© On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview 1: “DEVELOPMENT; FILM DISCUSSION”

ED KAUFMAN, MSW

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

ED KAUFMAN, MSW
111 N. Wabash, #1804
Chicago, IL 60602
312.782.7444
[email protected]

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or

reading interview #1 of our program on the Borderline Personality Disorder (BPD).

When I was in graduate school, classmates and I wrote lyrics to the tune ―Edelweiss‖
from The Sound of Music. The words went something like this:

Borderline, Borderline, I‘ve been assigned to treat you

You‘re alright; just uptight, feeble defenses defeat you.

At that time, some 30 plus years ago, the term ―Borderline‖ was still relatively new,
coined in the 50's by Dr. John Gunderson, to apply to patients who didn‘t fit other
diagnostic categories and were seen as falling somewhere in the precarious mental spot
between neurosis and psychosis.

The latest version of the Diagnostic and Statistical Manual of Mental Disorders of the
American Psychiatric Association lists nine specific symptoms, of which any five will
determine the diagnosis of Borderline Personality Disorder.

People with Borderline Personality Disorder show a profound lack of integration of their
personal identity. The consequences of this include failure in commitments to work and
chronic turmoil and failure in their interpersonal relationships. The suicide rate in this
condition is 10% -- it‘s as high as that of major depression, mania or schizophrenia, and,
by conservative estimates, some 6 million Americans are afflicted with this--that‘s 2 % of
the population. So it‘s 50 % more common than Alzheimer‘s and more prevalent than
bipolar disorder and schizophrenia combined.

1
While it‘s still not clear what the pure, hard core of the disorder is, it is likely to be a
mixture of a surprisingly strong genetic predisposition consisting of the traits of
impulsivity, aggressivity and emotional intensity, plus environmental factors. Some have
experienced neglect, sexual abuse, and trauma in childhood, but newer research shows
that this is not a prerequisite for the disorder.

These are the probably the most challenging of all the patients most of us see. Some
cling to their therapists, refusing to leave when the session is over, but two out of five
will quit treatment prematurely. They act out just when things start to be improving, and
are seen by most clinicians as confusing, upsetting, draining, and notoriously difficult to
treat. In fact there are times when the therapist is perceived and experienced as bad and
dangerous. Worst of all, of course, is our upset when the ―bad‖ patient doesn‘t appreciate
the ―good‖ treatment we are offering.

Yet many BPD patients eventually make modest, or even splendid recoveries.

Treatment approaches range from fairly classic psychoanalytic and its variants such as
self psychology and object relations theory, to biological, to cognitive behavioral therapy
and its variant, dialectical behavior therapy, to EMDR and NeuroFeedback therapy.
There are certainly many other approaches arising all the time, as knowledge about this
disorder continues to grow.

As Dr. Ted Millon told us in his interview which appears in Volume 7 of our program,
―Critical Issues in Psychotherapy,‖ the main error one can make regarding the Borderline
Personality Disorder is to be too narrow in one‘s focus. So, in this program, our speakers
are going to present a number of these diagnostic considerations and treatment
approaches. I‘ve arranged the presentation of these interviews in a loosely historical
order, with the psychodynamic theories coming first, and the neuropsychological topics
last.

Let‘s begin with the award winning film, ―You Can Count on Me,‖ as the launching point
for clinical examples. I hope you will watch the movie before hearing these interviews,
or some of the plot will be spoiled for you. Starring Laura Linney, who was nominated
for the Oscar for Best Actress for her performance in this movie, and Matthew Broderick,
the film depicts characters who demonstrate a number of features which may -- or may
not -- be indicative of the Borderline Personality Disorder. I think you‘ll enjoy the movie
and the subsequent discussions. Our speakers do not always agree on the diagnoses of
the characters in the movie, by the way, and there is certainly not a consensus of opinion
about treatment, each speaker making strong cases for the approaches he or she presents.

Our first speaker is Ed Kaufman, who will discuss some of the developmental issues
leading to the Borderline Personality, especially as these are portrayed in the film, ―You
Can Count On Me.‖

2
A Board Certified Diplomate in Clinical Social Work, Mr. Kaufman is a graduate of the
Child and Adolescent Psychotherapy program of the Chicago Institute for Psycho-
analysis, where he is a faculty member and clinical supervisor. In private practice in
Chicago, he has presented 50 papers at various conferences, on the diagnosis and
treatment of borderline children and adolescents, and he is a popular leader of film
discussions for groups of mental health professionals.

ALEXANDER: Mr. Kaufman, we would like to talk to you now about the movie, ―You
Can Count On Me‖ and hear your thoughts about which of the characters are Borderline,
why you think so, and just get your overall thoughts about the movie.

KAUFMAN: Okay, let me begin by defining some of the features of borderline

children and adolescence and adults and compare that with the features of normal/
neurotic children in adolescence.

When we think of normal and neurotic children, we think of a child who, in the process
of growth and development, has achieved ―whole object relations‖ and ―object
constancy,‖ which is the capacity to maintain a positive mental representation of the
maternal object, despite satisfactions or dissatisfactions. Then this good maternal image
supports the ego and being able to anticipate needs from within, and to transfer these
needs into some kind of relatively satisfying action. It also gives a reassurance of a sense
of self, even when faced with frustrations. In addition neurotic children and normal
children have a relatively stable set of defenses and with the exception of some of the
dissociated states, have a good sense of reality. Normal and neurotic children and
adolescence and adults have at their disposal ―signal anxiety‖ which enables them to
develop a pattern of coping mechanisms to anticipate danger, both internal and external,
conscious and unconscious.

Classically, the conflict for the neurotic is the oedipal conflict. That‘s what Freud wrote
all about. With the borderline child, adolescent, adult, the central conflict is related to
problems concerning separation and individuation, which may also encompass very, very
early life experiences. The absence of what Winnicott describes as ―a normally
predictable environment,‖ the lack of consistent caring of early needs deprive the ego of
an external organizer and borderline children do not have stable internalized objects.
They have achieved ―part-object relations‖ and if they have moved to higher level
relationships, they have shown a marked tendency to regress to this pre-object constancy
state under stress, so that objects, people, relationships very often are only seen in terms
of their function. This means that the objects appear to be alternately ―all good‖ and
need-satisfying, or ―all bad‖ and frustrating. As such, their egos are without the aid and
support of a good maternal image that the normal neurotic children, adolescents, adults
have, and therefore they do not have the ability to make decisions or to translate needs
into satisfactory actions.

There is a continuous struggle taking place inside of these borderline individuals between
the good and the bad objects. This is sort of like -- do you remember the first Star Wars

3
movie, where you have Darth Vader and Obi-Wan Kenobi, the good and the bad, and
they are fighting with each other? These kids struggle to maintain a positive image.
When they are able to maintain that positive image, they are able to function in a
reasonably adequate way, just as a toddler who is fretful when his mother leaves the room
is able to calm down when mother returns. So, the toddler‘s sense of well being is
connected with the positive mental image of the parent as well as the physical presence.
When that image is lost because of frustration or is replaced by a negative image, there is
regression. Then these children go into panic states where they seem to feel attacked, and
clinically we have experienced being with a patient where that patient has felt that they
have been assaulted or that the therapist had caused him some kind of pain. What has
actually happened is that nothing specific in the environment took place, but rather, the
child experienced an internal shift of object images and negative images of the maternal
object, and very often a negative self-image will pop in there.

Now, I‘m assuming, when I made that last statement that nothing untoward had taken
place in the interview, but very often this is sort of a spontaneous sort of thing.

Now I‘ll make a couple more statements and then move into the discussion of the movie,
because I‘m saying one of the characters has some borderline features.

Another characteristic of the borderline individual is a precariously functioning symptom

of signal anxiety. In normal and neurotic children, adolescents, and adults, the signal
anxiety works like a thermostat, making subtle shifts in the adaptive and defensive
mechanisms at their disposal. As such, they are able to experience reasonable
satisfaction and not to experience intolerable frustration in relation to either internal or
external needs.

The borderline patients are not able to achieve a homeostasis. It is as if the thermostat is
broken and so these children are unable to anticipate their needs and then their egos
become flooded with feelings of anxiety. This is experienced by these children,
adolescents, and adults as devastating. And, parenthetically, the anxiety that they
experience, as least the baseline level, is related to concerns about separation and feelings
of abandonment, and with that, a sense of annihilation.

Masterson sees this anxiety as being experienced by the borderline as a fear of a

rendezvous with death. Not infrequently, as Giovacchini points out, these children rely
on omnipotent magical fantasies designed to ward off their underlying feelings of loss,
separation, and abandonment by parental objects. Some of these children cling to their
fantasies because the fear is that if they were to let go of them, there could be nothing left
to replace them and even more importantly, since there is always the feeling of loss and
abandonment by the parent, these children cling to their fantasies because the fantasies, in
a pathological way, somehow contain, inhibit, and limit some of their feelings of being
overwhelmed by anxiety. This isn‘t too dissimilar to a neurotic patient who has gone
through treatment and feels good and feels better, but as they are leaving or terminating,
they kind of feel a nostalgia for their old feelings, because they were their old friends --
they protected them from being overwhelmed, in a strange sort of way.

4
So, for the borderline, as the developmental and environmental demands increase, we see
the defensive maneuvers utilized by them to ward off the anxiety, become more ego-
syntonic, and where there is super ego aggression along with ego regression, they are able
to feel freer to utilize their symptomatic behavior with minimal guilt.

