Pioneers in Object Relations Clinical Thinking:
When this man turned to his colleagues and family for sympathy, he was shocked to hear them say that they agreed with his boss. … Even when he started therapy, he still didn’t understand the problem, because he believed that all of these people were wrong about him. … (For such narcissists,) other people exist only the way a hamburger exists for them — to make them feel good. …They may charm you and manipulate you to make you see how wonderful they are, but as soon as they get your admiration, they’ll drop you.
Borderline Personality Disorder (BPD) is due to a developmental arrest of the self and the ego in the pre-oedipal stage approximately between the ages of two to three. I have called the key psychodynamic theme that results, The Disorders of the Self Triad: Self-activation leads to separation anxiety and abandonment depression which leads to self-destructive defenses. This dynamic is precipitated by real later life situations that require self-assertion and autonomous functioning or by events that involve separation.
These events interrupt the defenses; the patient begins to experience the abandonment depression and then defends by giving up self-assertion and activating self-destructive defenses whose symptoms can vary from obesity to anorexia, from clinging to others to distancing from others, from sexual promiscuity to the avoidance of sex, from alcoholism to drug addiction.
At the beginning of therapy, the patient will resist allying his emotions with the therapist because it means giving up his usual method of avoiding painful feelings of separation anxiety and abandonment depression. At this point he is inclined to rely upon the familiar strategy, which he thinks works, rather than one still unknown and untested. But the more he invests in the therapist, the more he will give up these old defenses and turn to therapy to work through these feelings of abandonment.
First, however, he must “test” the therapist with his habitual self-destructive strategies to answer two vital questions: Is the therapist competent? Can he trust her? Thus the first phase of therapy is the testing phase.
It is necessary for the therapist to patiently and consistently confront the patient with the genuine destructiveness of his behavior and of his distorted perception that a real therapeutic alliance or involvement in therapy is equivalent to the painful state of being engulfed or abandoned, which up until now has been the patient’s experience when activating the real self. At the same time, the therapist must demonstrate, by actual dealings with the patient, the necessity and value of trusting the therapeutic relationship.
A host of therapeutic values and actions contribute to achieving this objective: The therapist’s thoughtful concern for the patient’s welfare, the accuracy of the confrontations, the therapist’s reliability, and the refusal to exploit the patient or to permit the patient to manipulate. Only when the therapeutic alliance is established will the patient be willing to give up his lifelong dependence on the false self’s ploys for emotional security. This is a momentous turning point in the therapy for the person with BPD, as it means the transference acting out is being converted into a therapeutic alliance and transference, and that the patient is passing into the second or “working through” phase of therapy, where it now becomes possible to work through, attenuate, and overcome the depression.
In a sense, borderline-personality problems can teach all of us about the crucial balance between independence and the need to share our lives with others. Connections — in family, friendships, love and work — are healthy, but building a separate sense of self is critical. While life may involve compromise and some working toward others’ goals, it also requires forging one’s own individual and unique identity.