- Hi, my name is Yvette Esprey,
I'm a clinical psychologist from Johannesburg, South Africa.
In Johannesburg, I run my own private practice
and I do some lecturing for a psychoanalytic institute.
And I come from a background of working
quite intensely with personality disorders,
whilst I was head psychologist at a psychiatric hospital
for a number of years in Johannesburg.
And so, what I'd like to share with you in the lecture today
is really a particular kind of treatment approach
to working with borderline personality disorders,
which I have found enormously helpful,
and certainly has made sense for me in a way
that I've been able to translate into clinical practice.
With, obviously, varying degrees of efficacy.
Those of you who have worked with borderline
disorders or features will know that degrees of efficacy
really depend on so many factors.
But I do find that working from a particular
theoretical base, and specifically an attachment base,
has been enormously useful and helpful in my practice.
So what I'd like to do in this lecture is to start off
by giving you a theoretical underpinning to the practice
and to really tease out, firstly, what we mean
by "borderline", by borderline personality,
by borderline personality disorder,
and then to ground some of that definition
in an attachment context and to give
quite a detailed explanation of attachment theory,
and the links between attachment theory
and the presentation of borderline features and symptoms.
I'll follow that up in the second part of the lecture
with some comments about practice
and some of the core treatments, factors, and tenets,
and going into some detail around how to use attachment
when thinking about practice.
So, a lot of people ask me why I had a particular interest
in working with borderline personality.
Because, once again, as you all know,
it's a particularly challenging and difficult
aspect of clinical practice, and many many clinicians
would shy away from it, enormously.
I have to say that as I have grown in my experience
and as I have worked longer in my practice,
I have become far more selective about who I work with,
but I still have a fundamental interest
in working with those people who struggle
at their core, with their whole way of being in the world,
which is really, at their core, their whole personality.
Working within the borderline spectrum
means working with a diverse spectrum of disorders.
No one person will ever present the same as anybody else.
The entire system is involved,
so we don't work with just this symptom, or that symptom,
or just this aspect of the self.
We are working with the entirety of the person,
which makes it enormously interesting.
There is something about the intensity and the engagement
which is required when working
with the borderline personality disorder,
that I find very, very compelling,
and certainly incredibly engaging,
whilst also challenging.
I find this work gratifying, because of
those moments of breakthrough, and they don't happen often,
but when they happen, they are stunning,
and they can be life-changing.
So that's something that I hold on to.
Another reason for wanting to work in this area
is that it is one of the areas of clinical practice,
in which theory and practice correspond so well together.
I think that often, as clinicians, we have a tendency
to work from our intuition, from our gut,
to feel our way into a practice,
and often we might lack a theoretical foundation,
or backup, to what we are doing in the room.
Working with personality disorders gives us
an opportunity to really marry practice and theory,
in a very, very synchronistic way.
In fact, Caroline Garland, who is a trauma expert,
once commented on the usefulness
of theory for SS clinicians.
What theory gives us, is it gives
us the third voice in the room.
When we're sitting in the room,
and we're grappling for words,
we're grappling for ideas, we don't know what to think,
theory is very, very often the third space
that provides us with a moment to pause,
and a moment to make sense of what is happening in the room.
Theory, for me, is a tool,
and it's fundamental to really understanding
the particular mechanisms for change.
And finally, understanding the theory behind
the borderline manifestation, for me,
certainly helps to create an empathy,
which at other times is very, very hard to find.
When you are sitting with somebody who is hard to reach,
who may be being attacking, who is projecting
everything bad that they feel about themselves into you,
it can be incredibly hard to hold your bearings,
and to be grounded, and to like that person.
Theory, certainly for me, helps to create an empathy,
and allows me to connect with that
incredibly wounded part of the self,
with whom I am trying to work.
Now as I have mentioned,
there are a great number of challenges
when working with borderline personality disorder,
and I just want to pause there for a moment.
I'm always incredibly self-conscious when I use the word
"Borderline Personality Disorder,"
knowing, very, very well, just how pejorative
that term has become, just how stigmatized it has become,
and I do want to say at the outset in this lecture,
that I use that term for convenience,
because when you are listening to me,
you know what I'm talking about
and we have a common understanding
based on a common classification system,
but I'm aware that I'm talking about individuals,
and I'm talking about whole people,
and I want to do that with sensitivity,
and with empathy, and so I want to talk about
people with a borderline personality,
I don't want to talk about "a borderline,"
because I would hope that there can be
some kind of a space, or some kind of a life,
or some kind of an opportunity
beyond the label of "borderline."
So as I was saying, there are a great deal of challenges
when working with borderline personality disorder.
When I was training, I remember that one of my lecturers
said to me, "You can never have more than one person
"with borderline personality disorder
"in your practice at any given time."
And I remember thinking to myself,
"Why on Earth would she say such a thing?"
I mean, that seems bizarre,
until I started to work in the field and to realize
just how much space, how much energy, how much time,
and how much effort one person who manifests in this way
can take from the therapist.
And how you can have one person in your practice
who dominates your thinking,
both inside the room, and outside of it.
It is taxing and demanding,
and part of the reason for that is because
the way of being for a person
who lives in a borderline realm,
is such that, whenever they encounter another person,
and especially in the intimacy of the therapeutic space,
it is an opportunity for them to project all sorts of
very, very powerful affects and experiences into the other,
which means that very, very often
as the therapist, as you know,
we are having to deal with incredibly primitive feelings,
with the use of defenses around splitting, projecting,
and we, as the therapists, are engaged
in a long-term drama, which we must survive.
