Borderline Personality Disorder: A Conversation with M. Gerard Fromm, PhD, ABPP
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, PhD, 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.
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.
This six-part series, exploring borderline personality disorder, is taken from an interview, conducted by former Erikson Scholar Joshua Wolf Shenk in 2009, with M. Gerard Fromm, PhD, ABPP, a senior consultant to the Erikson Institute for Education and Research at the Austen Riggs Center.