- How does mentalization develop?
Very fundamentally, but not so simply,
it develops through having been experienced
in the mind of the other
within a secure attachment context.
In other words, through being held in mind,
through being considered by the other,
the capacity for mentalization develops.
It is only once we have been held
in the mind of the other that we can ever really
begin to know ourselves as developing infants,
as developing selves.
If the context is not safe, if it is not secure,
if it malevolent, what we often see
in traumatized infants and children
is a closing down of the mind to other minds in general.
In other words, rather than having the mind
being open to a caregiver who is malevolent,
or negligent, that mind becomes closed
once again as a protective mechanism,
but it also becomes closed to other minds
and so it doesn't ever develop.
It remains in the solipsistic vacuum
of non-development and of fragmentation.
This is when we often see an experience
of dissociation or detachment in severely
traumatized children and adults,
because for this person, the way in which
they keep themselves safe through the terror
of not being known in the mind of the other
is through mental isolation.
It's through the not knowing,
it's through preemptive acts of aggressive
in order to neutralize what they perceive to be a threat,
it's through formulaic, schematic and often inaccurate
representations of interpersonal interactions.
In other words, there's not any kind of a subtle
understanding of what happens inter-personally.
There are formulae and schemas which are applied
to interpersonal relating that are extremely rigid.
There is a dominance of projective mechanisms
that force unbearable mental states onto the other.
In the terminology of Wilfred Bion there is minus K.
There is no thinking.
There is a shutting down of minds.
This is the presentation of traumatized mind.
This is the presentation of a mind
which was not known in the mind of the other
in a secure and a safe and a proximal way.
So where does this lead?
I want to take you down this path now
to help to distill and to begin to differentiate
between some of the different manifestations
of personality organization.
So, to backtrack a little bit,
we're speaking broadly about borderline organization,
and within that borderline organization
there are different manifestations.
The biggest categories are the category
of narcissistic personality disorder,
of psychopathic or antisocial personality disorder,
and then the borderline, as we know BPD to be.
I want you to just go down this road a little bit
to try to differentiate between
the different kinds of manifestation.
If we have the infant's mind that has been
closed down to the mind of the other,
then we have a propensity for violence
and for aggression, which is used to stabilize the self.
We see this propensity manifest in adulthood
to violence, impulsive, inconsistent
and incredibly emotionally volatile behavior.
As soon as you see this presentation in an adult,
as soon as you see this kind of dis-equilibrated,
uncontained aggression and emotional instability,
then you have to know that there is
a reduced capacity for mentalization,
and that everything that is happening for this person
is an attempt, a primitive, infantile attempt,
to protect the self in the absence of an internal
apparatus that can erect feelings,
that can erect life experience.
If we look, for example, at self-mutilation,
self-mutilation, which used to really be
the cornerstone of borderline personality disorder,
and I think it's less so now because we
are starting to understand how self-destructive
behavior manifests in so many different ways,
but if we look at self-mutilation, for example,
we can see this thing as an attempt,
a desperate attempt, to self-regulate
and to self-soothe in the face of overwhelming affect.
The commonality which bridges all
of the different personality classes,
borderline, narcissistic, antisocial,
is a fragile, brittle self-structure which manifests
either as complete disorganization
or as excessive rigidity.
So you have these two polar opposites,
an incredibly rigid way of being in the world
or an incredibly disorganized way of being in the world.
Let's look at the extreme of excessive rigidity.
The narcissist and the psychopath shelters within
the formulaic schematic representations of relationships
in order to protect the self.
In other words, the way that a narcissistic
personality will engage with the world
is to control the other,
to control those with whom they are in relationship,
so that there can be no flexibility,
so that there's only rigidity of roles.
Certainly, this is one of the ways,
when sitting in the room with an individual,
to formulate around whether a person
is more borderline or more narcissistic.
When I feel controlled by a person,
when I feel like the way that I speak,
the way that I look, the way that I greet them,
the way that I comport myself in the situation,
is being straitjacketed by their demands on me,
then I start to have an inkling
that I'm sitting more with a narcissistic
structure in the room,
where if I step outside of that rigidity,
and of that projection of rigidity,
then there's going to be some kind of a shattering,
there's going to be some kind of a breakdown.
So those who present with a more of a narcissistic
structure are controlling and manipulative,
and those who are in relationship with them,
including the therapist, feel controlled and manipulated.
The irony of this is that that kind of a person
may present as highly stable.
That kind of a person may present with a long-term
relationship in which it looks like there's stability,
but that stability is predicated on absolute rigidity
and is highly dysfunctional.