ALEXANDER: I just want to go back a minute, Mr. Kaufman, and let‘s just define a
few of these things. Let‘s define ―ego-syntonic.‖

KAUFMAN: Okay. Many of us will commit an action and sometimes that action is
reprehensible to ourselves; we wouldn‘t do it. For instance, somebody goes to a
restaurant, accidentally walks out without paying the check. The restaurant owner calls
this to the person‘s attention and the person is apologetic, pays and is embarrassed by this
slip. That behavior is one that is not part of one‘s values system.

On the other hand, somebody else might do the old ―fly in the soup bowl‖ routine: take a
fly, put it in the soup, get a free meal and walk out without having to pay. That would be
syntonic, in other words, to not pay would be syntonic, whereas for the person who feels
bad about having made the mistake of not paying, that, for them, would be ego syntonic.

So, when I‘m saying that these individuals utilize certain ways of handling things to feel
comfortable, at first it might not be something that they would like to necessarily do.
Maybe they‘re a little apprehensive about smoking pot or using drugs, but as those
become effective in some kind of way, there is less and less and less conflict about
utilizing this thing, so that becomes ego-syntonic. When, as I said before, there is super
ego regression along with ego regression, they do it with minimum guilt. It is, ―Oh, I‘m
doing this and I feel bad about it, but I have to do it, so I don‘t feel bad.‖ They just do
it.‖

Again, as I said before, the symptoms begin to metamorphically take the place of parental
figures and protect them from over-stimulations by anxieties that they feel are intolerable
and affects they feel will overwhelm them.

ALEXANDER: Now let‘s define ―part-object.‖

KAUFMAN: All right, part-object. That explains a stage of development which

takes place before a child can understand or comprehend that they have two different
feelings about the same person, positive or negative. So, simply put, if mother satisfies,
she is good. If she frustrates, she is bad.

How you integrate the idea that the same person is both good and bad takes a while in
terms of development. So, what happens is a normal ―split‖ in the ego: the same person
is perceived as ―all good‖ and that same person can be ―all bad.‖

ALEXANDER: Okay, now we go on to ―ego regression.‖

5
KAUFMAN: Okay. Very often we have a series of progressions in terms of
development in which the ego is able to perform more and more tasks in helping the
individual adjust to the environment, harmonize things in terms of internal needs. The
classical language is, ―id demands,‖ but it could be ―hunger.‖ Yes, we should just say
that: ―You feel hungry.‖

How do you function? Well, when you‘re a baby you‘ll give a cry and mom will come
and give you a bottle. When you‘re two years old, you may feel hungry and you
remember, ―Oh, there‘s the refrigerator,‖ and you walk over to the refrigerator, you open
the door and you take something out of the refrigerator. As the ego develops, there might
be something on top of the counter that you desire if you‘re hungry, but you can‘t get to
the top of the counter and then you figure out, ―Oh, if I push the chair over and climb on
the chair, I can get it down, or I can take a stick and knock it off.‖ So, these are all
progressions in terms of the ego‘s getting more and more sophisticated at coping with the
inner world and the outer world.

Now, at certain points in time, the ego needs a rest and we have a temporary regression,
so one goes back to more infantile ways of being. We go on vacation and we know we
shouldn‘t eat this food, however, we‘re on vacation, so we‘ll eat that food and we‘ll
indulge ourselves in more childlike kinds of satisfactions. You come back from vacation,
we go to work, we‘re grown up all over again. We watch our diet, we do our exercise,
whatever it is. So, those are temporary regressions.

All right, so, in terms of the movie and in terms of the character, Terry, there is a more
permanent kind of regression in which there is a giving up of the more sophisticated
elements of the ego and reliance on lower level defenses such as denial, projection, and
introjection as opposed to some of the higher level defenses, like: undoing, in which you
symbolically atone for a hostile act; reaction formation, when the impulses are placed
with the opposite; isolation or intellectualization, which is part of adolescence; and
identification, which is taking on the traits of somebody else unto one‘s self. Those are
more sophisticated sorts of higher level functioning.

With introjection, you take on, for defensive purposes to defend against loss or
helplessness, some part, an introject into the self, part of another person in order to be
strong. For example, Popeye introjects the spinach whenever he needs help and is able to
grow from that, or projection, in which something unacceptable in the self is placed
outside of themselves, and denial, which is a blotting out of reality.

When there is an ego regression, you rely more and more on these more primitive
defenses and very often, because of that, we‘re not able to realistically function as well in
the real world. That is more permanent; it is not a temporary thing. Under stress, we can
all get crazy and do things in a more primitive sort of way.

ALEXANDER: Now finally on to ―superego regression.‖

6
KAUFMAN: Okay, superego regression. The superego -- it‘s the representative of
society. It‘s the conscience, or morality. It also includes the ideal aspiration, the ego
ideal. The superego is mainly unconscious and its functions include the approval or the
disapproval of the ego‘s actions, a judgment that an act is right or wrong, critical self
observations, self-punishment, demands that make the ego repent or make reparations for
wrong-doing, self love, self esteem and rewarding oneself for having done the right thing.

When a superego is functioning at a sophisticated level, we know that when we come to a

red light, we are supposed to stop, and then when the green light comes, if we‘re driving,
then we go, with the following exception: when we are at a stoplight, we may be
permitted to turn right on red if the circumstances are correct. If there are holes in the
superego, or ―lacunae,‖ the superego might say (a person‘s conscience might say),
―Listen, if I can turn right on a red, why can‘t I turn left on a red?‖ So that little hole is
there. When there is a regression, what happens is the superego becomes harsher, and
more strict. So, then you only stop at the red light. You cannot, under any
circumstances, turn right. You must stand still.

When children are young and they are first learning things at school, and their teacher
shows them how to add or how to subtract, and they present this to their parents and they
ask for another kind of problem to be solved, the parents set it up and the parents do it in
a way that is slightly different than the teacher, the child‘s reaction is, ―That‘s not the
way it‘s supposed to be. My teacher says so, and it doesn‘t matter if you have the same
answer.‖ Two and two is four and three and one is four? Uh huh, the teacher didn‘t tell
him about three and one, so it doesn‘t exist. Only two and two. So, that‘s a little harsher,
more literal superego.

Then as things slowly regress further back, the superego operates under talion law: an
eye for an eye and tooth for a tooth. So one kid was asked the question -- this is for real,
one kid was asked the question, ―What would you do if somebody accidentally hit you?‖
He answered, ―Well, I would accidentally hit them back.‖ So that is operating out of ―an
eye for an eye and a tooth for a tooth.‖ That is a much more primitive kind of thing. The
expectation of course, was if somebody accidentally hit you, you would forgive them.
You‘d let them say they were sorry. But a more regressed, more primitive superego is
going to say, ―That‘s a terrible thing and there is a punishment.‖

All right, how does that operate when, for example, an individual turns that castigating
superego on themselves? If you had a negative thought about somebody else -- you
wished that they would fall down, for example, your superego may say, ―Wait a minute!
You wish that person to fall down? Then, an eye for an eye and a tooth for a tooth,
you‘re going to fall down,‖ and you‘ll trip and hurt yourself. With some of these
accident-prone kids, that‘s what operating. There is self punishment. They are doing to
themselves that which they had wished to do to others. They may not have done that to
anybody else, but to them, the thought is the same as the deed.

7
So, when there are permanent superego regressions, there are self punishments, there are
self admonishments, and there may be, in the broad scheme of things, the whole question
of revenging oneself over and over and over again against somebody.

ALEXANDER: Does superego regression work in the other direction, where you lose
your rules?

KAUFMAN: Yes, I‘m glad you raised that. There can be such a disillusionment with
a person or persons or group that your superego is built upon, that you then abandon the
values that were inherent in that identification.

Now, one other thing needs to be included in this which is not a regression, and that is the
amoral character. That is, if the society one lives in says, ―Listen, in order to survive, you
live off the land,‖ and if living off the land means bamboozling somebody, swindling
them, getting their money, promising to do their driveway but just puts oil on it instead of
tar and it washes away in the next rain, that is an amoral character. That person is
actually living up to a moral code that is different than the regular society moral code.

So, you‘re absolutely right, yes, there can be a discarding of the superego altogether and
the superego then joins with the ego and the id and they say...

ALEXANDER: ―Let‘s party.‖

KAUFMAN: ―Party,‖ yes, that‘s right. One last thing and then we will segue into
the film. One of the features of borderline children and adolescents is that drive
development takes place, but isn‘t integrated within the ego. There is no drive phase
dominance. This means that the ego gives no direction to the drives or the feelings. So,
it‘s as if there is a whole range of feelings shooting up in all directions and no structure
and no mechanism to interpret what is happening inside of the individual.

Anna Freud says that it‘s as if the drives in the ego develop independently as if they
belong to two different people. In relation to this discussion, it‘s as if several different
stories are going on at the same time, but unlike a Robert Altman film, there is no
apparent or unifying theme at the conclusion of the process. So, somebody feels
something and they don‘t know whether they want to eat, whether they want to go to the
bathroom, whether they want go to sleep or whether they want to make love. They just
feel some, something. There is a confusion about what is the best thing to do.
Sometimes it‘s by guess and by golly, and sometimes what happens is they focus on a
solution that begins to take on a magical quality: ―If I only had this, if I only had that, if I
only received this or that, then I would feel better.‖ Very often, borderline and non
borderlines as well, will project their needs to relief onto external objects and then these
feelings are felt with rejection, disappointment and rage when they don‘t do the trick,
when they don‘t handle the problem.

So, that‘s one of the problems about not having a drive phase dominance. Someone can‘t
discern what their needs are. Do they need to go to sleep? Do they need to go to the

8
bathroom? A good parent will see their child with their hands gripping towards their
crotch and they‘ll say, ―Oh, you have to go to the bathroom.‖ After a while, the child
begins to realize that when they are having a certain kind of physiological response, they
have to go to the bathroom, or the parent will say when the kid‘s kind of cranky and
demanding, ―Oh, I think you‘re tired, you need to go to sleep.‖ The kid goes to sleep and
that was what it was, so they begin to recognize and select what they need to do in order
to feel better.