And sometimes it does feel like survival.
One of the other challenges in terms
of diagnosis and formulation,
when it comes to working with borderlines,
is that borderline personality disorder
is very, very often misdiagnosed.
Certainly, I know with a lot of psychiatrists
with whom I work, they would always prefer
to diagnose bipolar mood disorder,
and I think we can understand why.
When you're working with a mood disorder,
whose symptoms might very well mirror
some of the borderline symptoms that we know,
It's far easier to treat, pharmacologically,
so we can give a mood stabilizer,
we can give an antipsychotic,
and we can treat the mood disorder.
But how do we begin to medically treat a whole personality?
And so very, very often, those patients who
present very clearly with a borderline personality disorder
get misdiagnosed, or the diagnosis is deferred,
because to actually give that definitive diagnosis
makes treatment incredibly difficult.
We also know, of course, that patients
can sit with the diagnosis of both
a personality disorder and a mood disorder,
where the hypermanic symptoms of a bipolar mood episode,
can very, very easily mirror
the symptoms of borderline pathology,
and that both of those experiences
can co-exist for the same person.
What is extremely fundamental when
diagnosing and formulating around personality
is to establish a clear history
and a clear pattern of behavior.
We simply cannot diagnose a borderline personality
based on one discrete episode of regression.
Every single one of us is vulnerable to regressing
in the face of major life stresses, or major life traumas.
Every single one of us is capable of being reduced
to infantile states of mind and to primitive feelings,
when faced with overwhelming experiences.
So in order to diagnose, accurately, a borderline pathology,
we have to have a long history,
where we can quite clearly see the markers
of the development of a personality that,
for this person, is dysfunctional in the world.
A further challenge in working in this area
is managing the countertransferance.
So often our countertransferance as clinicians
is they're a tool which we use to help us to make sense
of what is happening in the world of the other.
Quite often when working with personality disorders,
it is our countertransferance that can become
an obstacle to working with the other.
Certainly, there are times when I
have been working with a patient
whose transferance is so powerful,
and whose projections are so overwhelming,
that I find it difficult to continue.
At times I feel unable to continue.
And so making sense of our countertransferance
reactions is incredibly important.
And making sense of how it feels to sometimes be hated,
to sometimes experience the full force of persecutory rage,
making sense of that is so very, very important.
But once again, to reiterate, that the countertransference
is really what helps us, most accurately,
to tune in to the internal world of the other.
Finally, the challenge of working in this area,
is the challenge of reaching a place of intense humility.
To recognize, in the other,
what has to be borne, and what has to be survived.
To recognize in the other, that in the face of overwhelming
obstacles, internal obstacles and external obstacles,
there is the strength of the human spirit
and the life instinct.
Sometimes I'm absolutely blown away
by the circumstances of some of my patients' lives,
by the circumstances of their early childhoods,
bu the circumstances of their internal worlds,
and yet they still have a life force,
some kind of a libidinal instinct that pushes them through,
and that gives them the courage to continue to live.
And I find that enormously humbling.
So, working with borderline personality disorder,
in fact working on the personality disorder spectrum,
we really have so many treatment modalities at our disposal.
There are so many different ways of thinking about BPD.
We have had Kernberg, we have had Masterson,
we have had Linehan, we have Fonagy,
we have countless theorists who have
given us their treatment modality.
Ultimately, at the end of the day,
I think that, for each of those theorists,
the way in which they propose we work,
really works for them.
So ultimately, as a clinician,
we have to decide for ourselves what works for us.
Of course a treatment of choice,
certainly I think in this country,
is dialectical behavior therapy, is DBT.
Which really focuses on emotional disregulation,
and I think can be an enormously effective
way of treating the illness, and treating the disorder.
But the one thing about DBT is
that it focuses on symptom relief.
It focuses on what manifests,
every day, in this person's life,
and may not get to what we believe is the
underlying psychological deficit,
which is born out of an early attachment relationship.
I found that attachment makes sense, for me,
and so does the attachment-based way of thinking about
and working with borderline personality disorder.
I would like to shift the focus a little bit now,
and talk about contextualizing BPD
as a disorder of the self.
James Masterson was very instrumental in rewording
the notion of a personality disorder,
and rethinking it into a disorder of the self.
Thinking about a borderline personality
as being a disorder of the self
is more nuanced, and it really focuses us on
the self, on the development of the self,
on the parts of the self that struggle
to be effective in the world,
to live an effective life, and to be functional.
So, we might want to ask ourselves,
"What are the characteristics of a developed self,
"versus the characteristics of a more disordered self?"
"What are the things that make us functional, as people?"
And certainly, whenever I read through this list,
I always refer to myself, and I think about
how many aspects of the self I can relate to directly,
and I'm sure in listening to this,
you'll do the same for yourself.
But one of the most important things
that forms a coherent self
is the ability to view ourselves, and others,
in stable and complex and accurate ways.
In other words, to really be able to have
a nuanced picture of who we are in the world,
and of who the other is in the world.
I remember so often when working in my psychiatric hospital,
when interviewing patients as they came in,
and asking them to describe themselves,
how I would be faced, quite often,
with dumbfoundedness, with confusion, with inarticulateness,
when I said to them, "Tell me who you are."
"Tell me who you are as a person."
And there was a real inability to fine-tune,
or articulate, characteristics of the self.
Similarly, I might say to them,
"Tell me about your mother," or
"Tell me about your partner," or
"Tell me about your child," and there would be an incredibly
striking deficit, and inability,
to describe the other person.