As we know, there are two kinds, thanks to Rosenfeld,
there are two kinds of narcissists,
the thin-skinned and the thick-skinned.
Your thick-skinned narcissists are inaccessible
and defensively aggressive and will show
violence when threatened.
That's really your antisocial
and your psychopathic personality types.
Whereas your thin-skinned narcissists are much more
subtle in diagnosing and formulating.
They present as vulnerable and fragile,
and quite often the violence is towards the self
rather than against the other.
But both, the thin and the thick-skinned
narcissist will react impulsively to the anticipated
or to the actual experience of one important affect,
the affect of shame.
Shame is core to the vulnerability
of the narcissistically constructed individual.
Shame or humiliation is experienced
as potentially annihilating.
I don't mean symbolically annihilating,
I feel like I'm being annihilated, I mean literally.
The experience of shame when it floods the system
feels like it's going to obliterate them.
It's not an "as if" feeling.
The psychological experience of mortification
is equated with the physical experience of distraction,
and so we call this ego distractive shame.
Quite often, tragically,
a thin-skinned narcissist will make,
often, successful suicide attempts
when faced with shame.
For example, a highly successful entrepreneur
who has had success all of his life
and then is suddenly faced with failure,
a breakdown of his rigid way of being in the world
and his rigid way of seeing himself in the world,
the shame of that failure is so intense,
it's so annihilating, that the only way
to respond to it is through an ultimate
and fatal attack on the self.
So quite often suicide attempts
for the narcissistically constructed patient
is in response to some kind of an experience
of failure or shame.
Once again, when you are taking a history
or when you are starting to get to know a person
and get to understand their history,
you will start to identify experiences of shame,
or experiences of humiliation that may have led
to past breakdowns or past hospitalizations
or past suicidality.
This notion of the internal
being the same as the external,
in other words, shame isn't an abstract affect,
it is a concrete reality.
This is known as psychic equivalence,
where there is no difference between what is happening
inside and what is happening outside.
It won't be I feel shame,
it will be I am shame.
The totality of myself is shame.
Shame has taken over
and it is annihilating me.
It has the capacity to demolish.
In summary, if we think about the core pathology
of this broad spectrum of borderline organization
and of the so-called Cluster B personality disorders,
we see that there is an intrinsic instability of the self,
which comes together with the defenses
which are used to protect the self,
and this results in the core pathology
which we see presented in our rooms.
What are the core differences between
the borderline and the narcissistic presentation?
Once again, I do think that accurate
formulation is extremely important.
For the borderline personality,
the self-structure becomes unstable,
most crucially when mind meets mind.
In other words, as soon as this individual
is in relationship, there is a possibility,
in fact, there's the inevitability, of disorganization.
This quite often results in a terrible, terrible tension
between the longing that an individual has
to be in a relationship, and the overwhelming
disorganization which happens when they are in relationship,
which basically means that there is no--
(clears throat) excuse me...
which basically means that there is no safe space, ever.
Being alone is overwhelming and terrifying,
because another mind is needed.
Being in relationship is terrifying and overwhelming,
because the proximity of that mind is so frightening.
It's frightening because there is no way
of really understanding, mentalizing, making sense,
of what is happening in the mind of the other,
or of what is happening internally.
For the borderline structure,
the context of relationships is disorganized.
For the narcissist or for the psychopath,
relational representations,
the way in which relationships are seen,
or understood, are solidified,
and the other becomes forced into a particular mold.
This can look like relational stability, as I said.
So you can have a narcissist who is in relationship
with somebody who, for whatever their
psychodynamic reasons might be,
are able to take on the rigid projection,
creating a stability of system,
but within a very, very dysfunctional
psychological milieu.
The thing with the narcissist
is that the self is incredibly brittle
and can shatter very, very unexpectedly,
very, very suddenly,
and this can result in an outburst of intense violence,
intense anger, intense rage,
and so we talk about the narcissistic injury
and we talk about narcissistic rage,
which, once again, is this system's
utterly desperate attempt
to reestablish some sense of balance inside.
During regressive behavior for the borderline
patient within relationships,
and for the narcissistic patient
when there is a rupture of rigidity,
there is always going to be a return
to infantile modes of thinking,
and this manifests in three possible ways.
Firstly, through psychic equivalence, as I said earlier.
This means that the internal and the external
feel like they are the same.
When sitting with a borderline patient
who says to me, "I'm dying" and I might say to them,
"You feel like you're dying"
and she says to me, "No, I am"
that is what she means.
It means that this feeling inside of her
is equated with the reality of dying.
Affects are not "as if."
Affects are the totality of experience.
Affects are experienced as concrete objects
inside the self.