So, that is the background. These borderline individuals are struggling because they
don‘t have the equipment to cope with the exigencies of life. Borderline states, as
mentioned earlier, generally are associated with issues around separation and
individuation, but they can occur later on if there is a superego regression and if there is
an ego regression at the same time, so acquired skills such as object constancy and certain
kinds of more facile and flexible ego defenses and adaptations get lost in the process and
they begin to rely on more and more primitive kinds of ways of coping.

In the movie, ―You Can Count on Me,‖ manifestly, the movie is about a brother and a
sister whose parents are killed in an automobile accident when the siblings were children.
The movie opens up with a scene containing the death of the parents and really
demonstrating how fatal life can be when things go out of control.

We are introduced to the local sheriff, Darryl, who comes to break the news to the
children and the babysitter Amy about the death of the parents and in the dialogue
between Darryl and Amy, the issue about death being hard to deal with comes to the
front, and then the scene shifts to church spires and steeples. The minister is there and
Sammy, the older sister, is attentive to the service. Terry, the younger brother, cries and
wipes tears from his eyes, and he is clearly not attentive to the church service at all.

This scene foreshadows the psychological adjustments that these children will make in
their adult lives. Terry regresses psychologically in both the ego and the superego.
Without the support of the superego, his ego seems to be at the mercy of his impulses and
as time goes by, he begins to make increasingly a borderline personality adjustment.

On the other hand, Sammy, who does show signs from time to time of ego regression,
nonetheless still shows an age-appropriate superego development. She identifies with the
church, as providing some structure and relief in her life. Later in the film, in a dialogue
with her priest, she speaks of her attachments to the old rules of sin and damnation as
being easier to deal with than the more empathic, insight oriented, psychologically-
minded approach to human frailty. It‘s this later approach to human frailty that confuses
her. She struggles with this all the time. But, she does use the superego in the form of
the church and the rules and the regulations as some way of holding herself and her
family together.

In the movie in the first glance at their adult entities, we are introduced to Sammy. She is
leaning by her parent‘s grave and she is praying.

9
Terry, on the other hand, is shown to us dressed in sort of a disheveled state, wearing a
blue knit wool hat which he bought for a buck on the street, and trying to borrow money
from his pregnant girlfriend to travel to Scottsdale, New York to borrow money from his
sister, Sammy, to pay for the girlfriend‘s abortion. He is unable to tell Sheila, the
girlfriend, that he loves her when she requests those words from him. So, he is really
struggling about his attachments and people are serving functions. He is going to go to
his sister to get money, he is taking money from the girlfriend. He can‘t quite get it
together. So, we follow him on the bus ride and there he is, he is riding the bus, he is
going back home and he is smoking marijuana on the bus as the bus passes the cemetery
in which his parents are buried.

Again, the director focuses on the employment of the superego in the form of religion to
provide comfort to the ego. He contrasts this with Terry‘s disorderly life, habits, and the
detailing of the discoordination of his ego and the regression of his superego.

Terry and Sammy demonstrate the uneasiness of their relationship over a reunion that is
the next scenes that follow. Terry is already a day or so late because he was confused
about bus schedules and accuses his sister of dressing formally. She counters that she
dressed up to celebrate the occasion. The t-shirted Terry states that he is the ―haute
cuisine‖ of fashion, a comment which goes over his sister‘s head.

This sets up the running commentary on Terry‘s part explaining his constant wandering
and misfortunes as providing him with a worldly experience and that he is not coddled,
like his sister. So there is a rationalization for the search for the lost object. You travel in
one part of the country and look for a job, you get the job, you get in trouble, you have to
leave or you stay in jail or you get arrested -- whatever it is, he is always on the go.

It‘s like the sailor. When they are on land, they dream about the sea, and when they are
on the sea, they dream about land. So, Terry is able to explain that this provides him with
this worldly like existence, and it‘s clear that it has been a year that the two have not
communicated and Terry has spent time in Alaska, in Orlando, and in jail.

When the later is revealed to Sammy, she becomes extremely self righteous, exclaiming
that she didn‘t know if he was dead or alive, that she is horrified that he was in jail and
she explains that she wishes for mom, the dead mother, were here now, presumably to
help manage Terry and she suggests going to church as a substitute. She is going to lend
Terry her ego. But there is the wish for the lost mother, as if she is going to make
everything right and everything that needs to be made right is projected onto Terry. I‘ll
get more into that later on.

He dismisses religion as containing fairy tales. She says he has no anchor -- well he‘s got
anger, but he has no anchor! -- and he responds by saying that he is simply trying to go
and get on with his life.

One of the subthemes in the movie relates to problems in relationships. In this context,
Sammy, although she has a higher level psychic structure, seems to have as much

10
difficulty in attachments as her wanderlust-filled brother. She flits from one relationship
to another and fears the possibility of marriage as strangulating. She oscillates in her
connection with Terry, although not unprovoked, but seems to be struggling with trying
to catch up also with her 8-year-old son Rudy.

We are also introduced to Brian in the film, her obsessive compulsive boss who she
eventually has an affair with. We are also introduced to Bob, an old boyfriend who has
proposed marriage to her and whom she describes as being like Peter Pan, never quite
growing up, which is another reason not to get close to him.

Then, finally, the next subtheme involves Terry‘s relationship with Rudy. Terry, for brief
moments of time is able to respond in a responsible fashion, both in deed – picking Rudy
up on time, and in words – ―Fasten your safety belt.‖

However, he does not drive Rudy to a babysitter. Instead he brings him to a construction
site where he is temporarily working and Sammy is not informed of this change in plan,
so she panics and tries to find her child and goes to the construction site and is soothed as
she watches Terry teach Rudy how to drive a nail in with a hammer.

This sets up a stage which is fascinating throughout this next part of the film, and that is
that a whole series of issues surrounding fathers and sons that begins to emerge. There
are all kinds of fathers: there is Brian, the bank manager, who is a father-to-be; there is
Terry and Sammy‘s father who abandoned the children by dying. There is Rudy‘s father,
whom Rudy has not seen and who left an abandoned mother and child, and there is
Father Ron, who is the priest who comes by to try to give counsel, as best he can, to both
Terry and Sammy. So, there are all of these father figures and father ideas floating
around in the next segment of the film.

What we begin to see unfolding is Rudy‘s wish to find his father and Terry‘s wish to help
Rudy grow up by actually meeting his father, and there is the wish on Rudy‘s part that his
father is wonderful and good and whatever else. I mentioned ―Star Wars‖ before – this is
the same story that Luke Skywalker went through. He was wishing that Darth Vader was
terrific underneath that hollow mask.

So anyway, there is a situation in which Terry brings Rudy to Rudy Senior‘s house, and
Rudy Senior ejects both Terry and Rudy, and rejects openly Rudy by denying his
paternity. In the course of this, Terry gets into a fight with him and to me, as I
understood it, this really represents his rage and revenge at the abandoning parent, which
is one of the things that borderlines wrestle with. They wrestle with, ―I‘ve been
abandoned, but I want to make contact, but I want to kill the person who abandoned me,
so I‘m in this dilemma. If I want to be independent of them, I might be killing them,‖
and there is a whole cycle that goes on around this abandonment and loss.

But in the film, they are coping with the pain of the actual abandonment of the father, the
emotional as well as the physical that goes on and Terry‘s feeling, after he is arrested for
this act, is that he cannot do anything right. Even though he tried to do the right thing by

11
bringing the two Rudys together, even though he knew that Rudy Senior was an SOB, he
was hoping that maybe he wasn‘t still as big of an SOB as he was before. Maybe he was
a smaller SOB but he would at least be friendly towards little Rudy.

Following this arrest, Sammy basically orders Terry to be out of the house; it‘s too much.
Rudy the child goes into a state of denial that Rudy Senior wasn‘t his father. The man
said he wasn‘t his father, therefore, his father didn‘t abandon him, therefore his father is
still around to receive him, and Sammy has to work with the child‘s painful, painful,
painful denial of the actual rejection and abandonment.

You know, when we think about borderlines, they are struggling with that sense of
abandonment. Sometimes they understand it in terms of rejection, i.e., mother goes in the
hospital. Well, if she had loved the child enough, she wouldn‘t have gotten sick and gone
into the hospital. But there is a disruption and there is a false sense of loss and
abandonment.

You can see in this film, as Sammy is working with Rudy, there is cutting into some of
this denial and reaffirming their own relationship. You know, ―You don‘t have a father,
but you‘ve got me,‖ so on and so forth. Then the boy has to deal with his uncle, who had
at least been a temporary kind of father figure or maybe an older brother figure --
somebody who would take you fishing. So, I‘m leaving that open, but certainly someone
he could look up has to leave. Then we see his anger at his mother for making his uncle
leave, and then coping with the mother‘s pain about having to do this.

It‘s interesting in the film that at some point, Rudy goes from his silent anger at his mom
for having thrown Uncle Terry out and hurting him (Rudy) and to feeling compassion for
the mother‘s pain and going over to soothe her, which she doesn‘t quite recognize it at
first. He says, ―Mom, I‘m no longer angry with you,‖ and extends himself back to her.
However, she is not quite able to extend herself back to him, but the point of the matter is
that the boy was able to see the mother as a whole object, even though there had been the
frustration, as well as satisfaction, so that he was able to then respond to her needs and
her pain as an individual.