Or alternatively, the self and the other
is described in very contradictory ways.
So for example, a person may say,
"Ah I really, I love people! I'm very outgoing!
"I really really enjoy people."
And then, to follow that up, immediately,
with a completely contradictory statement
about being isolated in the world,
or about not being able to relate to people.
And whilst those splits are so starkly obvious
to the observer, to the person that split is not recognized.
And it's that kind of splitting of the self
that kind of inability to accurately
portray the self and the other
that is a cornerstone of a disordered self.
Another very important aspect of a developed self
is the ability to maintain intimate,
stable, and satisfying relationships.
And of course we know that that isn't only
within the realm of romantic relationships.
We need to ask the question,
"Can this person relate to other people?",
"Do they have a history of friendships?"
One of the most very, very important
questions to ask a person, "Do you have friends?",
"For how long have you known them?",
"What is the depth of that friendship?"
Are they able to form attachments
and relationships with their pets, for example,
with people in their lives, or have they
got a history of truncated relationships
and broken friendships, and a clear inability
to hold on, or to establish intimacy?
Thirdly, a developed self is able to
experience, in self, and to perceive in others,
the full range of affect appropriate at any given moment.
In other words, we all have the capacity to
experience emotions in varying degrees of intensity.
We feel strongly about things,
we feel happy, we feel sad,
we feel devastated, we feel joyful,
we feel sad, lonely, hurt, angry.
And are we able to feel those myriad emotions
appropriately, at different times, in our lives?
And are we able to perceive those emotions in other people?
It's about affect tolerance, and about emotion regulation,
which is so important to a developed self.
Fourthly, the ability to regulate impulses.
Can you manage impulsivity?
How do you manage if you feel overwhelmed by a situation?
What do you do when you feel lost, or alone, or scared?
What do you do when you feel angry?
Are you able to sit with those feelings,
or do you have to do something,
to extricate yourself from that feeling,
because it is just too much?
And how does that impulsivity manifest?
So impulse regulation, capacity to manage impulsivity,
is a very important aspect of a developed self.
Importantly when we are considering more
psychopathic or narcissistic personality structures,
is the ability to function in line with
some kind of a consistent moral code.
In other words, to have a suitably integrated superego.
That part of ourselves that knows what is right or wrong.
That part of ourselves that knows
what our actions might do to others.
That part of ourselves that understands
the consequences of our actions.
And that's a fundamental aspect of a mature self,
is to be able to differentiate that,
and to be able to make decisions based on that.
Is there the ability to differentiate
what is real and what is not real?
In other words, the capacity for reality testing.
Is there the ability to respond to stress,
resourcefully and appropriately?
And is there the capacity to recover from painful events
in a way that is mature and appropriate?
In other words, we all struggle with painful events,
with loss, with death, with trauma.
But the question is, "How quickly do we
"pick ourselves up from that place of despair?"
And that was always one of the things
that helped me to differentiate,
when I was working in a psychiatric context,
between those with a personality component,
and those who were suffering with straightforward trauma.
There's never a straightforward trauma, but
nothing, I think you probably understand what I mean.
So, somebody who goes through a trauma,
and who is unable to pull themselves back together,
and who is reduced to a place of absolute despair,
where they fragment and fall apart,
they can no longer function,
they can't go back to work,
they can't maintain their relationships,
they might become suicidal,
that is a shattering of the self,
and an inability to pull the self back together,
which would be a more appropriate way
of dealing with a trauma.
And finally, a developed self has the insight
and the capacity to observe themselves.
And this is, I can't stress enough how fundamental this is,
when thinking about whether or not a person
can be diagnosed or formulated as
disordered in terms of their self,
the capacity to know what is happening.
So for many of us, we may well know
when we're being dysfunctional,
or when we're acting inappropriately,
or when we're feeling something
that perhaps we shouldn't be feeling.
But we know it, we can observe it,
and we can comment on it.
Whereas with somebody who sits with a disorder of the self,
there isn't that distance, there isn't the luxury,
of that distance, and the luxury of
being able to comment on their own behavior.
Overridingly, a mature and a developed self
has a sense of vitality, which allows for passion,
and for meaning-making, and for creativity.
And it's that kind of vitality, that kind of life force,
that kind of creativity that we so seldom see
in those people who manifest on the borderline spectrum.
There's also the capacity to mourn, to accept,
and to surrender to experiences in life,
which the disordered self simply cannot bear.
So if we step back a little bit from those capacities
of the mature and developed self,
and we think to ourselves,
"Well, what are the core incapacities
"of the borderline personality?"
I would say that the core of a disordered personality,
a disordered self, are the following.
Identity distortion, a real inability
to portray self, or other, in accurate ways.
Inadequate relationships, or the inability
to maintain satisfying relationships.
Affect disregulation, really not being able to
manage feelings, tolerate feelings,
or express feelings appropriately.
And impulsivity.
In addition to this, whilst reality testing
globally might be fairly intact.
In other words, many of the people with whom we work,
who present with a borderline disorder,
are absolutely able to live in the world,
they're able to, they're not psychotic,
they don't present with any kind of a psychotic disorder,
so on the face of it, they seem functional in the world
and able to differentiate what is real and what is not real.
But if we start to really nuance
what we mean by reality testing,
then we start to see that their
sense of reality can be distorted,
certainly when it comes to perceptions of self, or other.
But in the main, reality testing is intact.
However, when we are talking about
the narcissist or the psychopath,
a very, very important feature of their disordered self
is the inability to distinguish right from wrong.