Affects are experienced as having the capacity
to damage, to destroy, to annihilate.
So when somebody says, "I'm in such a state of grief,
"I fear that my grief is going to kill me."
If they are sitting on the neurotic spectrum,
then we can understand that they
mean that in a symbolic way.
But if they are sitting on the borderline spectrum,
then we need to understand that their literal fear
is of being killed off by their grief.
The second infantile mode of thinking
is that of concrete reasoning,
where suddenly there's an inability to think abstractly
about life, about relationships, about experiences.
Reasoning is reduced to primary process thinking.
Reasoning is reduced to concrete,
thinking to concreteness.
Finally, there is a regression to dissociative states.
Association can sometimes be achieved
through self-mutilation or through self-destructive behavior
but is also achieved through just shutting off the mind.
So, in periods of regression for these patients
we will see the tendency to just shut off
and to disassociate from experiences,
from feelings, from what is happening internally.
It is usually in one of these periods of regression
that we meet these individuals.
Seldom, if ever, are you going to get somebody
who manifests with a borderline organization
come into your room and saying,
"I'm just here to explore myself."
That's not going to happen.
We are going to meet these particular individuals
in times of crisis, in periods of regression,
following some kind of an experience
which has precipitated a breakdown.
So we are going to be meeting them
in their most infantile states of mind,
manifesting psychic equivalence, concrete reasoning,
and dissociative potential.
I certainly can recall meeting a number
of my more long-term patients,
with whom I have a much more reciprocal
relationship now after many years of working
with them and getting to know them,
but with whom, in the first session,
the first few sessions, I felt a terrible
disassociated experience,
where they simply were inaccessible to me.
As I think about that now, I'm reminded
of what brought them into my rooms in the first place,
and how, from a place of absolute survival,
the need for survival,
there was a disassociation, a cutting off of the minds.
It is the manifestation
of infantile processing
which we see in our rooms
when we first encounter our patients.
I want to turn now to the question
of what is the underlying mechanism?
What is the core psychological process
activated through the attachment system
which underpins all of what I've been describing?
I've spoken about what happens when things go wrong,
about the manifestation of that,
about how that creates what we know today
to be personality dysfunction or personality disorder
or disorder of the self.
But where does it come from?
What is that core underlying difficulty?
Now, I'm going to repeat
because it's really important
that the crucial context is the attachment relationship
between the infant and the primary caregiver or caregivers.
What optimally happens during attachment,
and optimally this happens completely unconsciously
and as part of the fabric of this developing relationship,
what happens is what we refer to as affect mirroring,
the mirroring, the reflection, of feelings, of affect.
An infant or a child will have an internal experience,
which will be expressed through facial expression,
through gesture, or through an unconscious communication,
and the attuned caregiver will mirror,
in an accurate way, that feeling back to the child.
Let me put that into more concrete terms.
You have an infant or child who is having
a physical experience internally.
It's a physiological experience,
which is a response to having had something
taken away from them.
They were holding a toy.
That toy gets taken away from them,
and they now have a surge of sensation internally,
and the caregiver,
let's call her the mom,
the mom says to the baby,
"You're so cross that Mommy took that toy away from you."
In that moment, this internal physiological sensation
becomes converted into an abstract construct.
It becomes converted into the affect
of frustration or of anger.
It is through this affect mirroring,
it's through this accurate attunement and reflection
that self-states, the ways in which the child
begins to know itself, become internalized.
When that feeling arises again, and again,
that child will have an internal representation
that will help it to make sense of that feeling.
The way in which the infant is seen
and recognized and held in mind
and then reflected back to themselves,
will shape the self-representations.
Let's say, for example, you have a child
who has the same experience that I've just described.
They have something taken away from them,
and they're overwhelmed by the sensation
which we know to be anger or frustration,
and the mom laughs and says,
"Oh, you're so funny."
Can you see how inaccurate that reflection is?
That that infant is left with a sense
of not knowing what that sensation is really about
and internalizing something that is just inaccurate?
That's quite a simple concrete example,
but I hope that it illustrates the point,
which is that correct affect mirroring
will allow for accurate internalization of self-states,
which then allows for a growing self-knowledge,
a growing knowledge, of what is happening inside of me.
In order for affect mirroring to be effective
and to be attuned, it has to meet two basic criteria.
The first one is what we call contingency.
What this means is that the reflection,
the mirror, has to be an accurate reflection.
If the infant is feeling sad,
the affect mirror needs to be one of sadness.
That's contingent, it's accurate.
The second criterion is what we call markedness.