The director keeps on putting these little clues in for us to pay attention to.

Two more things and then I‘ll stop and will respond to whatever questions you have for
me. In the film, one time when Sammy and Rudy are at church, there is a whole hello
and goodbye with the minister and the scene is immediately shifted to Terry, lying on a
couch watching a television program and if you listen to the background sound, the
television program is about a 15-year-old, who objects to being controlled by his older
brother and has dropped out of school and is smoking dope, and is going to run away
from home. So, we have this potential borderline adjustment reaction going on.

ALEXANDER: In other words, if you didn‘t get it on your own...

12
KAUFMAN: Yes, he underscores it, at least as far as I can see.

There is another wonderful scene in terms of some of the lacunae in the superego in
which Sammy goes and she has an affair with her boss.

ALEXANDER: Now, ―lacunae‖ -- I just want to go back because you have used the
word before and I will just have you define it.

KAUFMAN: Lacuna, that means like it is a little hole. Have you ever seen Swiss
cheese? Okay, Swiss cheese, even some muensters, actually, are fairly solid, but they
have little holes in them and the idea of lacunae is that the structure of the superego is
there, however, there are these holes and certain things sort of slip through. You see this
with really young children, i.e., the child is sitting with a book and is saying, ―No,‖ as
they rip the page. The idea is there, but the structure isn‘t, so the impulse comes right on
through and the page gets ripped, or you get some other kind of thing which we all do.

We all have these little tiny holes. We go out for dinner and we have a wonderful meal.
Then we come home and we say, ―Oh, my God, I ate too much. I shouldn‘t have had this
and I shouldn‘t have had that.‖ Well, if we shouldn‘t have had this and we shouldn‘t
have had that, we wouldn‘t have ordered it in the first place. Right? If the superego were
solid, if it didn‘t have little holes in it … but, somehow, by virtue of the little hole, you
were able to have your dinner and lament it at the same time!

(laughter)

ALEXANDER: You‘d be happy and miserable at once.

KAUFMAN: That‘s right, that‘s right.

ALEXANDER: The whole thing. So, to go back.: Sammy and the boss.

KAUFMAN: Okay, Sammy has her first liaison with the boss, and as she finishes
that liaison, the movie starts playing ―The other woman‖ song. She is the other woman.

Then the next scene is she goes to the priest and says, ―Listen, I‘m coming to you to have
you help me with someone whose life is out of control.‖ She isn‘t meaning her, she is
meaning her brother. So, this is the way the director uses a variety of things to pull us
back and remind us about what is going on and what some of the contradictions are and if
we didn‘t catch the points, he will sing it for us or play it on the radio for us, so that is
where, I think -- I‘m not saying he‘s consciously aware of but preconsciously aware of—
he shows us some of the issues that characters are struggling with and some of the
personality disorders that the characters are struggling with.

ALEXANDER: Now, I‘d like to ask you some questions about the movie. These
children -- we see them at probably ages 9 and 7, or maybe older because she‘s got
braces, she‘s getting braces.

13
KAUFMAN: Well, there‘s a hint, I presume that that is who the mother is referring
to: ―Why do they take 11 year old girls and put braces on them at a point in time when
they are feeling so self conscious and vulnerable to begin with?‖

ALEXANDER: So, you‘d say maybe they are 11 and 8 or so.

KAUFMAN: Something like that, yes.

ALEXANDER: Alright, so…

KAUFMAN: Specifically because they keep on mentioning the age of Rudy, and,
―You don‘t know how to deal with an 8-year-old boy,‖ so he must have been 8 at the
time of the parent‘s death.

ALEXANDER: That‘s right, yes. So, we don‘t know anything about what their
relationship with their parents were like. We don‘t know if they had achieved object
constancy, we don‘t know if they had negotiated their way through all of their separation
and individuation issues. These are things that we don‘t know. So, my question is, let‘s
assume that they had. Let‘s assume that the parents were good enough.

KAUFMAN: Right.

ALEXANDER: Pretty good parents. I mean at least the mother notices that her
daughter is uncomfortable, was self conscious. At least she notices things. The question
is this: can a borderline state occur as a regression? You touched on it just a little bit.

KAUFMAN: Yes, I think so, I think so.

ALEXANDER: So then it‘s not really a development issue.

KAUFMAN: It is a developmental issue. However, sometimes, there may be certain

vulnerabilities, or fixations or arrests, or whatever that when a trauma hits, there can be a
pull back to earlier stages of functioning, including these primitive states that we are
talking about. So, it is a development issue, and in the general composite of things, you
would see people who had difficulty and I think almost every theoretician around states
that it happens somewhere between that period of time between 18 and 24 months where
one doesn‘t quite get through the separation/individuation process. One doesn‘t quite get
through the establishment of whole object relations and object constancy.

But, Fred Pine raises a kind of interesting point. He suggests that object constancy
doesn‘t ―POOF‖ happen like magic at 3 years of age. He sees it as a kind of gradual
thing that builds up, let‘s say at 5 years of age.

So, in my sense, yes, somebody could be traumatized and could regress back to an earlier
time and if they aren‘t helped, and this is where Masterson comes in, they aren‘t helped at
a young age with the abandonment anxiety or depression, that they could get fixated at

14
that stage. In other words, what became a temporary adaptation gets fixed because they
haven‘t been able to resolve the problem. That‘s what I think happened with Terry.

Now, Sammy, we get a little bit of something there in which there is some discussion
about her adolescence and her being wild and acting out and she demurs but then Rudy
and Terry sort of look at each other and giggle and then we hear about the escapades with
her first husband. So, she also kicked up her heels but she had a superego to hold on, to
get back to and I don‘t think that Terry had that, nor did he have anybody helping him
with the mourning process.

Here we get a little tricky because you have two different levels going. One of the things
that Anna Freud talked about was that once you achieve object constancy, you can give
up old objects. That is, once you have something, you can want it, you can let it go.
Eckstein talks about the same kind of thing. You can‘t give up that which you never had.
So, you either have to keep it in some kind of idealized view of all good or all bad, or
you‘re a complete loser, you don‘t have any option.

So, that is a much more primitive stage of the game, when we‘re looking around for the 3
year old or the 4 year old to feel connected and give up some of their grandiosity and
some of the grandiosity of their parents or the idealization of their parents and accept
them as human beings. That is the process that gets worked through over and over again.

Now, these kids not just had the normal developmental issue to deal with, son of a gun,
they had a real loss of their parents, and how do you let go of the objects? Clearly,
Sammy moved toward or gravitated toward, for better or worse, the church, and the
church gives her some sense of balance and she is able to give comfort. Terry just has his
symptoms. He has not been able to find anybody that he can substitute because he cannot
really mourn or give up. Now the movie says that maybe he can, because he goes and
visits the cemetery just before he leaves town. Of course, he had been poo pooing his
sister for staying and going to the cemetery and hanging there with the folks. So, again,
you need to have something in order to be able to let go. So, as I say, yes, it can take
place later, on but if you don‘t get help with the abandonment or feelings of abandonment
and the mourning and the grief, then you can‘t work it through and let go of it. I don‘t
think there was anybody helping these kids. That is what I‘m saying.

ALEXANDER: My next question has to do with the different schools of thought about
the borderline personality and the more I get into this, the more I find all of these
differing approaches. There is the psychodynamic world and then there is the world
where borderline is viewed as a post traumatic stress disorder or where it is viewed as an
organic or genetic situation or where it is a cognitive problem. But, even within the
psychodynamic world, there are some pretty strong differences of opinion and I was
wondering if you could, in any way, summarize them. The difference between the
Kernberg approach and the Masterson approach.

KAUFMAN: Masterson and Kernberg – I‘m oversimplifying. Kernberg has the idea
that the point of emphasis is at working with the split in the object and the defenses

15
associated with maintaining the split. In other words, the split comes about through
normal development when our egos are not able to integrate the concept of ambivalence:
how could the same person who has satisfied us also be the same person that frustrates
us? So, we split them off in terms of ―the good mother‖ and ―the bad stepmother,‖ etc.,
folklorically. So, his intention is: look, the borderline patient is fixated that way and
because they are fixated that way, they can‘t tell from one minute till the next, is the
object good or is the object bad? If the object is good, does that make them bad and if
they are good, then is the object better, and all this kind of mishmash. So, his idea is to
interpret the splits and to work on the defenses of the split; to him, that is the key issue.

Masterson says, ―Look, I think working on the depression is the key issue, so that is
where I‘m going to focus my energy.‖ Some people then talk about parameters in
treatment: if you‘re a psychoanalyst, do you have the patient lying down or sitting up,
those kinds of things because the patient needs to have a handle on reality. Do you use
primarily, and this is very germane to us as psychotherapists and clinical social workers,
is the therapy only supportive or do we do some kind of interpretive kind of work in
order to enable the ego to grow and development?

But everybody seems to say, ―Hey, look.‖ The dynamics that Rudy Eckstein and Judith
Wallerstein wrote about in the 1950s seem to be at the basis of all occurring around that
separation/individuation phase, or whatever phase you want to call it, but it is between
that 2 and 3 year phase. As a result of the deficiency in that (let‘s say you can take a
psychological point of view), the individual is not able to self soothe themselves, or the
individual is unable to decide whether or not they have to have a glass of water or
whether they want to go to sleep. If they could figure out that they wanted a glass of
water, then they won‘t be thirsty and they will be fine. But, that is a way of soothing
yourself.