There is a fundamental impairment of moral sensibility,
which is often very, very easy
to see, and to recognize.
When working with a disorder of the self,
we will frequently see that the attribution of blame,
for experience, is almost always and inevitably
outwards into the environment.
In other words,
the self will never be held responsible
for what is going wrong.
It will always be, "Why is the world against me?"
"Why is this person against me?",
"Why does this always happen to me?",
as opposed to having a firmer internal acts of control,
where they might say,
"Well what is it that I might be doing?",
or "What kind of responsibility can I bear
"for the outcomes in my life?"
We see a consistent pattern of dysfunctionality.
And we see, within this consistent pattern,
particular personality traits that are
inflexible and maladaptive.
Certainly inflexible and maladaptive to you and I,
that when we observe them,
we can see how dysfunctional they are.
But another fundamental aspect of the disorder of the self,
is that, for that person, the way that they are
in the world is ego-syntonic.
In other words, it's congruent for them.
What's not congruent, is the way that the world,
the way that we, respond to them.
So finally, just to pull together
the diagnosis and the classification of BPD,
inevitably, it involves the whole self.
We do not deal with discrete or separate symptoms.
We can't take impulsivity and treat that discretely.
We can't take self-destructive behavior
and treat that discretely.
We can't take that deep, dark depression
and treat that discretely.
We have to think about the wholeness of the system.
And fundamental to that, is understanding the genesis
of where this particular fractured self comes from,
because it comes from somewhere.
Thinking about classification systems,
you'll all aware, of course, of the
controversy and the debate, I would imagine,
around BPD, that there's been a great deal of discussion,
historically, about what it actually means,
and how to classify it, how to define it,
and that culminated in the atheoretical symptom list,
which we now have in the DSM-5,
which is commonly known,
and it's an easy-to-tick-off checklist
of symptom presentation, which allows us
to give the diagnosis of a BPD.
In contrast, however, and certainly my choice
of diagnostic classification system,
is the PDM, the Psychodynamic Diagnostic Manual.
In the PDM, what is considered
is the whole range of functioning,
which presents within the BPD spectrum.
Consideration is taken of developmental factors.
Consideration is taken of environmental factors,
and current context, and support systems,
and so that if you use this particular classification system
in diagnosing or formulating around your patients,
you are really getting a much more multi-dimensional
picture of this person, of this individual.
And really, it is only over time
as we get to know a patient more and more intimately,
that we can really comprehensively
formulate and understand their particular manifestation.
Certainly I've had people, with whom
I've been working for many, many years,
five years, I've got somebody I've
been seeing for seven or eight years,
where getting to know them has really happened over time.
So my initial formulation
of borderline personality disorder,
whilst it was accurate, it certainly wasn't
nuanced enough for me to fully comprehend
the way that this particular person manifests.
Over time, we are more able to do that.
The PDM really draws largely
on Otto Kernberg's psychoanalytic structural theory,
which I'm going to go into a little bit, later on,
where broad areas of functioning are taken into account.
And so what the PDM suggests, and as Kernberg suggests,
is that there is a borderline organization,
there is a spectrum of borderline functioning.
There is not one borderline personality disorder,
rather there is an organization, there is a spectrum,
there is a range of functioning,
and within this range of functioning,
there are particular manifestations.
And so if you look at the PDM diagnostic system,
they have named a number of
manifestations of the borderline organization,
depending on the specific defenses used,
and these will include the schizoid personality,
the paranoid, the psychopathic,
the narcissistic, the sadistic,
the masochistic, the depressive,
the somatizing, the dependent,
the phobic, the anxious, the obsessive-compulsive,
and the histrionic, and I'm sure that
as I'm saying this to you, some of you are thinking
to yourselves, "Ah, that particular patient or client,
"sounds like they've got that particular
"manifestation of defenses," or
"Ah, that particular label makes sense
"to me for somebody else."
And so the PDM really gives us an opportunity
to fine-tune, and to refine our way
of understanding this person.
And of course, the more that we can
refine our formulation, the more able we are
to really attend to this person with
a treatment that is going to be the most adequate
for them and most appropriate for them.
But I do want to pause a little bit now and step back,
and look at Kernberg's structural diagnosis of personality.
Some years ago Kernberg suggested
that we need to be looking at the
diagnosis of personality disorders
from a different perspective,
that we need to shift away from specific
behaviors and symptoms, to considering
what is happening intra-cyclically.
And of course, we are referring to
a psychoanalytically oriented theorist,
and so he is interested in what is happening
in the internal world, as am I.
And so rather than seeing
a borderline personality disorder as a personality type,
we rather look at a borderline level of functioning.
And at that borderline level of functioning,
all of these different manifestations,
the paranoid, the phobic, the anxious,
the histrionic, the narcissistic,
they all function with weak ego strength.
Their overall adaptive functioning is impaired.
It's more impaired than we see in neurotic patients,
but it is less impaired than we see in psychotic patients.
At this level of impairment,
we understand that there is a fundamental arrest
of ego capacity, and of the self.
And so he proposed an intrapsychic structural approach
to diagnosis, and he proposed
three broad structural organizations.
So if you can imagine that there is the neurotic level
in the higher end of the hierarchy,
right at the bottom end of the hierarchy is
the psychotic level, and then in between the two,
that's the borderline range.
And it is within that borderline range
that we see a massive fluctuation of functionality.
So certainly, you can have some highly functional
individuals, who are operating within the borderline range,
but you are tending towards a more
neurotical level of functioning.