Certainly, I've noticed this, if you just observe
mothers and children in any kind of social context,
you'll quite often see mothers responding,
or caregivers responding to their children
in a very, very animated way.
The child at the cash register wants a chocolate
and mom says, "No, you can't have a chocolate
"because we're going home for lunch
"and you're not allowed to have a chocolate before lunch."
This little boy starts tantruming and screaming
and crying and mom goes,
"You're so cross, you're so cross, aren't you?"
Can you see that kind of animation
is what we refer to as markedness.
In reflecting in that marked way,
mom is communicating that this feeling
that she is expressing is not her own feeling,
it's his feeling.
He clearly understands mom is showing me
what I am feeling.
I am feeling cross, angry and frustrated.
Markedness becomes a communication.
This is your feeling,
it's not my feeling.
In that way, affects and feelings
and emotional experiences can be taken back in
in a processed way.
If mirroring is not contingent,
so, in other words, if the affects
that are given back to the child are not accurate,
let's just think for a minute what that, then, creates.
It creates an inaccurate,
a false internal self
that actually doesn't correspond
to what that person is actually feeling.
The infant, then, internalizes a self-representation
that doesn't actually reflect anything that is real,
so you start to develop an ongoing falseness of self.
If the mirroring is not marked,
in the way that I just illustrated,
then self-states, what's happening inside,
is experienced as if they are happening externally,
and so there's no internal symbolic representation
of affect states.
An infant doesn't begin to internalize
what belongs to her.
So these feelings remain outside,
and they remain frightening,
because they have not been taken back in
and housed in the self.
Wilfred Bion, who wrote a theory on thinking
a long time before the attachment theory
was written about, would refer to this
as a breakdown of thinking.
He would describe it as an inability
to convert raw beta elements
into processed alpha elements.
What happens when beta elements
are not converted into alpha elements
is that because of their rawness
and because of their overwhelming nature,
they have to be expelled.
This leads to the use of the mechanism
of projective identification.
If feelings are not converted into something manageable,
they get thrust out, expelled projectively,
and forced onto the other,
so that feelings are never earned within the self.
What happens in this case is
that second order representations...
A second order representation refers
to the symbolic conversion of a self-state.
The first order representation is
how it's feeling inside at a concrete manifest level.
When it gets given a word,
when it gets converted into language,
it becomes a second order representation,
a symbol of the actual feeling.
These second order representations are inadequate.
This inadequacy, this inaccuracy,
results in a sense of internal chaos
which can only be stabilized
through what we now know so famously
as the acting out behavior of the borderline patient.
We know that the way in which our patients
survive and manage their lives is by acting out.
Once again, I just want to make an aside here.
That is a term that historically
has become pejoratively used.
You might say to somebody, "Oh, stop acting out"
or "He was just acting out"
or "They were acting out"
or "There was a whole lot of acting out going on."
But if we actually distill that and think about
what it actually means,
this person has no other option.
The only way to get through the next moment
is to do something,
and that doing is the acting out
of an aggressive impulse or a violent impulse
in a way that will then help them
to rid themselves of a particular kind of feeling.
Then what happens is those internal feelings
that are unmanageable can only be acted out
and projected when there is a target
for that projection,
which means that this particular individual
coming out of this particular inadequate
development context,
is going to constantly be on the lookout
for another mind, an other,
who can be the recipient, or the target,
of the acting out.
When alone, the borderline patient has to sit
and contend with the internal persecutory
and chaotic experience, which is psychically equivalent,
in other words, which is real, as I said.
They don't feel chaotic,
they are chaotic.
When in relationships, this chaos just gets projected out.
So you can see this really, I mean, I think,
quite tortuous double bind that these
individuals find themselves in,
where in being alone they are desperate,
in being in relationship, they are desperate.
There is very little peace,
very few peaceful moments in either of those states.
The three systems clusters of affect, identity
and impulsivity all arise from an instability
in the self-structure, which results from some
kind of a constitutional propensity
coming together with impaired early caregiving,
and all of this results in an inability
to narrate internal experiences accurately.
In other words, all of this results in an inability
or an inhibition of mentalization.
Comprehension of one's own and of the internal
world of others is significantly compromised.
Relationships with others are a minefield.
relationship to the self is a minefield,
because there was not that initial context
within an attachment relationship
that provided the grounding for an accurate
knowledge of self in a symbolic second
order representation kind of way.
Part of what makes this theory so compelling for me
and part of what helps it to make so much sense for me,
is that fact that it corresponds also
with emerging neurobiological research.
Let me give you a little bit of an insert around that.
I'm not going to go into too much detail.
What we do know is that in the first
18 months of life, what develops first
in the brain is the right brain.