So, there are a lot of different words that are around, but we are saying, look, these are
kids who are having different parts of their psychic structure disrupted and their object
relations disrupted and how do we come together about it. The differences in emphasis, I
guess, is like two different piano players. One person is going to put this kind of
emphasis and one is going to put that kind of emphasis, but they are still going to end up
in the same place, hopefully, at the end: once, let‘s say, you work through the split in the
object, really, you want to get to the depression; once you‘ve finished working through
the depression, you got to deal with split in the object.

Then most of all, you go back to Eckstein‘s contention that you have to have object
constancy and that by being with the patient and being available empathically and
making contact empathically and making judicious kinds of interpretations or
clarifications, you‘re developing points of contact which the patient can use to form a
consistent object, and once they form a consistent object with you, they can give up some
of their symptoms. They are less threatened, less frightened about being ridden with
symptoms. So, as I say again, all of these things are multifaceted. It‘s a still a diamond.

16
ALEXANDER: Well, Mr. Kaufman, is there anything that you would like to add? Any
additional thoughts that you have about the film, about the borderline personality and its
causes before we close the interview?

KAUFMAN: Well, I think I‘ve kind of gone through the borderline personality and
some of the causes. All we can say, as far as the causes, is that something happened
between the child being able to maintain a kind of positive connection with the parent.

Now, there is one other thing, now that I think about it, in terms of the Kernberg and
Masterson approach. Masterson seems to allow for the fact that sometimes the bad
objects are actually bad in reality, okay, and not really psychological constructs. So that,
yes, mother can, in fact, abandon and it isn‘t just a sense of a ―felt‖ abandonment.

ALEXANDER: Kernberg doesn‘t see it that way?

KAUFMAN: He sees this really as –and this is my reading, so let me say, ―I‘m not
going to say Kernberg says, I‘m going to say, ‗Ed Kaufman‘s sense of what Kernberg
says‘‖ is that he seems to be suggesting that these good and bad object splits are really
the product of some internal stuff with the patient, having to do with their own
aggression, their own feelings, this and that and the other thing which they have not been
able to integrate.

What does that mean? It means that at some point in time in the course of treatment, the
patient is going to say, ―Was it real or was it Memorex?‖ and depending upon your point
of view, you‘re going to say, ―It was real but it was also Memorex,‖ or you‘re going to
say, ―No, it‘s all Memorex,‖ or you‘re going to say, ―No, it‘s all real.‖

That may be the difference of various schools of thoughts: how do they emphasize that.
Sometimes you know that, ―In fact, my wife did have a bad stepmother,‖ or ―Mrs. White
was a very lovely lady and she served coffee and crumpets down at the corner and she
was being very attentive to the child,‖ or so on and so forth. You‘ve seen it with your
own eyes, frequently enough, that you can say, ―Okay there‘s a distortion here.‖

ALEXANDER: This film provides a very rich discussion, I think, and I thank you for
providing us with a very rich discussion.

KAUFMAN: You‘re welcome.

This concludes our interview with Ed Kaufman. You may reach him by calling 312 –
782-7444.

I must say here that the views expressed by our speakers are theirs alone and do not
necessarily reflect the opinions of On Good Authority. This is Barbara Alexander. Thank
you for listening.

17
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview 2A: “Brief Treatment with Borderlines”

SANDY HOTCHKISS, MSW

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

SANDY HOTCHKISS, MSW

745 N. Marengo
Pasadena, Ca 91106
626.584.4810

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or

reading interview #2A of our program on the Borderline Personality Disorder.

In our program, Volume 7, Critical Issues in Psychotherapy, two of our speakers spoke
about the borderline personality, and we are reproducing several moments from those
interviews.

First, Sandy Hotchkiss will summarize three levels of borderline personality so we can
have some more nuanced criteria about this disorder. These will help us predict the kinds
of treatment and transference issues that may arise in treatment, and thus may help our
decision making about what to offer to the patient.

Sandy Hotchkiss is a licensed clinical social worker and board certified diplomat in
clinical social work. She received her master‘s degree from the University of Southern
California in 1981. Her work with character disordered patients is informed by post-
graduate studies in self psychology and supervision in the Masterson approach. Her most
recent publication was in the Clinical Social Work Journal on the topic of patients with
Munchausen by Proxy Syndrome.

ALEXANDER: Ms. Hotchkiss, we would like it if you could please give us a review of
the three levels of personality that you presented to us in our previous interview.

HOTCHKISS: Borderline patients do have one characteristic that can help us optimize
our therapeutic effectiveness: they are, by definition, object related. That means that

18
what goes on in their field of their current object relationships is of crucial importance to
them, and can help us structure our interventions.

In his 1984 book, Borderline Personality Disorder, psychiatrist John Gunderson describes
three levels of functioning in borderline patients that are based on the patient‘s subjective
experience of a primary object or objects. Each level has its own constellation of
symptoms or other clinical phenomena which also help us recognize the borderline
pathology and formulate an appropriate response.

These three levels have been described in greater detail in the previous On Good
Authority interview, but we will briefly review them here.

Level One is the borderline patient at his or her highest level of functioning. A primary
object is present, and the patient perceives the object as supportive. The presenting
symptoms may be loneliness, emptiness, depression, boredom, or masochistic type
behaviors. Depression in such patients often lacks the intensity of a major depressive
episode, and instead has a vague, empty quality, or seems to come and go without
apparent precipitants. Often there are intimacy problems in the primary relationship.
The patient longs for closeness but often distances in subconscious ways.

The Level One patient may lack the intense anger, affective instability, impulsivity, and
florid self-destructiveness that we typically associate with the behavioral components of
borderline personality disorder. We must tune in instead to the affective components that
are manifested in unstable relationships characterized by over-idealization as well as
devaluation, self image problems, chronic feelings of emptiness or boredom, and
preoccupation with issues of abandonment. These are also indicators of borderline
personality disorder.

In contrast to the Level One borderline patient, the Level Two patient, whose primary
object is present but perceived as frustrating or in danger of being lost, is easily
recognized by most skilled clinicians. The familiar hallmarks of borderline pathology:
anger, devaluation, and manipulation, are abundantly evident as the patient struggles with
the prospect of abandonment.

Gunderson tells us that borderline patients have in common the need for a reliably
available other who can be controlled. When the primary object frustrates this need or
threatens to end the relationship, the borderline patient will regress in predictable ways
that express the sense of deprivation. Pervasive anger may stop short of open rage and
come out instead as sarcasm, argumentativeness, or demands. If loss seems imminent,
there may be devaluation or a suicidal gesture that dramatizes the need to prevent the
loss. If the anger spins out of control, there may be paranoia. All of these reactions are
efforts, often conscious, to control or coerce the object into staying.

The Level Three borderline patient has lost the primary object either temporarily or
permanently. Since the concept of object relations refers not only to others in the
external environment, but also to internalized self objects, this state of objectlessness can

19
also result when trauma such as rape or life-threatening illness causes fragmentation of a
fragile sense of self. There may be psychotic episodes, panic states, impulsive acting out,
or prolonged dissociative episodes. These represent the patient‘s attempts to cope with
fears of aloneness and the sense of badness that arises from the conviction of having
failed or wronged the lost object. In the case of dangerous impulsive acts, the patient may
be trying to initiate social contacts which offer the possibility of control over some new
object.

Listeners interested in contacting Sandy Hotchkiss may call her at 626-584-4810.

20
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview 2B: “Disorders of the Self”

KARLA CLARK, Ph.D.

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

KARLA CLARK, Ph.D.

1330 Lincoln Avenue
San Rafael, Ca. 94901
415.456.3138

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or

reading interview #2B of our program on the Borderline Personality Disorder.

Our last speaker in this segment, Dr. Karla Clark, also spoke to us in volume 7 about
understanding patients with the disorders of the self based on their attachment styles, and
we are reproducing some highlights of this interview for you.

Karla Clark received her Ph.D. from the California Institute for Clinical Social Work.
Following that she spent several years in advanced post doctoral training in
psychotherapy of disorders of the self at the Masterson Institute, where she was also a
faculty member for nearly ten years. She is a very popular speaker, and has written
several papers on work with patients having disorders of the self, from a developmental,
self, and object relations perspective.

ALEXANDER: Dr. Clark, I've done a survey of our listeners and almost unanimously
people are very concerned about their work with borderline patients, establishing and
maintaining relationships with them, and especially, dealing with the ruptures in
treatment: the suicidal threats, the patient running away from treatment, the engulfing,
the distancing, and the boundary issues. These are the concerns that people have about
working with borderline patients, so I thought we might try to address some of those
concerns.

CLARK: Let me start this way: borderline is a tricky word. As I travel around,
what I hear for the most part from people is a definition of borderline that is just like you
gave it, which is in terms of behaviors: ―A borderline patient is a patient that gives you a

21
hard time; a borderline patient is a patient who is a drag and doesn't play by the rules and
acts out more than he or she reflects.‖

This is closer, if you remember way back in time, to Kernberg‘s early definition of the
borderline patient: a patient who has identity diffusion; a patient who splits; where
impulsiveness and lability of affect, and other kinds of things are the issues. It's a
perfectly good definition of Borderline.

I was trained in a different tradition. I was trained by Masterson, who uses ―borderline‖
in a way that's very much more specific, not only to talk about people who are ―that
way,‖ the way Kernberg describes: the people who have a very specific sort of notion of
what it takes to get along in the world and what is going to get them into trouble. So I'd
like to back up and talk about ―that,‖ not really just in terms of Masterson‘s work but also
what I've done with it.

So to set the stage for that, I want to back up, and first of all talk about what I see at the
moment as being an intrapsychic structure of the mind as it's relevant to this. I basically
have taken Masterson‘s work, and the work of Fairbairn over in England, and some
Kohut, and some Kernberg, and put them all together and made a synthesis that I guess
you'd have to call ―mine,‖ at this point, but I still think that most of the roots of it are in
Masterson‘s work and you will hear that voice probably of all the voices most strongly,
as I put this together.