And then you have those indviduals
who are operating at a much lower level
within their borderline range,
in fact, virging on the psychotic, where sometimes
they might even dip into more psychotic waves of relating.
But there is a broad range available
in which to diagnose and formulate each individual.
But in each case, the psychic structure,
which is present for the individual,
performs a very, very important function,
and that function is to stabilize the mental apparatus.
That function is to stabilize the self.
And I think this is a point that I can't
express often enough and emphasize enough
and I'm going to repeat it a number of times
in this lecture, which is to say that the ways in which
the BPD presents, the ways in which
these individuals present, are all adaptive.
They are all ways of trying to stabilize
an unbalanced internal situation.
The defenses that they use,
the ways in which they act in the world,
they are all attempts, and often desparate attempts,
to stabilize an unstable internal experience.
And so this particular psychic structure,
this borderline psychic structure,
becomes this particular individual's matrix
from which behavior springs.
The particular behavioral symptoms that we see
comes from an intrapsychic matrix.
And there are three ways of really trying to think about
what this intrapsychic matrix looks like,
and how it functions.
Firstly, we look at degree of identity integration.
Secondly, we look at types of defensive operations.
And thirdly, we look at capacity for reality testing.
So for example, if you were looking
at the neurotic individual,
somebody who presents as neurotic,
is going to present with an integrated sense of identity,
where the primary defense is based on repression,
and there is very, very strongly intact reality testing.
If you look at somebody from the
psychotic end of the spectrum,
obviously there, we have a complete
fragmentation of identity, we have identity diffusion.
We have very, very, very primitive defenses,
and often times, we have a complete lack of reality testing.
But for the borderline, somewhere in between,
we have a relative degree of identity diffusion.
We have primitive defense structures
which are primarily based on splitting.
And we have relatively intact reality testing.
But let's tease this out a little bit further
and I want to take you into each of these three dimensions
so that we can fully understand how they might
present themselves in different individuals.
Starting with identity integration.
The lack of an integrated identity,
which leads to diffusion, is seen in a
very, very poor concept of self and other,
as I spoke about earlier.
The subjective manifestation of us,
in other words,the way that a person feels
in the context of identity diffusion,
is a feeling of chronic emptiness.
And so often, when I say to somebody,
"How do you feel inside?"
they might say, "I feel empty, I feel dead,"
but often that word empty has a resonance
which is quite powerful, and it really communicates
that sense of internal hollowness,
with which they live, every single day.
Within this identity diffusion there are
contradictory self-perceptions and contradictory behavior,
that can't be properly integrated
in any kind of emotionally meaningful way.
They are shallow, and often
lacking in authenticity, relatedness,
and relating to others.
There is a real inability to gain
a clear picture of self and of others.
And there's a real lack of engagement.
Certainly, often when I first meet patients who come to me,
in the initial sessions, I find it very, very hard
to truly connect with that person, to find that person,
and I can feel the way in which they have used their mind
to protect themselves from real, authentic engagements.
So there can be the display of engagement,
there can be a pseudo-engagement,
but to really access that person
feels incredibly challenging and very, very difficult.
So there is very, very often superficial relating
that goes with this kind of identity diffusion.
To move on to the defenses, as I said earlier,
the kind of defenses that the
borderline organization will resort to
are incredibly primitive defenses.
The more neurotic individual is going to use repression
to literally push down,
to literally keep away,
experiences or feelings that are going to
overwhelm daily functioning.
But repression is different to splitting.
Splitting is a literal dissociation of experience,
a literal cutting off of feeling,
of experience, of self and of other.
And these defenses are absolutely fundamental
to the survival of the ego, and I always find
this notion incredibly painful and sad to consider,
because if we think about the genesis
of splitting defenses, splitting originates
in early infancy, all of us, going through infancy
and toddlerhood and childhood, used splitting
to help us, to ward off experiences that were
too challenging or too overwhelming or too painful.
And that was a very adaptive function as a child.
Infants and children need splitting defenses
in order to help them to negotiate
the growth of the self,
and the negotiation of the external world.
So quite often, for example, you will see
an infant or a toddler who suddenly gets overstimulated
if they're being tickled or teased or they're laughing,
they're suddenly being overstimulated,
they might just turn away, in a very literal way,
as if to say, "You don't exist anymore.",
"You're not there anymore."
That's a very literal illustration
of splitting, of pushing aside,
and in that moment, that little one
needs that, fundamentally, in order
to get through that overwhelming stimulation.
But with the development of the robustness of the self,
that kind of need for splitting
should ideally fall away,
because the individual is then able to negotiate
extreme feelings of distress or overstimulation.
But for the borderline personality patient,
that splitting is still the primary way
of managing overwhelming affect,
of managing overwhelming experiences.
And of course, within those key defenses
are things like primitive idealization,
where people are seen as all good or all bad,
where parts of the self are seen as all good or all bad.
And as a clinician, certainly I've had this experience,
they can be the experience of being completely idealized.
And it's wonder to bask in that glow
of being the good object,
but of course we have to remind ourselves
that it is an absolute experience,
and not based on reality,
and equally, it is absolutely appalling
to have bear the brunt of being the all bad object,
or to witness the patient seeing themselves,
and holding themselves, in that all bad way.
So primitive idealization and primitive devaluing
is one of the core defenses.
Projection, and most notably, projective identification,
where difficult or overwhelming experiences
are thrust out psychically into the other.
Is another core experience, which is precisely why,
as clinicians, we will feel things in our bodies,
we will feel things in our system
which are a direct missile
thrown out by the person in the room with us.