What develops within that right brain
are the capacities for emotion regulation,
the capacity for impulse control.
The right brain becomes the template for making sense
of interpersonal relationships and for relating.
You can see that that right brain is implicit
in all of the things that I've been speaking about.
It's implicit in all of the functioning
that is so severely compromised for the borderline patient.
What we know, then, from neurobiological research
is that the integrity of that right brain
and the way in which it develops is directly linked
to the early attachment context.
So in situations of trauma or abuse or neglect
or insensitivity or impaired or disrupted attachment,
for whatever reason, that right brain
is not going to develop optimally.
Those capacities for emotion regulation,
for impulse control, for making sense of interpersonal
contexts, becomes contaminated in some way,
becomes compromised in some way.
So at 18 months with this developed right brain
there comes the development, the consequent development
of the left brain, and with that, the consequent
development of verbal acuity.
If the right brain is malformed,
or if it hasn't developed to its optimal capacity,
then the left brain's verbal capacity
to narrate experience is also compromised.
So we often see, with our borderline patients,
an incredible inability to find words for affects.
That's linked to mentalization, as I've described.
It's linked also to a verbal paucity,
a paucity of vocabulary around feeling words
and feeling states.
I've so often had an experience of asking a patient
what they're feeling, only to be faced
with complete blankness.
They can be having an affect storm in the room,
tantrums and shouting, and I can say,
"What are you feeling?"
They might say, "Freaked out!"
I say, "Freaked out is not a feeling word.
"Can you give me a feeling word?"
There's a complete stuckness and an inability
to find a word that accurately corresponds.
Can you see here, then, the complex intermarriage
between the attachment theory,
where this person has not been given an accurate
affect representation from the caregiver,
and simultaneously they have not developed
the verbal acuity in their brain development
to narrate an affect experience?
So you have, I think, a very, very snug
parallel relationship between attachment theory
and neurobiology, which just makes the theory
that much more compelling for me.
It also helps me to think a little bit
about what my job is in the room
and a little bit about what might be happening
neurobiologically between myself and the patient.
Sometimes I like to...
Well, it's not something I like to do
but I find it necessary or important
to remind myself that when I'm sitting
with the most compromised
of my disorders of the self patients,
I am sitting with literal brain dysfunction.
That helps me, sometimes, to manage the frustration
that I feel, the impatience that I feel,
when whatever I'm doing is just not working.
What is fundamental for me to always recall
when sitting in those situations,
is that whatever that person is feeling right now
is absolutely overwhelming for them,
and what I am feeling doesn't even
come close to their experience.
I'd like to move, then, onto the second part of the lecture.
I'd like to move on to thinking a bit about the practice
of what we do with this knowledge about attachment
and with this knowledge about neurobiology
and about the importance of the relationship.
When working with BPD, there are a few things
that we have to take into account,
that we have to take as a given,
that we have to know is there.
We have to know that there is always
going to be extreme anxiety.
We have to know that there is always
going to be intense reactivity.
There is going to be the capacity
for very regressive disorganization.
We have to know that there is the lack
of self and object constancy.
We have to know that there are fears
that coexist with the longing for attachment.
All of these are going to manifest themselves
and permeate in the room,
that anxiety, that reactivity,
that incredible fragility and vulnerability
to what's happening moment by moment in the room,
the very, very rapid regression
to a disorganized way of being,
the fears of abandonment that come
from lack of object constancy.
I'm just pausing because I'm actually thinking
about a conversation I had before I took
the break to teach this summer,
and was saying goodbye to one of my very, very
longstanding patients who is significantly
borderline in her presentation,
and as she walked out the door her looking back at me
and saying to me, "What happens if you don't come back?"
and being reminded in that moment of,
in spite of all of the evidence that I always come back,
and in spite of all of the evidence of a long history
of a relationship between the two of us,
she still can't know the constancy
of our relationship.
So lack of object constancy is going to bring up
all sorts of abandonment fears,
all sorts of fears of being left, of being rejected,
during times of absence, during breaks.
In fact, at the end of every session,
there is the possibility of an abandonment fear
because the connection is coming to an end.
For many people, holding onto the connection
between sessions becomes incredibly difficult.
It's almost as if, when you walk into the room
and you sit down with your patient,
these factors have to be something
that is in your mind all of the time,
knowing that it's there.
In order to mediate that, part of what we have to do
is to offer a therapeutic context that includes
clear limits and structure, consistency,
and even at times possible contracting around behavior.