What I did is what I said to myself that I agreed with Fairbairn, that probably the most
important survival mechanism for a newborn is the capacity to work out a way to attach
to caretakers, and that secures survival. If you look at the new work of people like Allan
Schore who's working with neurobiology, actually, that attachment also sets the stage for
how the brain is literally going to develop its hard-wiring.

So, what happens is a child is born with an enormous biological need to secure a
relationship with the mother that will work well enough so that they can survive and so
that their brain is going to grow in some way or another. And this is close to what
Fairbairn suggested half a century ago when he said that the basic drive is attachment.
So I started from that perspective. I started thinking about a person as ―attachment-
driven,‖ and the success of the person being based on how well they can elicit ―supplies‖
which help them grow from these attachments around.

So, attachment basically is formed through feelings, which become increasingly

organized as a child gets older. A child who‘s going to develop a self disorder develops a
notion that he's going to have to sacrifice either attachment or autonomy in order to
secure supplies, some sort of survival supplies from the mother. What is interesting to
me is that it looks, at this point to me, that there are four basic ways that a child who is
caught with a mother who doesn't respond to his sort of organic natural being effectively
is going to develop a deviant attachment style. One of those is a kid whose mother will
take care of him as long as he acts helpless and regressive, and is pleased at sort of
having to take over, in his mind. Now this may not really reflect what the mother is

22
really like; this is the kid's interpretation of the scene. But this child feels as though he's
going to get rewarded as long as he is passive, as long as he is not very independent, as
long as he turns to her for care. He's not particularly fussy about the perfection of her
care, he doesn't care whether she does it perfectly, and he's not very interested at all in
whether she sees him as perfect. He's simply interested in care. He feels good as long as
he acts regressively, and he has the assumption that the attachment person is going to take
care of him under those circumstances.

Now on the other hand, if he starts to act more autonomously, he has a vision in his head
of a mother who withdraws or attacks him for signs of being a separate person, an
individuated person, with an agenda of his own. So, in terms of attachment modality,
you have a kid who feels as though he's going to get supplies, get cared for, have some
kind of emotional connection as long as he acts kind of clingy and helpless, and lets his
mother do for him. He has a notion that he's going to be terribly alone and abandoned if
he stands on his own.

This is usually based on real transactions, although it's the child's distorted view of them.
This doesn't necessarily reflect who the mother of father really is; it's a kind of a schema
of ―caretaker.‖ That schema gets lodged as strongly as it does in the brain, interestingly
enough, because it takes the child off ―true.‖ It's natural to separate and individuate and
want to grow up, and it's natural to be able to do that without sacrificing your important
connections. A person who is moving from an authentic central part of themselves does
those things without feeling as though they are going to be abandoned if they do them.

On the other hand, if you have to twist yourself in some way that isn't following nature's
course, become clingy and baby-like for example, you‘re going to develop what
Masterson calls, ―a false self.‖ That is an adaptation to secure attachment at the expense
of who you really might be, so that you‘re really depleted in the effort. So the false self
of a person, Masterson would call ―borderline,‖ and I've stayed with his nomenclature
throughout, although by sticking in the attachment piece, I've changed his basic theory.
That's a subject for another day. But the attachment modality, then, for a person he
would call, ―borderline,‖ is to cling, and he's going to feel good -- there are going to be
powerful, strong, pleased, safe, good feelings attached to that, and an assumption of a
caretaker who will take care of you if you do that. The assumption is that the second you
stand on your own two feet, that person is out of there, and you‘re very, very alone,
feeling ill equipped to be alone. So, the only way to stop that terrible feeling of being
alone and ill-equipped and really in danger of dying is to go back and to cling to the
mother again.

That person is going to go out into the world -- as they grow up, they‘re going to have
more and more trouble as they go along in their life, because there's going to be more and
more pressure on them to behave as an autonomous person, and they're going to respond
to it by acting in a way that they associate with care, which is to act more and more
helpless and clingy. So they get to be an adult and they come into your office and they
fall at your feet and say, "Take care of me." So that's one way that a person can be very

23
chaotic and be responded to by the therapist as a pain in the neck -- they're unusually
helpless, chaotic, and regressive.

One of the ways that you begin to suspect that somebody is borderline is that you feel
like taking care of them. True borderlines make you want to take care of them, and that's
one of the ways you notice it. You take into account however, that they have strengths in
the ―true self‖ which are being disavowed, you see.

Now at the lower end of the borderline scale, there is less evidence of capacity to cope,
and you may have to be more directive, and care-taking, but if you are, when you‘re
dealing with that kind of person, watch to see if it helps them pull up, or if, as you take
over, they do less. If they do less, it's probably a tip off that you ought to back off the
care-taking more, and let them do more and then see if that helps push it in the other
direction.

Again, the model I'm using is one that's a knock-off of the one Masterson uses, but is not
quite his. The assumption, which is buried in his work, but not in his formal models of
the structure of the mind -- it's definitely part of his work, it is not a departure from him
in this sense -- the idea is that you speak to the strengths of the person, which the person
thinks they are going to get them nowhere. So, you have to find those strengths, and then
you talk to those, and you don‘t talk to the ―false self‖ modality.

Now I hope, you or your listeners are thinking at this point, ―But wait a minute. Aren't
there people who are not that sick who do this?‖ and the answer is, ―Yes.‖ The thing
that's very interesting about this kind of way of thinking about patients, is that it applies
to people who are healthier as well as to people who are at the more disturbed and chaotic
end of the spectrum. There are a fair number of people who are not self-disorders at all,
who have the idea that the way you get along in the world is to be helpless and bat your
eyes and have somebody else take over, and that you‘re going to be left out in the cold or
abandoned if you stand up for yourself. But they have more central self to bring to the
party, and you need to spend less time with them working on dismantling the notion that
to get along with other people, you have to cling. They do that only in more extreme
situations.

What I really want people to think about, if I were to summarize what I'm trying to do, I
would ask people to think about the attachment modality of their clients, and I would also
ask them to pay enormous attention to whether the interventions that they do help people
get more in touch with their feelings, not their thoughts, but their feelings, because just as
it is through feelings that these deviant attachment modalities are locked into the mind,
it's through the discharge of feelings that they are unlocked.

ALEXANDER: One of the feelings that I want to talk about with you is anger, because
it‘s been so axiomatic, at least early in my graduate training, that you don‘t ―do anger‖
with borderlines: you don‘t confront them on their anger; you don‘t discuss their anger;
you don‘t point it out to them. You try to side-step it, I guess, so I wonder where that fits
in.

24
CLARK: I think that people don‘t know who they are unless they know how they
feel, and a lot of times, especially if you‘ve had to pull yourself way off the center of who
you really are in order to get along with the people who are most important to you, you‘re
going to be very angry. I don‘t know how you‘re going to get better if you don‘t address
that. So, anger, for me, is no different than any other deep feeling. I want to help my
patient access those feelings safely and talk about them, rather than act them out, as a part
of the ―getting better‖ process.

Why do we have anger in us? I don‘t follow Melanie Klein in believing that anger is, at
root, the death instinct, and a destroyer, and a murderous thing. I think that people
mostly get angry when their efforts to form and maintain a self and get along in the world
are thwarted. Anger is a healthy adaptive response to severe threat, and if you don‘t have
access to it, I think you‘re in a lot of trouble. So the issue is to be able to discover it and
also to regulate it.

ALEXANDER: I think that the magic word that you said was to ―safely‖ deal with it.

CLARK: That‘s right.

ALEXANDER: In what kind of situations would or wouldn‘t you interpret anger?

CLARK: Well, you see, I wouldn‘t interpret it. What I would do, is talk to more
adaptive functions, saying ―Look, this particular way of coping with a dangerous feeling
is, in fact, weakening your self.‖ Therapy is about the exploration of feelings; it isn‘t
about giving love. There‘s no encouragement of expressing feelings for their own sake.
There‘s a context which is, ―Does expressing the feeling serve you, or work against
you?‖

Then you speak to the patient, again, as though you are speaking respectfully to ―a real
human being,‖ not to a thing, ―a borderline,‖ who is a thing, but to a real human being
who is trying to deal with their problems. If you deal with feelings in that way, you will
not endanger your patients, nor will you encourage outbursts that they can‘t tolerate.
Destructive anger needs to be dealt with as something that‘s hurtful to the treatment.
Appropriate expressions of anger need to be supported and listened to.

ALEXANDER: Very good distinction!

CLARK: Yes, I mean it‘s a very important one because the whole issue -- can
you imagine having to conduct a psychotherapy, a real in-depth psychotherapy, in which
you had to edit out certain feelings because your therapist shied like a frightened horse
every time you came near them? It wouldn‘t work too well.

Try to think about your patient‘s feelings and behaviors in the context of their theory of
what it takes to be attached to you, and what‘s going to happen if they‘re not.
One of the problems with all of the training that we get, especially those of us that are in
the analytic parts of the spectrum -- the training is very good. We need it because

25
everybody needs really powerful tools to do good work. So we need that training. But
there is something about the training that also pulls us away from our own real and
spontaneous selves, and our capacity to relate to patients as people with us. I think we
become afraid to do that. Our supervision, consultation, reading, everything makes us
really afraid, and I think ultimately, we‘ve got to push beyond the techniques to a place
where we remember that we are humans sitting with other humans, and talk to them that
way.