And in that moment, what is happening for the individual
is that they cannot tolerate whatever the experience is,
and they have to rid themselves of it
in a very, very direct way,
and locate that in you,
in you as the clinician, in you as the other.
Another common defense is that of denial,
where the person might exhibit
quite extraordinary lack of concern
about people and their lives,
or about loved ones, people who they are close to.
There might be an absence of anxiety
or an absence of appropriate emotional reaction
to hearing news about important things.
And this is what happens when denial sets in
once again, as a way of protecting self from feelings
that are just too, too, too painful, too difficult.
And I suppose the reality is that,
if we can really, truly comprehend
that when an experience of pain, for example,
or of fear, or of sadness, is experienced
as a concrete object internally,
we can understand how frightening that is,
and how important it is to try to get rid of that feeling,
by throwing it out, and hoping
that somebody else will catch it.
So those are the core defenses
that really center around splitting.
The third aspect along which Kernberg suggests
that we diagnose and formulate our patients
is along the line of reality testing.
And included in this, it's not only understanding
what's real and what's not real in the perceived world,
but it's also about the capacity
to differentiate self from non-self,
so "What is me?" and "What is not me?"
And this often manifests itself in relationships,
"Where do I begin and end and
"where does the other begin and end?",
which is why so often we see in
borderline relationships either a complete merging,
or a complete splitting-off or complete separation,
and the ability to maintain appropriate boundaries
is extremely compromised.
Part of reality testing is the capacity
to realistically evaluate one's own affect,
to realistically evaluate one's own behavior,
or thought content.
So, for example, if I'm feeling absolutely furious
because this bank manager is not doing
what I have asked him to do, which is to
change my account to another account,
and in this moment, he is the target of all of my rage,
it is absolutely fine to take my cup of coffee
and throw it over him, isn't it?
It's that kind of reality testing that falters,
because, for that person, and I'm describing a real event,
for that person, in that moment, that behavior is justified,
because that experience is compartmentalized,
and split off from the norms of society,
and the norms of interpersonal relating.
And so whilst, in our borderline patients,
we may not see a gross breakdown of reality testing,
such as we would see in a psychotic person,
if you start to fine-tune, it then becomes possible
to recognize those moments of reality breakdown,
particularly in relation to self-perception,
perception of others, and the perception
of what is appropriate between self and others.
Now Kernberg has, what I find, a very useful
structural interview that he suggests
we apply when we first meet a person,
but I quite like to just have these three aspects
of intrapsychic experience sitting in the back of my mind
when I meet a person, and as I get to know them,
so that I start to get an idea
of how they are in terms of their identity integration,
how they are in terms of the defenses that they use,
and how they are in terms of their reality testing.
But if we then think to ourselves,
"What actually happens in the room?"
So we've got all this theory, all these notions
of what might be happening internally,
but what am I going to see when I meet a person,
and they're sitting in the room with me
and I start to work with them?
What am I going to be able to recognize
both in the way that they relate to me
and in the way that they relate to others
in their lives, that they describe to me?
And I think that there are three core symptom clusters
that we will see, no matter what particular manifestation
of borderline organization we have in our rooms.
The first symptom area is that which centers around affect,
that we are always going to see
intensity of affect in some way.
Very, very often that intensity of affect
will manifest as anger or aggression,
and it may not be the overt aggression
that is channeled outwardly,
anger against the other, anger against me as the clinician.
It may well be anger that is internalized,
anger against the self, anger that implodes
inside the self, but nonetheless
they are powerful anger affects.
We see also affect of instability, and so
from one minute to the next, sometimes in a 50 minute hour,
we can see a rollercoaster of emotions,
from absolute joy to the depths of despair,
from one session to the next.
In the accounts that the person gives
of their daily interactions,
we see a real affect of instability,
and we also see, and quite often as a
consequence of the affect of instability,
unstable relationships, we also see
incredibly intense relationships,
just as we experience an intense relationship
in the therapeutic context.
So that's affect.
The second main symptom area is around identity.
The chronic emptiness that we will see,
abandonment fears, because if the self is not seen as whole,
and if the other is not seen as whole,
and if it's not possible to understand
the relationship between self and other,
then the possibility of being left, of being abandoned,
becomes terrifyingly real, and so whenever
a BPD comes into the context of a relationship,
so, too, comes the possibility of abandonment,
abandonment anxiety, abandonment depression,
abandonment fears.
And so we see clinging, we see merging,
we see desperate attempts not to lose the object,
which forms part of the identity component.
And the third core symptom is around impulsivity.
So, just because you've got somebody in your room
who's never cut themselves, or never hurt themselves,
in a literal kind of way, doesn't mean that they don't
show, in some way, the impulsivity that is so
characteristic of this particular type of patient.
Self-harm will almost inevitably manifest in some way,
and it may not always be overtly evident at the outset.
Reckless behavior, substance abuse,
and once again, substance abuse may not be
gross alcohol abuse,
or gross recreational drug abuse,
it may be consistent use of pain medication,
it may be the consistent use
of over-the-counter sleep medication,
where, somehow, this person is turning to substances
to help them to manage their everyday existence
and to get through their everyday lives.
So we have consensus
around the core affect areas.
We have consensus around
how we experience those patients
who present with a BPD in our rooms.
But there is not consensus
about the underlying psychological mechanism
that informs this particular disorder.
What is it that creates
this particular manifestation of the self in the world?
And this is where I want to talk,
a little bit, about attachment theory,
attachment theory as the foundation,
attachment theory in terms of helping us
to understand what goes wrong.