Of course, we know that Kernberg was one of the people
who really advocated
for acting out contracts,
contracts around acting out behavior,
around suicidal gestures, whereby he would,
and he does still, as far as I know,
put in place contracts which state that if the patient
acts out in a particular way or does a particular thing,
there will be treatment repercussions.
Many people found this punitive or disastrous
in terms of building up trust,
but, in fact, what he is doing,
and what we are creating by contracting in that way,
is a set of limits which can create
an experience of safety.
This is often difficult to do
because this kind of individual as a patient
is also going to be the kind of individual
who is going to ask for intercession contact,
who's going to email or phone or message you
or ask for extended sessions
or not be able to end sessions
or act out in all sorts of ways
around the limits of a therapeutic relationship.
If you're empathically attuned to the vulnerability,
or if you are role responsively drawn into
an enactment of a particular kind,
it may be very, very tempting to succumb
to the needs of this person
and to give them what it appears that they need,
which is your constant attention
and your ever availability,
but, in fact, what that does is it increases anxiety
and it increases the potential for regression
and for fears around abandonment.
So, always stick to what we know about the frame
and about the boundaries through clear limits
and structures and consistency.
That includes clear
and advanced warning of breaks,
of vacations, of holidays that are being taken,
so that that can be anticipated and worked with.
As a therapist, we need to be a real person.
Working in the classically analytic way,
on the couch or with long silences,
with absolute neutrality, which of course we know
is not possible, but more neutral than usual,
that will only be experienced as persecutory
and it will only evoke intense anxiety,
and that is not something
that we want to give to our patients.
So we need to be real in the room.
We need to be authentic in the room.
We need to have, for our patients, a genuine devotion.
That doesn't mean that we like them all the time,
that we love them all the time.
In fact, it's almost inevitable that there are
going to be times when we dislike them
or even hate them,
but we need to feel a genuine devotion
to their treatment and to their care,
and not because that's part of our job
as a clinician is to be devoted to people.
It's because this particular patient
is going to very quickly know
whether you are authentic in your clinical attempts
or whether you are holding back in some way.
So there needs to be some kind of authentic
and genuine devotion.
Borderline patients are incredibly and exquisitely
sensitive to shifts in affect of tone.
If you are slightly off, perhaps you're having a bad day,
perhaps you're going through some of your own life trauma,
and it comes through in any way in your tone,
in your manner, in your body language,
in your gestures, the borderline patient will pick that up.
That's not to say that we can never bring
that into the room.
Of course, we're human.
How can we not bring that into the room?
But it is about understanding
that when the patient responds to us
we need to somehow authentically be able
to respond in return, and to understand
the impact that that can have
on their experience of the relationship.
We need to remember that they are easily terrified
that they will be criticized or abandoned or humiliated,
that there's always the threat of that happening.
A note about the transference.
In my opinion and in my experience,
it is absolutely not helpful to work with transference
in the classical analytic way,
in other words, to make historical links
with early object relationships.
Rather, to work with transference in the here and now,
in other words, to work with the relationship
in the room as it unfolds and as it develops
in a much more present way.
This is because for the borderline patient
transference is very seldom experienced
in an "as if" way.
For example, for a more neurotic patient,
she might say to you in the session,
"You're just like my mother!
"How can you be doing this to me?"
At the end of the session she gets up
and she turns to you and says,
"Thank you very much, I'll see you next week."
She's left the transference in the room,
because on some level there's an understanding
that you are not her mother,
but that this is something about this interaction
in this room and she's leaving it here.
Whereas for the borderline patient,
you are her mother, so if you say,
"You're responding to me like I'm you're mother"
she's going to say, "Yes, isn't it terrible
"that I've found a therapist who is my mother?"
There isn't that "as if," stepping back,
self-observing quality that is necessary
to be able to work more classically in the transference.
The therapeutic approach needs to be structured
and active and affectively expressive.
Expressing affect is cornerstone.
What are some of the treatment strategies
that we're going to use coming from
this more attachment-based approach?
The overall and rather, I think at times,
grandiose goal is to stabilize the self-structure
through the development of stable internal representations,
so really to give an experience, ultimately,
of internalizing representations of the self
that are accurate and stable,
and in this way, being able to stabilize the self.
We aim to work towards the formation
of a coherent sense of self,
who am I in the world,
and the capacity to form secure relationships.
But if we look at the hierarchy of therapeutic
and treatment goals, this overarching goal
may well feel like it's completely out of reach
and so we need to break it down
and look at particular strategies
that we can use moment by moment,
session to session, sometimes for years upon years
when working with severely
personality compromised patients.
At the outset, there needs to be a clarity of purpose
and of therapeutic expectations.
Very, very often somebody who sits with BPD
will judge the motivation of others based on outcomes.