The important thing is that the final perspective with a patient really needs to be that you
are a human being sitting with another one, and that your tools are there to help you; that
your understanding of what they need, attachment modalities or anything else are there to
help you. Ultimately, you are one person sitting with another, and you do least damage if
you always remember that and act like a real person. From that, if the patient has any real
possibility of being a patient at all, they have something to pull with instead of being
pathologized, and that‘s very, very important.

ALEXANDER: Dr. Clark, thank you for a very human, warm, and respectful interview.

CLARK: Sure, my pleasure.

Listeners interested in contacting Dr. Karla Clark may call 415-456-3138.

This concludes our interview with Dr. Karla Clark. We hope you learned from this
interview and that you enjoyed it.

I must say here that the opinions expressed by our speakers are theirs alone, and do not
necessarily reflect the opinion of On Good Authority.

Until next time, this is Barbara Alexander, thank you for listening.

26
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview 3: “OBJECT RELATIONS APPROACH”

FRANK SUMMERS, Ph.D.

Interviewed by BARBARA ALEXANDER, LCSW, BCD

(Edited slightly for readability)

FRANK SUMMERS, Ph.D.

333 E. Ontario, Suite 4509B
Chicago, Illinois 60611
312.266.8230
To order Dr. Summer's book, Object Relations Theories and Psychopathology, call the
Analytic Press 800.926.6579.

Welcome to On Good Authority. I‘m Barbara Alexander. You are listening to Interview
#3 in our program on the Borderline Personality Disorder. In this interview, we will be
exploring treatment of individuals with borderline personality disorder from the object
relations perspective.

While ego psychology and classic psychoanalytic theory view human motivation as a
compromise or a conflict between the competing pressures of drives, defenses, anxiety,
and guilt, many clinicians today see this as narrow, reductionist, and removed from actual
experience.

At any rate, from the object relations perspective, symptoms are rooted in the early
relationships with both parents. These early relationships exist to serve a function: the
development of the self. The child whose emotions and interests are not responded to
will bury his or her genuine experience.

A primary task of object relations treatment is to interpret modes of relating through the
current relationship that develops between patients and therapist, rather than making
conscious the unconscious elements of any conflict. The modes of engagement between
patient and therapist are themselves the means for understanding the patient‘s self-
structure.

While ego psychology is essentially a one person model -- in other words, the attention
and domain of inquiry lies entirely within the patient -- by contrast, the object relations

27
model is a two person‘s model. The therapeutic goal is not insight per se, but the
facilitation of new relationships. Through the relationship with the therapist, the patient
is helped to relinquish pathological relational patterns and replace them with others based
on the patient‘s authentic experience.

In work with the borderline personality, the same arguments hold as in the treatment of
many disorders. The insight and relational oriented approaches, view the cognitive
behavioral approach and medication as ―quick fixes‖ that don‘t last. The research-based
cognitive behavioral approaches view the insight and relational approaches as basically a
bunch of unsubstantiated palaver.

I myself believe it is vital to keep an open mind, and to see what we can learn from and
about both.

Well, that said, let‘s hear from our speakers themselves about their work.

Our first speaker, Frank Summers, Ph.D., is an associate professor of psychiatry and the
behavioral sciences at Northwestern University and holds faculty positions both at the
Chicago Institute for Psychoanalysis and the Chicago Center for Psychoanalysis. His
previous book Object Relations Theory and Psychopathology, has been hailed as the best
available survey of contemporary psychoanalytic theory and technique. In his current
book Transcending the Self, Dr. Summers provides case discussions demonstrating how
psychoanalytic therapy informed by an object relations model can affect radical
personality change. Dr. Summers maintains a private practice in psychoanalysis and
psychoanalytic psychotherapy in Chicago.

ALEXANDER: Dr. Summers, let‘s begin this interview with the discussion of the
movie, ―You Can Count On Me,‖ because I think you have a different point of view
about it which will help us get into your definitions of borderline through the object
relations model. You didn‘t think the characters were borderline.

SUMMERS: I‘m sure the first character you‘re thinking about is Terry, and I realize
he‘s a person who, in conventional terms, many people might well think of as borderline
because of his erratic behavior. There seems to be a lot of impulsivity, but you see, I
don‘t think in terms of symptom constellations or even behavior per se, because I think
that that leads to a too broad and vague of concept of the borderline disorder.

I think the term ―borderline‖ is overused. Very frequently, if somebody acts the way
Terry, in the movie, for example, acts: impulsive, seems to not think things through,
drifting around, or patients who are explosive, immediately they are called borderline,
and it means nothing more than that the patient is very difficult, very difficult for the
therapist and they are difficult. But what you‘re doing then is you‘re conflating a whole
group of different people with one vague appellation that really becomes meaningless
then, from my point of view.

28
I think borderline is only a meaningful concept if I can apply it to a delimited group, and
I base my diagnosis, of course, on the object relations constellation of what is the
underlying structural difficulty.

Now, I tend to group pathology according to the sense of self and the corresponding
object relationship. Each type of self-structure requires a different kind of object
connection that fits that self-structure. So, people who have a fragile self, that means a
self that is very unstable, it doesn‘t feel like a strong sense of ―Who I am,‖ require a
fusion with the object -- that means the object has to provide the strength, the stability of
the sense of self. So, such people seek merger in their object relationships.

Consequently, when there is a disruption, or when there is the merger, that in and of itself
threatens the minimal sense of self that the person has. That‘s the ironic paradox of such
cases: precisely because the self is fragile, when there is an object connection, what they
seek is a merger, which threatens such sense of self as they have. Consequently, they
need to push away from the object, often in a violent way, certainly in an aggressive way
at minimum, in order to sustain such sense of self as they have. But then they have a
fragility, then they lack the sense of wholeness, so that draws them back to the object.
And this is the oscillation that one sees in such people, and that is what I call borderline.
The reason I call it borderline is because in both states -- in the merged state there is a
loss of sense of self so there is a borderline psychotic quality to it, where there is a loss of
sense of who I am, and in the other state, in the pushing away in order to achieve a sense
of boundaries, in order to push away, the other person is perceived as a threat, often as a
destructive threat because the other is potentially destructive to the sense of self, and that
is the paranoia that one sees in the borderline disorder.
So, if we view borderline from that perspective, then it‘s a limited group of people who
tend to form object relationships in those ways based on a fragile sense of self.

Now, when I get to Terry, I don‘t see that. Terry does a lot of impulsive things, he does a
lot of very problematic things, he is immature. We can describe all those things, but I
don‘t see his object relations as organized around a need for merger or fear of merger. If
you look at his behavior, in the movie, the kind of problematic behavior he shows, at
least in the context of the movie, tends to be in reaction to what he regards as insults,
injuries to his self-esteem.

An example of this occurs when his sister brings in the religious figure, the minister or
priest, to talk to him because she feels he needs religious counseling. He‘s insulted by
this. He takes it as a blow, and as a consequence to that, he then is so angry and feels so
deeply injured by it that he then says he‘s not going to take his nephew fishing, which, of
course, infuriates her.

Now that‘s a very extreme reaction; it‘s a very immature reaction in conventional terms.
You know, ―You did something I don‘t like so I‘m not going to do this to hurt you back,‖
to punish her for what she did. That shows the depth of the insult, but it‘s not around a
sense of merger or fear of merger. It‘s around an injury to his pride, an insult, and that‘s
what causes the acting out.

29
The way I see his behavior, his behavior is organized around a desperate attempt to try to
achieve some sense of self respect. When he feels he gets it, he feels boosted, and when
he doesn‘t get it, you get all kinds of intense reactions, such as intense anger. So, some
of his more problematic behavior – well, look for example, at the plumbing situation
where he is going to try to fix this leak. When he can‘t and the plumber comes, he‘s
enraged. There‘s another insult that he suffers in the movie. That makes him angry. He
withdraws, he sulks because of the insult to his pride. It does not have to do with merger
or fear of merger; it has to do with his self respect.

I could go on and on with other examples: when he feels good, why does he do some of
the things that he does? He does it to try to achieve some sense of appreciation from
others because he is so desperate to achieve some sense of self respect. So he takes his
nephew out to play pool because pool is something that he is good at, that he can feel
good about, and he wants the child to admire him. I would even say he needs the child to
admire him. And then, he realizes that one thing this child wants, of course, is to meet
his father. He is curious about his father. So without thinking about the consequences,
almost in a driven way, Terry impulsively takes this boy off to meet his father, which is a
horrible idea, of course. But he‘s not concerned about how horrible or good the idea;
he‘s only concerned that he is doing something that will make the boy feel good about
him -- that this is what the boy wants. He thinks he can get the boy‘s admiration and
pride by doing something that the boy wants. He doesn‘t think past that.

That‘s what I would call a narcissistic character structure. Everything is built around a
desperate effort to feel some sense of positive self esteem, which he can‘t get, and he
feels so badly about himself inside that anything that reflects negatively on him he acts
out in some angry, passive aggressive or directly aggressive way. That‘s a structure that I
see as built around what I call ―the inadequate self.‖ I call it ―inadequate self protective
object.‖ He feels inadequate, he‘s looking for objects that are protective. What does he
say at the end of the movie? When his sister says, ―What‘s going to happen to you?‖ he
says ―Nothing real bad because I know that whatever happens to me, wherever I am, I‘ve
got you caring for me.‖ That‘s what I mean by ―protective object.‖ She serves as the
kind of object that every narcissistic character disorder seeks: somebody who‘s always
there so he can always feel boosted by her. This gives him the sense of protectiveness.
So, that‘s how I see him, I don‘t see him as a borderline; I see him as somebody with a
severe narcissistic defect.

ALEXANDER: What about his treatment of his girlfriend? He walks out the door, he
says, ―I love you but I‘m leaving,‖ essentially.