I'm certainly not saying that it's the only explanation,
but certainly it's an explanation that makes sense for me,
and as I said earlier, it's an explanation that certainly
helps me to be in the room in a particular kind of way.
Now, thinking about the etiology of BPD,
there has been some current research
which has looked at genetic components.
In other words, is it an inheritable disorder?
And there is some evidence that suggests that,
but there's also increasing evidence
that there is an environmental component
to creating BPD that we simply cannot ignore.
And what is, I mean, coming back to
the age-old nature-nurture debate,
what is probably most likely the answer
is that there is some kind of a coming together,
a marrying, of what the individual brings
constitutionally into the world
and the way in which that constitutionality matches,
or meets up, with their particular environmental context.
So certainly, and once again, having worked
with a diverse range of people,
I do believe that some people are born with
a clearer propensity to aggression, for example.
And if you take that clearer propensity for aggression
and you match it with with a particular
early attachment environment,
you can create a volcano
of anger and rage and aggression
that is going to spew out and spill out
all the way through the lifespan.
Similarly, you might have people
who are born with less constitutional aggression,
and yet still they come up against
an early environmental context that is
problematic for many ways that I'm going to go into,
that then creates the foundation for the growth
of an anger, of a frustration,
and of an aggression, that then
is going to manifest throughout the lifespan.
Attachment, that relationship between the infant
and the primary caregiver or caregivers,
can be understood to be the mediator
between the environment and the constitution.
So how do those two things lock together?
They lock together through the
interpersonal context of self and other.
And as we know, human beings are not one of the species
that can be born into the world and fend for themselves.
Fundamentally, we need, not only
at a physical and a biological level,
but at an emotional level of attachment,
we need the other to help us to survive
and to help us to grow.
So the underlying premise of attachment theory is that
the adult personality is the outcome of development,
and that a personality disorder, or a disorder of the self,
is the consequence of an environmentally-induced
distortion of psychological functioning.
In other words, the way that the psyche functions
is a consequence of something
that has been distorted environmentally.
So to back up just a little bit,
and to think about attachment theory more broadly,
we know, for example, that Bowlby introduced us,
most fundamentally, to different
kinds of attachment styles, and broadly speaking,
he spoke about secure versus insecure attachment,
and we know that those can be broken down
into different kinds of attachments,
such as anxious, avoidant, or disorganized attachment.
Most importantly, in the context of BPD,
we are looking at the possible existence
of a disorganized early attachment,
so the early attachment relationship
created a sense of internal disorganization.
And this is why, for those people
who have to live with and survive BPD,
they have to live with and survive an ongoing
internal experience of chaos and disorganization.
What is fundamental to secure attachment?
So secure attachment is about proximity.
It's about closeness.
It's about mental closeness.
It is about evoking an experience of safety.
And that's not just pockets of safety,
it's an experience of consistent
and reliable and ongoing safety.
And this experience of safety results in the development
of psychological processes that are robust and flexible.
An experience of safety within the context
of a close, emotional relationship
is absolutely essential, it is fundamental,
it is cornerstone for the development
of an autonomous sense of self,
and for the development for all of those
aspects of the self that I spoke about earlier,
the capacity for flexibility, the capacity for
an integrated sense of who we are,
the capacity for vitality, for creativity,
for reality testing, for all of the things
that help us to be functional and happy,
or at least content people in the world.
And it all comes down to an early experience of safety,
which then creates a fertile ground for the growth
of robust and flexible psychological processes.
A robust self protects the individual
from the stresses of everyday life.
A robust self is that which mediates
between our experience of the world and the world itself.
If this sense of safety
is ruptured or compromised,
or if it is inconsistent, or if it doesn't exist at all,
what it creates, what derives from that,
is the potential for the development of anxiety and anger,
which then become the way in which
the mechanism stabilizes itself.
So whilst, for a robust personality,
there is a flexibility to dealing with stresses
that come along every day and through life,
in the absence of an experience of early safety,
anger and frustration become the mediating factors.
Anger and frustration become the ways
in which the self is balanced.
Now, what is it that's going to create
the circumstances for this emerging self
to go along the wrong path?
The emerging self is most under threat
when in close emotional contact with another self.
So, in other words, when the mind of the infant
comes into contact with the mind of the other,
that is the most precarious experience of all.
If the mind of the other is receptive,
if the mind of the other is conducive,
then it is a safe connection.
But if the mind of the other is closed,
if the mind of the other is dysfunctional,
or disordered, or disorganized itself,
then that coming together creates
an explosion of disorganization that then
lays the foundation for the development of the self.
When mind meets mind,
it is the most dangerous situation of all.
When the mind of the caregiver
shows little understanding of the child's internal state,
then that child is setting off on a precarious course.
If the early attachment environment is not good enough,
and we're not saying perfect, remember
that Winnicott said we need a "good enough"
early environment, not a perfect one.
If the early attachment environment
is good enough, the child will develop
a sense of agency, an agentive self,
where thoughts and feelings can guide action,
and this is facilitated and stabilized by a caregiver
who provides a particular intersubjective context,
and the self becomes increasingly
strengthened through interaction.
But in cases of neglect, or of insensitivity,
or of all of the other ways in which
poor attachment manifests,
then the self becomes unstable,
resulting in anger and aggression,
and this anger and aggression then becomes incorporated
as part of the self-structure.
So, that means that anger isn't
an experience and an affect that can be used
when it is needed, so for many of us, hopefully,
anger and aggression can be used in the service
of motivating or of managing a situation,
and then discarded.