So if at the outset we can agree on a set
of expectations around the therapy,
then that is very containing,
it's very safety inducing.
The way in which you decide to work with this person
needs to be based on an understanding
of how this particular patient
is stabilizing their self-structure.
In other words, are they stabilizing
their self-structure through somatizing?
Are they stabilizing their self-structure
through violent acting out against
somebody in their life?
Are they doing it through self-mutilation
or suicidal gesture?
Are they doing it through substance abuse?
What are the particular manifestations
of the stabilization techniques for this particular person?
In understanding that, you then need to fashion
your interpretations and your interventions,
which are then relevant to that.
Mental closeness is an absolute prerequisite.
In other words, you need to be present
in the room as much as you can be.
You need to offer mirroring that is contingent
and marked, that is accurate
and which shows that you're communicating
the internal experience of the patient.
The task, really, is to find a way
to mirror and to shadow the patient's mind
in such a way that it creates
an experience of proximal safety.
It's important to make interpretations
and interventions based in the here and the now.
Sometimes they need to be concrete
in order to move towards a more symbolic way
of making interpretations or interventions.
Working with a BPD, we absolutely have to be able
to accept becoming, at times, aspects
of the alien self if necessary.
In other words, we have to be able to accept
that we will experience, at times,
what it feels like to be the patient,
that their internal experience
will be projected onto us and into us,
and that we will be asked to hold and to bear,
the experience for and with them.
That is part of the job that we do.
I want to talk in more detail about
the identification of affects.
Even though affect dysregulation is a symptom
of a deeper underlying deficit,
the deficit around mentalization,
because affect storms disrupt treatment,
we do need to work with our patients
towards achieving affect control.
Firstly, we need to make sure that we present
a context that is safe and non-punitive.
Then we need to help the patient
develop a vocabulary around affects,
to develop a vocabulary which then allows them
to start saying things like, "I feel"
and then to link that feeling with the cause.
I feel because...
So how can we start to link feeling,
or affect, with experience?
How can we start to identify the precipitance
of affect storms or affect outbursts?
We need to clarify and name feelings.
We need to give words when words are absent.
We need to help our patients to be able to understand
the sequence of events that leads them
to feeling emotionally out of control.
Then we need to be able to help them understand
how the sequence of events may well be
a replication of other relationships,
so if this is how you are being with me
when you get angry with me or upset with me,
or when I do something that feels dangerous to you,
is this also, then, the way that you feel
when your partner does something similar,
or when your child does something similar?
To broaden the impact of the intervention
beyond the therapeutic context.
The way that I think about therapy
in the borderline realm
is that I like to think about it as a constant
and ongoing act of translation.
We are called upon to be interpreters
of the internal world of the other,
and to translate into meaningful language
an experience for them which previously has been
beyond translation and beyond understanding.
Identifying affects is a core, core, core task of this work.
Enhancing mentalization.
As a therapist, we must maintain a mentalizing stance.
In other words, we need to be constantly questioning
and asking ourselves what internal states in you
and in me can explain what is happening now,
so that we can start to link external events
with internal experiences.
At any given moment in a session,
we need to be aware of our ongoing narrative
of our internal process, as well as of what might
be going on internally for the patient,
and then to surface that,
so that effectively we begin to model mentalization,
we begin to show what it's like to mentalize
even though we mostly do it in our ordinary lives
in a more implicit kind of way.
Modeling mentalization in this way
and talking about what's happening
in you and in me and between us,
then allows for the development of a particular language
between patient and therapist whereby we can begin
to start to communicate with one another
in a very, very particular way,
and we can start to learn the kind of words
that make sense in this particular context.
Modeling mentalization is about being articulate
about the internal narrative of self and other.
I've spoke a little bit already
about the countertransference,
but I want to mention it again
because countertransference can be incredibly
useful and important as a tool for understanding
what is happening for our patients.
I want to translate countertransference
in this particular context
into projective identification.
Obviously, not everything that we feel
is going to be projective identification.
Part of what we feel is going to be
our own role responsiveness.
Part of it is going to be our own woundedness,
our own trauma, our own history,
our own currency and everything else
that's going on with us,
and we know that about countertransference.
But a great deal of what we're feeling in the room
is going to be projective identification,
and it's going to be projection.
Always have a vigilant eye around that in trying
to make sense of how this is communicating
a significant aspect of experience
from the patient to ourselves.
It's incredibly important when working
with a borderline patient to bear in mind the deficits.
I have worked with many people who have been hospitalized,
who have been hospitalized repetitively,
who have long histories of suicidality
and self harm, who bear all the literal scars
of a borderline personality disorder.
