the experiences of being in

identification with the aggressor, or victim, or bystander, or rescuer; and

will be delayed until they can do so

• the process is held up by the analyst failing to bear / allow

themselves to be bad, to fail, to be defeated, or to be good, loved

etc.

“Don’t look back!” Faith in the process

Treatment models

Otto Kernberg & the Menninger Foundation

Transference Focused Psychotherapy (TFP)

• ‘Patients with Severe Personality Disorders … (‘significant ego-weakness’) …

improved more with a psychotherapeutic approach that focused on transference

interpretations in the sessions’ (with support outside the sessions ‘to maintain the

treatment frame’) (Kernberg et al. 2008, p. 601-2)

• Pts suffer from ‘identity diffusion’ - a chronic, stable lack of integration of the

concept of self and of the significant others… ultimate cause: … failure of

psychological integration resulting from the predominance of aggressive

internalised object relations over idealised ones…. to protect the idealised

segment of self and object representations … there are primitive splitting and

dissociative mechanisms’ (p. 602)

• ‘Main strategy’ of TFP: ‘the reactivation in the treatment of the patient’s split-off

internalised object relations that are then observed and interpreted in the

transference’ (p. 603)

• Interpretation links the dissociated positive and negative dyads/transferences,

which underpin the split and identity diffusion e.g., indifferent mother / bad child

vs. totally caring mother / happy child.

• Transference interpretations are linked to the patient’s problems in external

reality, in contrast to Kleinian technique (p. 609)

Dialectical Behaviour TherapyLineham (1993, et al. 2006)

• Sees Borderline Personality Disorder as due to the

individual’s emotional dysregulation

• Validates affective states and teaches skills to avoid

or distract in order to reduce or eliminate painful

emotions and stop problem behaviours

• Clear and articulated treatment structure, priority of

the issues to be addressed, stress on and protection

of the frame of treatment

STEPPSSystems Training for Emotional Predictability and Problem Solving

Nancee Blum

• A group based learning programme based on CBT principles,

focused on learning:

• to challenge maladaptive schemas

• self-care skills: sleep, exercise, diet

• problem solving, communication and relationship skills

• skills for dealing with intense emotions, anxiety,

depression, anger, and self-destructive impulses

• encouraged to share appropriate topics from their skills

training with close friends and family members, and also with

their therapists

Supportive Psychotherapy(Clarkin et. al. 2007)

• Seen as due to a deficit

• Supportive psychotherapy aims to strengthen

patients’ adaptive functioning by means of:

• cognitive support (advice or information giving)

• affective support (reassurance, praise, verbal

conveyance of empathy)

• direct intervention in patient’s life

• minimal transference interpretation due to fostering

positive transference

Schema Focused Therapy(Young et al. 2003; Giesen-Bloo et al. 2006)

• Problem due to ‘maladaptive schemas’ - cognitions

• Deficit model: patient has unfulfilled ‘core childhood’ needs,

such as safety, a stable base, predictability, love, nurturing,

attention, acceptance, praise, empathy, realistic limits, and

the validation of feelings and needs

• SFT addresses these needs with: cognitive restructuring,

emotion-focused techniques, behavioural life pattern change,

‘limited reparenting’ and ‘schema mode work’

• Explicitly supportive, recommending the therapist nurture,

praise, provide extra time and transitional objects and, ‘when

appropriate’, physically hold the patient

• Aggressive affects seen as stemming from justifiable anger

Mentalisation Based TherapyBateman & Fonagy (1999, 2004)

• Based on consistent efforts to increase the patient’s

mentalization. i.e., the patient’s capacity to recognise

mental states in themself and others & to allow self-

reflection and assessment of others to improve

mental functioning and symptomatology

• Disagrees with early interpretation as it may impute

mental states to patients that are incorrect

• vs. TFP which aims to interpret and help the patient

link dissociated, conflicting mental states as they are

reflected in the transference

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