No. Anger and aggression become part of the self.
They are intrinsic to the self.
And this means that any attempt at self-assertion,
any expression of a need, of a wish, of a demand,
is always going to be accompanied
by some kind of an aggression,
in order for the self to remain intact and stable.
And so self-assertion can never
be separated from anger or aggression,
there's always going to be an aggressive underbelly,
an aggressive component.
And of course, as I said earlier,
this is also going to differ depending on constitutionality.
Kernberg, as I said, he was very much,
I mean he was a very interesting theorist actually,
I really like Kernberg because he was
one of the people who tried to marry
drive theory with object-relations theory.
So he basically believed that we are all born
with the intrinsic drives, the libidinal
and the aggressive drives, and that
we take those into the world with us.
But then he flipped it over to object-relations theory
and said that the way in which those particular
libidinal and aggressive instincts manifest and are shaped
then becomes predicated on the early environment,
the early developmental context into which we are born.
And so, depending on the constitutional propensity
for anger or aggression, the volume
of that anger or aggression will differ with each person.
So we have a situation now of an infant,
of a child, who has been born into an environment
that isn't going to offer her a reliable sense of self.
She's been born into an environment
where there isn't the safety and proximity
of a stable caregiver who's able to hold her in mind,
in an accurate and safe way.
And this then creates a self-structure
that is predicated on anger, that is basically unstable,
and that can't hold a center.
The fundamental question,
a very important question for us as clinicians,
is around whether or not these
distortions of the self are irreversible.
And certainly when I was first training, some time back,
one of the overriding beliefs in this area
was that these kinds of distortions couldn't be reversed,
that if you were born into a context which then created
a disorder of the self, or a disordered personality,
the potential to shift that, or to change it, or to
grow through that was incredibly hard, if not impossible.
But increasingly now, with research around attachment
and with neurobiological research,
which I'm also going to speak about a little bit later on,
there is the increasing evidence that, in fact,
these distortions can be reversed,
if treatment is offered in a particular kind of way.
So the question is, "Are these distortions irreversible?"
And increasingly we are knowing and understanding
that the answer to that question
is no, they are not irreversible,
that within a particular treatment context,
or within particular life conditions,
these early distortions of self can be
mediated and hopefully even reversed.
The capacity to create a narrative of thoughts,
the capacity to mentalize
around thinking and around thoughts,
can overcome the early flaws within the self-system,
can overcome the early experience
of disorganized attachment and create
an internal situation of balance.
And so I want to move on to now,
an understanding of what I mean by mentalization.
And to say that I'm not sure how
commonly discussed, or thought about,
or described mentalization is in this country,
because it really is a term that derives from British,
a British school, from the British attachment school,
from Anthony Bateman and from Peter Fonagy and Mary Target,
who work out of London, and they have created
and developed a very, very coherent attachment
model based on mentalization and mentalization practices.
Now, mentalization is not a new term,
it's certainly not a new construct,
but it is a term and a construct that they have
popularized more recently and which we can draw on
and which I certainly draw on a lot in my work.
But mentalization really refers back
to the capacity to think, it refers back
to the capacity to understand and interpret human behavior,
in terms of underlying mental states.
So in other words, if I have the capacity to mentalize,
it means that I am able to describe
what is happening in my internal world,
in terms of underlying mental states,
in terms of my desires or my beliefs,
I can talk about what is happening inside of me,
in quite a dimensional and nuanced way.
Similarly, I am able to mentalize around
what might be happening in your internal world.
So, through unconscious cues, through social cues,
through intuition, through the knowing that comes
from interpersonal interaction, I might be able
to understand, and to pick up, and to then
describe what is happening in your internal world.
And we do this all the time.
We do this all the time.
We do it unconsciously.
We do it implicitly.
You're in the shop, you go to the cash register,
you're paying for your goods, and your intention
had been to say to the person at the cash register,
"Hey, how are you doing? Isn't it a beautiful day outside?
"I hope you have a good day."
But as you approach her, you see that her eyes are downcast,
her body language is turned away from you,
and there is everything about her demeanor which says,
"Don't speak to me."
And you pick up on that implicitly.
It's not a conscious process, you don't think to yourself,
"Oh I'm not actually going to greet this person
"because I can see that they don't want to be intruded on."
It's an unconscious process of understanding
what might be happening, internally, for her,
And then it's an unconscious pulling back on your part,
which is a respectful response
to what you have implicitly read.
That's mentalization, and it's
something that we take for granted,
many of us, in our relationships.
But it is something that is so crucial, absolutely pivotal
to the healthy functioning of interrelating.
It is a capacity, which for the borderline person,
for the borderline patient,
is either impaired or it is lacking.
And once again, having worked with a number of people,
I have seen situations where mentalization
is more or less intact, and certainly situations
where mentalization is almost entirely absent.
So much so, where I might say to a person,
"You know, if you're going to cancel that arrangement
"with your friend, how might they feel about that?"
And she looks away from me, and pauses for a moment,
and then turns back and says to me,
"How can I know how she's going to feel about it?
"I'm not her."
And can you see in that simple statement,
a fundamental breakdown in the capacity
to have any sense of, to intuit, to know, to narrate
the impact of her actions on another person.
It's a fundamental breakdown of mentalization.
And so the capacity to understand and interpret
human behavior, in terms of underlying mental states,
is the most profound interpersonal
mechanism which we have, and it is that mechanism
which is lacking for the borderline experience,
and it is that mechanism that we want to try to work on
when we are working clinically with this type of person.