Tuesday, July 6, 2010

Borderline

I never fail to be surprised at how Borderline Personality Disorders can so effective in reminding one of how unprepared one can be for their latest form of 'defensive attack'.
I've said before that Borderline Personality Disorder is often undiagnosed Post Traumatic Stress Disorder until proven otherwise. There usually is an early trauma. That's certainly what the psychoanalysts found in the cases they treated. However today as often as not the 'borderline defences' are a product or part of the addiction picture.
I've met addicts who have had to all intents and purposes model childhood but as a result of their addictions developed the classic borderline way on interacting.

Borderlines are 'felt' before they're seen. There's an 'emptiness' that they themselves will acknowledge. It's a form of fear and rage mixed all in one. Often the borderlines personality disorders fall under the category of 'sociopath' or 'psychopath' when in fact they aren't per se. It's just that they really can get under your skin.

Often it's not in what they say or do at first but in the particularly contemptuous and mealy tone of voice.

I specialized in borderlines at one time, doing in depth psychotherapy with them, before the trend in psychiatry reverted to drugging them under the diagnosis of Bipolar Disorder. Bipolar disorders in contrast usually respond to medication whereas more often than not borderlines who respond to low dose antipsychotics or anti depressives actually get worse with disinhibiting higher dosages of the medication. Classic bipolars don't get behaviorally worse with more medications but usually may benefit. Borderlines who don't respond to psychopharmacology and most don't because Borderlines are personality disorders and Personality Disorders are not treatable with medication, are often then labelled Schizoaffective.

Personality Disorders require symptomatic medications but the treatment of choice is group therapy and individual therapy in combination. The more severe the personality disorder the more necessary the group therapy to disperse the rage and neediness and to confront the principal defensive strategy of borderlines "splitting'.

Borderlines are at their worst 'paranoid' disorders and they literally burn through communities and therapists seeking allies.

Counsellors, privately paid, often fall prey to high functioning borderlines because they need the patients and the borderlines need constant gratification.

The trouble is that the borderline's principal psychotherapeutic need is to work through the feelings of rage and emptiness and learn to 'self soothe' rather than demand attention and rescue from the community.

The borderline transaction that I seem to be blind sided by is that the borderline presents asking for information and I proceed to this in the traditional transactional analysis role of parent or older sibling imparting knowledge to the younger or new comer seeking knowledge. The borderline however is not actually wanting 'knowledge' but because their rage is centered on their parents are indeed 'setting' a person up and using the opening 'gambit' to seek weakness and plot attack at the absent or negligent or abusive parent.

I find myself telling a person about a drug, or therapy or service only to then be attacked with the statement 'you don't care', 'you're not hearing me', 'you don't want to help me', 'you think you know it all' or any version of what is decidedly demeaning belittling hostile communication completely out of context with the opening of the session.

Borderlines often carry over massing amounts of hostility for previous interaction with yourself, another therapist, a parent, police or whatever.

It's recognisable in the degree of angst in the tone of voice which is so out of place with the overt content of communication. This is because the 'information' asked for isn't really what it was all about but rather it's at the emotional level and no one can actually 'meet' the extremely unrealistic emotional expectations that come as part of the borderline parcel.

Next thing I know I've been psychologically whacked and even as I'm becoming defensive before the increasing 'name calling' and raised voice or worse the lowered cold rage voice, the borderline will say "you're being defensive'. And suddenly the borderline is the 'therapist'.

Thanks to Berne and transactional analysis, an externalization of Freud's and Jung's internal constructs its possible to see that all of this is happening in the broken 'parent-child' relationship that the Borderline brings to every interpersonal interaction.

There's 'projection' and 'merger' and dissociation and frank psychosis. Analysts used terms like 'internalized objects" and 'projective identification' to try to put words to the experience the therapist has of being literally psychologically mauled because the borderline needs to do the 'first strike' defence and psychically kill the therapist who represents the 'bad breast' or 'bad parent' as Melanie Klein described these defences.

Addiction makes all this that much rawer and borderlines previously vulnerable to alcohol are more often than not using cocaine which might well cause the 'regression' to this early adolecent or earlier interactive function where 'acting out' is the 'norm' of interpersonal behaviour.

Borderline Personality Disorder is still acknowledged as a condition which is treated by traditional psychoanalysis. Possibly this is because the traditional psychoanalyst especially the Kohuts and Kernberg schools have sufficient training to remain neutral and not see the behaviour of the Borderline than anything other than the sickness it is. It's so much easier to 'react' to it but then that's the 'repetition compulsion' of the Borderline's world. Not therapeutic but hard to resist. Most therapists deal with this by further 'neglect' and refuse to accept 'Borderlines's as patient.


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1 comment:

Lenore Sigrid Clemens said...

again, another interesting explanation - especially interesting about what medication helps & doesn't. As well as sleep, food, rest, holidays, time alone (for me) laughter, :). I'm always surprised at the difference in myself when I forget to take something.
The labels can be problematic as so many illnesses, damage, needs, broken pieces overlap, interact and can look alike. Yet, the labels are helpful if the correct diagnosis in anything is good for getting the right treament.
There are so many aspects of being human which can look like something else until we get the whole context.
And not all therapists can help all patients.
Love is the most healing of all energies. And it is so important to be with people who treat one well - because the effects of the type of behaviour you write about can themselves be deeply damaging. Interesting, where damage becomes a "mental illness" or, a wound which needs healing time.