Interview with Dr. Jerry Fromm on BPD, page 2
In addition to relationships, how does borderline manifest?
Well, we’re talking about instability, and the basic instability has to do with one’s sense of self. Often, a borderline person tries to play out a role, or a variety of roles, but can never settle fully into one. The psychoanalyst Helene Deutsch considered this the “as if” aspect of the person’s personality — so we have person who acts “as if” they are this or that, but never really occupies a place of depth or substance. With borderline, you see people who may try to be one sort of person, but it doesn’t fit as a true identity, and so they look for another, and on and on. They identify with certain roles and environments. And they can be, at times, competent in those contexts. Their adaptation seems solid, but also brittle, because real identity is a deeper process than performance or behavior, where our daily actions and roles flow from a consolidated and durable sense of self. Donald Winnicott saw the borderline problem as related to what he called the “false self,” where you have a social self that feels completely alien from a more spontaneous or perhaps chaotic inner self. The person with BPD sometimes adopts a chameleon-like way of being.
This makes me think of the famous cases of Borderline Personality Disorder — like Marilyn Monroe, someone who can adopt roles, be what she is asked to be.
Yes, and the paradox is that there can be quite a creative capacity to shift and adapt, depending on the moment and the circumstance. And the person’s creativity is not only used defensively. There is such emotional intensity in people with this trouble, coupled with so little capacity to put it into language, that the arts can be an enormously important expressive outlet. And genuine art can come of it – work in which some form can be given to what is otherwise experienced as simply chaotic intensity.
But the borderline problem presents a real threat to creativity, too. You see this in psychotherapy when patients become too anxious to free associate. Letting your mind go can arouse anxiety in anyone, to some degree, but most people can notice these emotions and still use the experience as a kind of deep play for the purpose of getting in touch with oneself. But a person who is very concerned about losing control – and losing one’s mind - will be terrified by the invitation to free associate. I think you can actually measure progress in treatment by the increasing ease people have in just speaking their thoughts. And that relates to creativity, openness to taking a chance, spontaneity and so on.
What do people suffering from this condition look like and talk like? How would a doctor or a family member recognize borderline?
There’s a tremendous range, and it partly depends on what defense is in play. In other words, is a person suffering in the moment from their solution or are they suffering from the problem? Often people will develop an eating disorder or harm themselves by cutting or burning. You might say that these behaviors condense the struggle between expressing a strong feeling and controlling it. The behaviors are, in their peculiar way, “solutions.” Remember, part of the trouble here is emotional disregulation. And cutting oneself, paradoxically, is an organizing experience. It focuses you in one direction and it distracts you from the more chaotic, emotional pain. Often it punishes you – for some crime you feel you have committed – but it brings both the company and absolution of somebody coming and taking care of you. So it then becomes a tool – sometimes used manipulatively - to get people to stay with you. It solves lots of problems at once. And very often, people who are starving themselves or cutting themselves — they don’t feel it. They’ve managed to develop a kind of psychic numbing capacity, so one of the interesting things you notice when people get better is that the cutting starts to hurt.
Of course, these so-called solutions deepen the problem. We’ve discussed what happens in relationships, when a person gets in the bind of needing another person (say, a romantic partner or parent) and pursuing it to the extent of living in a very false way of being — being “good” or thin enough to make another person like you. We often see a person with borderline chasing after love and using sex to try to get love, so there can be these bouts of promiscuity — and this leads to a vulnerability to sexual abuse and abusive relationships.
Sometimes people’s solutions break down completely. -They might enter a phase that looks manic, making frantic efforts to find a new partner or dull the pain through substance abuse or buying things. Sometimes, suicidal behavior occurs as a response to a sense of total breakdown into desperation. I see a close link between what can look like a bipolar condition and the ups and downs of an underlying sense of chaos, of desperation about being alone in the world and of rage at the person who left you alone. The caricature of this is the Glenn Close character in Fatal Attraction , who will go to whatever extremes necessary to get the attention of her lover; she is determined to vengefully right a wrong and, even more so, to undo a rejection, at the cost of destruction to everyone’s life.
Clearly, BPD can be accompanied by other diagnosable disorders.
Yes, we see a great deal of co-morbidity with things like substance abuse, eating disorders, manic behaviors, major depression. These troubles can be immediately devastating for the patient and the people around them — for family and friends and colleagues. We also see a great deal of post-traumatic stress disorder. It often turns out that in the early history there has been an abusive relationship, perhaps even childhood sexual abuse, and often trouble in the early maternal relationship. There are a variety of ways a bad fit can develop in early attachment relationships, which then have consequences for the child’s development, including the ways emotional events are processed by the mind of the child. One problematic consequence can be the turning to male figures, and if it introduces the problem of premature sexuality, it becomes a disaster. So behind “borderline” is often trauma, and empirical data show this.