But then I have worked with people who,
upon meeting them, are articulate and insightful
and intelligent and functional in the world.
It's very, very easy for those people,
with those people, to forget the underlying deficit.
For many of those particular people,
the underlying deficit becomes activated
in the context of relationships
where suddenly they become concrete
and impoverished in the intellect and in the insight
in relation to themselves and others
because being in a relationship has undone them.
It is the recipe for the disorganization
of the early attachment context.
Once you know that somebody falls within
the borderline organization spectrum,
don't take your eye off the ball.
Bear in mind the deficits and remember
that intellectualism and verbal acuity
does not equate to the capacity to mentalize
and to be aware of that.
Similar to bearing in mind the deficits
is the importance of the keeping in mind
the possibility at all times of the worst
outcome of self-harm or self-destructive behavior.
I learned this the hard way
when I lost a patient to suicide.
It was an invaluable lesson for me
and remains an invaluable reminder
of how somebody can move from a place
of seeming to be fairly balanced
and fairly stable to taking their own life
from a place of impulsivity and disorganization,
in response to an external precipitant.
We are working with a population
of individuals who face despair in a way
that is incomprehensible to many people,
and who sometimes will step over the edge
and will do so successfully.
Always bear in mind the possibility
of acting out in that kind of way.
On that note, I suppose in your own mind
to establish a therapeutic hierarchy.
As I said earlier, we're finally aiming
to create a coherent sense of self based
on accurate self representations, et cetera, et cetera.
But for each person the priority in the treatment
is going to be different.
For some people, it is about keeping them alive.
For other people, it is about helping them
to survive their relationships.
For other people, it's about helping them
to adequately parent their children.
But always bear in mind what your primary
priority is for this particular intervention.
Always hold in mind the role that we play
for these people fundamentally in their development.
Part of the role that we play is the role
of maternal container.
Elizabeth Meins described the notion
of maternal mind-mindedness,
which is the way she described the way in which
mothers respond to their infants
when using mental state language.
Through being a maternal container,
and through maternal mind-mindedness,
we are essentially an interpreter
of the mental states of our patients.
Remember that the value of therapy
for the borderline patient is in the experience
of another mind which has their mind in mind
in a compassionate, thoughtful, mentalizing way.
For many of these patients,
that is a new experience.
It's something that they've not experienced before.
They have never had somebody hold them
in mind quite in that way.
They haven't had somebody try to fathom
what is happening for them internally.
For them, this relationship with you
as their clinician and as their therapist,
becomes their first experience of being held in mind.
As clinicians when working with the borderline
personality disordered patients,
we don't only offer warmth and containment
and compassion, we also offer a thinking space.
In fact, I quite often start off my therapies
by saying to new patients,
"I'm offering you a space to think about yourself."
To many people that might seem almost simple.
Think about myself.
But for many people, thinking is a task
which they have not yet accomplished,
and it's a task which can be accomplished
through the therapeutic relationship.
Once again, for me the most comforting
and certainly exciting aspect of current
neurobiological theory is around the suggestion
or the evidence that brain functioning
can be literally shifted through an attachment
relationship or an attachment context,
which means we may well have somebody
who starts the therapeutic journey with us
with a relative degree of brain dysfunction
because of an impaired early attachment context.
But through our maternal mind-mindedness,
and through the thinking space which we offer
and which we create, there is the potential
to correct, to heal, the neurobiological deficit
which was there initially.
Now I want to make one final point before I end.
It is so easy to lose ourselves in this kind
of a therapeutic context precisely because we are dealing
with primitive states and primitive feelings,
all of which we, ourselves, have experienced
and do experience at different times in our lives.
There is always the invitation, the pull,
to regress, to collude, to act out, to join,
to lose, in a disorganized way, our own bearings,
which is why when working with the borderline patient,
just as they need a mind to hold them in mind,
so we, as the clinician, need a mind
to hold us in mind, which is why supervision
or consultation is absolutely essential
if you choose to work with this particular population.
We need a space in which we can have our own
internal processes and our own management
of the situation, held thoughtfully by another person.
I want to end by saying that there's one phrase
which I carry with me into the room
whenever I work with personality.
It's a phase which carries a lot of meaning
around the importance of thinking,
around the importance of reflection,
around the importance of slowing down
in order to make sense of something.
That phrase is the job that we have,
the task that we have with every one of our patients
is to help them to create a moment of pause
between the impulse and the act.
I'll repeat that.
Creating a moment of pause
between the impulse and the act.
If we can accomplish that in small or big ways,
then we have accomplished something
extremely significant and curative.
Thank you.