I don’t mean to blame the parents. People generally do the best they can. One of the things we have seen so regularly here at Riggs is intergenerational transmission of trauma. So, for instance, our patients’ parents may have survived the Holocaust, which can produce devastating effects on what they can let themselves feel, what they can talk about, and how they raise their children.
In the face of competing diagnoses, what moves borderline to the top of the list?
You work with what’s most acute. So, for example, if substance abuse is the most acute problem, you have to find a way of helping the person become sober. And it helps a lot if you’ve been able to put the underlying problem in a clearer perspective — to help the patient see that this is a false – or temporary and costly - solution, and to examine the contours of the real problem. This isn’t easy, because feelings have gotten so distorted. What’s often in the background for people with eating disorders is that all feelings — loneliness, fear, anger — get channeled into hunger. These feelings become concretized in terms of hunger for food, which is then reacted against and so on. You get a loss of boundaries around discrete feelings, and sometimes when a person is growing up, their feelings have been regularly misinterpreted in such a way as to confuse them and also to fit a parents’ needs for them to be one way and not another. It sounds fancy, but it’s really very simple: How many times do parents feed the child when the child is upset about something else entirely? The child wants to be recognized as angry about something and is bought off with a sweet instead.
Once a person has gotten some control over a chronic acting out solution— and we’ve talked about all the ways that can manifest — you can move into a substantive treatment, in which, hopefully, the patient will feel a little freedom from the impulse to act and will have gained a little insight, so that, when they find themselves in a red zone, they know it, and we know it, and we can work with it.
How do you work with BPD at Austen Riggs?
A person in a borderline state has had trouble in their primary relationship of dependency in life. Setting up an intensive psychotherapy invites them to depend on their therapist, thereby creating a situation, a charged situation to be sure, where the problems can be felt first hand and talked about. We can connect what happens in the therapy to the therapeutic relationship itself, and to other people in the patient’s life. So you have a way of working with the trouble in the immediacy of the therapeutic relationship, including sorting out what’s the patient and what’s the therapist and a building of what some theorists call “reflective functioning” or “mentalization.” By that we mean the capacity –often not achieved in a chaotic home life – to think about what might be going on in the mind of the other person. Who is bringing what to the dynamic? Where is the reality, and where are there distortions in thinking? What we often see are spikes of feeling at boundary moments, including the end of the therapy hour, and those are major opportunities to sort out what the patient has done with this in their mind and where that comes from.
But this kind of relationship trouble is a precarious and sometimes life-threatening experience for people — and something they’ve been living with for a long time. So it’s important that we also have people here the patient can go to after the therapy hour, so that they don’t have to be alone. The nursing staff is critical, as is the patient community. At some level, a borderline person feels troubled all the time — unstable, insufficient — but the patient community invites you into alternative roles, where, say, you’re putting together an evening of some activity, or voting on something in a community meeting. Also, when the person’s feelings break out into action rather than language, it happens in a context of others and in our program, a group of patients meets with you about that.
Say a person really loses it, and cuts himself. At Riggs, we have a series of patient-run work groups. One is called the Task Group, which gets referrals about troubled or troubling behavior. So now this person sits down to discuss with a small group of their peers what happened, the effect of what happened on the rest of the community, how other people have dealt with that impulse, what was going on in the social situation that upset the person, and so on. This can really change a person’s perspective, because he or she has let loose with something very angry, without a second thought that there are other people who will feel the effect of it. And now you have those other people speaking back, saying things like, “When you did that, I was reminded of what happened in my home when my father got drunk, fell on the floor and was bleeding all over the place. It really got to me – then and when you did it.” For people who are caught up in their own minds, it comes as a huge surprise to see how other people are affected. This creates a tension, but I think a healthy tension. It humanizes the target, so to speak, and reminds people that there is something – a human community – there for them, that they actually care about, and that they have a responsibility to, something larger than themselves.
Another aspect of Riggs that’s extremely helpful for the borderline patient is the openness of the setting. This isn’t just a physical fact: that patients can come and go as they wish, and that there are no locked doors and no privileging system. It is also a structuring value. The openness of the setting represents a foundational recognition of the independent authority of the patient. Patients like this are so vulnerable to a kind of regression that can become a chronic way of being. They’re so likely to say, in effect, “I will trade my capacities for your care.” And that’s just deadly. The open setting requires people to take up their authority for their daily lives and to hold onto their strengths, at the same time that they are getting in touch with their vulnerabilities. In an open setting, patients are invited collectively to contribute to the running of the hospital — holding elected leadership positions, running meetings, weighing in on the issues. They keep the place going. People, especially with the kind of relational instability we’re talking about, are desperate to belong. They want a community, and that tempers things when times get tough.
A borderline person can look really bad and then bounce back and look really good. You’ve got to have a setting that allows for that range. A corollary to this aspect of the community program is the activities department. Many of these patients are enormously creative, but they haven’t acquired a real ability to use language to master and express emotion. So the Shop, where there are materials, where it’s non-verbal expression, is hugely important.
Interview with Dr. Jerry Fromm Continued page 3