SUMMERS: See that to me, that doesn‘t make a borderline or not. That kind of lack
of concern for others doesn‘t make him a borderline. If you apply borderline on that
basis, then you wind up applying it to a very wide range of people.

Many of the people I see, not all certainly, but many of them have very little ability to
respond to another person‘s subjectivity. They regard other people, primarily, as either

30
objects of gratification or frustration for them, and this is pretty much the way Terry
regards people, what Kulick called, ―an archaic self object.‖ She‘s there for him.

We know very little about her of course, but she‘s there for him when she‘s useful to him:
he wants to get money to take care of the abortion, but he really shows very little concern
for her. When he says ―I love you,‖ it‘s at her behest and nobody‘s convinced, including
her; she knows he doesn‘t love her. I don‘t think he has the capacity to love her, because
he can‘t experience her as a separate subjectivity. That‘s characteristic of a narcissistic
pathology; it doesn‘t make him borderline. If you call that borderline, then you include
all people with narcissistic defects as borderline and now it becomes a vague term that
doesn‘t have a specific meaning. It simply applies to people, anybody who exists at that
level; it doesn‘t distinguish between what‘s fundamentally a narcissistic defect, as it is in
him, versus an issue of a fragility of self that requires a merger, as it is with borderline
patients like the kind I write about in my chapter on fragile self-fused objects. Those
people are not like Terry. Those are people who seek and desperately try to form
relationships based on the other person‘s being a part of them, and when they‘re not, their
reactions tend to be to be paranoid or bereft-- complete abandonment.

ALEXANDER: Would you say the girlfriend based on, well, he leaves her she makes a
suicide attempt. Is that borderline behavior, would you say?

SUMMERS: She might be, she might be. But of course, we don‘t know enough
about her. All we know is that she knows that he doesn‘t love her and he‘s going away
for a couple of days, he says, and then she tries to make a suicide attempt. So, it could
be. We just don‘t have enough evidence. She might be the kind of person who has to
have somebody there for her all the time in a fused way, and when there‘s a disruption
she feels so bereft she tries to kill herself, so it could be. We just don‘t know enough
about her. I don‘t think there‘s enough evidence to say that but it‘s certainly possible.

ALEXANDER: Let‘s talk about fragile self-fused object. This is the essence of your
model, I think.

SUMMERS: Right.

ALEXANDER: And I‘d like to talk about how you understand that and how, then, we
understand the change process for the borderline personality

SUMMERS: You‘re right, that is the essence of my concept of borderline pathology:

these are people who have suffered an early arrest in self development, such that they can
only really feel a sense of who they are with an object which is not regarded as separate
from them, but is a part of them, with whom they merge. The other person is supposed to
operate according to their behest; there‘s no separation of self and object. And of course,
that can‘t really work. There are very few people who are going to cooperate with that.

Consequently, they‘re continually confronted with the separateness of the other, and it‘s
that reaction to the other‘s separateness that gives me, anyway, in my model, the

31
diagnosis of borderline. That‘s when you get to see what the underlying pathology is
about because it‘s not a reaction of feeling one‘s self esteem injured, as I think is what
was going on with Terry, but rather a sense of not having a self, of being lost, having no
bearings, no way to guide themselves, no moorings in the world, a loss of who I am,
feeling completely abandoned and alone.

That‘s why with the borderline, you get so much paranoid ideation because the only way
the patient can understand the other separating them, is, ―You must be trying to hurt me.‖
What the patient feels the need for is the other to be there and meet all kinds of needs of
theirs. There is no sense of ―Well, is this realistic? Could somebody else really do this
for me?‖ That doesn‘t exist in the world of the borderline. It‘s an expectation. It‘s not a
wish, ―I wish it would do this for me.‖

My borderline patients expect me to drive them places, take them places, give them
money, be there for them whenever they want. They‘ll miss a session without calling if
they simply have something that‘s better for them, that‘s more gratifying for the moment.
Then, when they feel the need, they will call me and want a session right then, and get
enraged at me when I don‘t provide it.

Now, this is not feeling insulted. This is, again, as it was with Terry, this is about a sense
of, ―If you‘re not there for me whenever I need you, then you‘re separate from me.‖ And
that‘s what they can‘t tolerate. So, the only way they can understand that is, ―You must
be trying to hurt me. The only reason you could do this is you want to injure me.‖

The idea that you have your own separate life, your own subjectivity, in contemporary
parlance, is not part of their experience. They‘re not at that level where they have ever
recognized that the other person has a subjectivity of their own that they have to adapt to,
and not only adapt to, but appreciate and experience. That doesn‘t exist. What exists for
them is a fragile sense of self that can only feel completed by the other being there
whenever they feel the need for it, so that the other operates like a limb that‘s part of their
body, a psychological limb, if you like.

Now, why this occurs, what the origins of it are, I don‘t think we could say we really
know. We can certainly speculate that this has to do with a very early disruption in their
connection with their parenting figures, and they operate very much like the children in
the Bowlby studies, in the attachment studies, who have what they call ―the anxious,
insecure attachment,‖ where they never really feel attached to the mother, as opposed to
the children who have ―the secure attachment,‖ and the ones who have the attachment but
that it‘s always problematic. These are the kids who are always highly, highly anxious,
who can never let the mother out of their sight because they never feel that connection.
That‘s the way borderlines act. So, we can certainly speculate that these are the kids who
have never had what Bowlby calls ―a secure attachment.‖ They‘ve never had a secure
base. That‘s the way the act. They spend their lives searching for that.

And of course, that‘s what they expect of the therapist. Again, it‘s an expectation, it‘s a
demand. It isn‘t a wish. It isn‘t like ―Yes, that would be great if you could do it, but I

32
know you can‘t.‖ There is no, ―No you can‘t.‖ There‘s no distinction between wish and
expectation. If they wish it, they expect you to meet it.

That is how they‘re different from other patients. If you don‘t do it, they‘re completely
disrupted and they interpret you, of course, as intending to injure them, and that‘s where
you get the paranoia.

Now we come to the issue -- of course, a very tricky issue that you raise -- as to how does
one treat such a person? What kind of transformational possibilities exist?

Such people really can be treated if we are willing to give ourselves over to the kind of
relationship that they need, as much as we humanly can within the context of our
psychotherapeutic role.

I emphasize that part of it because what I‘m saying can be misunderstood as ―You‘re
supposed to be completely selfless and try to give them the relationship that they missed
in childhood.‖ Of course, that is simply not possible. We cannot reverse history, we
cannot be their mother, but we can adapt ourselves to the meeting of at least some of their
needs in some of the ways they want. We can never completely do it, we can‘t be
omnipotent. We can‘t reverse history. The patient is always going to be rubbing up
against the reality of our limitations. But if we are able to adapt ourselves enough to be
available enough to the person, they get something out of that relationship. They get a
sense of connectedness that they can‘t get anywhere else. And it‘s out of that sense of
connectedness that the transformational possibilities arise.

ALEXANDER: It‘s a big ―if,‖ because the reason that the borderline has such a
pejorative meaning is because these are patients that are so intensely difficult for
therapists to cope with and to deal with because what about your own personal limits?
How do you accommodate to them and still maintain your own true self?

SUMMERS: Yes, well this is, of course, one of the key issues in treating the
borderline patient. And you‘re absolutely right that the reason ―borderline‖ has a
pejorative connotation, which I hate and which is why I don‘t really use the term, is
because they‘re so difficult. The fact that they‘re difficult is a reality. They‘re very
difficult for me. They‘re difficult for every therapist I know. There‘s nothing wrong
with acknowledging that such patients are difficult.

What I have a real problem with is labeling the patients, ―Borderline,‖ when what I mean
is, ―They‘re very difficult for me; they create a lot of strain for me.‖ So, I tend to go with
―fragile self-fused object‖ to get away from that kind of pejorative labeling of the patient.

Now, to get to your question, the limitations of who we are as people is a reality that the
borderline patient has the most difficulty with. If we could somehow be completely
selfless and give ourselves completely over to the patient, presumably the patient would
not have conflict with us, because we would meet every need in exactly the way that they
want. But, the patient really doesn‘t require that if we can meet those needs in some way,

33
but you‘ve got to meet it in some way, and there is the certain element of self-sacrifice
that I think is imperative to the treatment of such patients. I think every therapist has to
address that within themselves: ―Am I willing to give the kind of sacrifice that this
patient needs to treat them successfully?‖ The answer may be yes, the answer may be no.

I have no problem with a therapist who says, ―I am unwilling to do what is required

here.‖ That‘s fine. What I have a problem with is someone who goes ahead with the idea
that, ―I will treat the patient,‖ but then is unwilling to make the self-sacrifice that is
required. You‘ve got to go into it knowing that it‘s going to take a great deal of self-
sacrifice and be willing to do that, because then if you don‘t, that‘s where you really get
into trouble. This is where therapists wind up blaming the patients, kicking them out of
treatment.

Most of the borderline patients I‘ve seen, I have not been the first therapist, and the
reason is that in almost in every case, the therapist gets involved with the patient and then
can‘t tolerate what‘s required, can‘t tolerate the patient‘s demands. That‘s where they get
rid of them, and things actually get much worse, because now the patients has to deal
with, basically, being rejected by their therapist. That‘s what it amounts to. That‘s when
the therapist starts saying, ―hospitalization,‖ ―go to another therapist,‖ the patient then is
rejected and then they are worse than they were before.

So, it does require a great deal of sacrifice. You‘re not going to be able to be your true
self, but, you have to know your limitations. You have to know what you‘re willing to do
and what you‘re not willing to do. I have, with many borderline patients, been willing to
take phone calls at home, but I also have my own life. I don‘t want my family life to be
completely consumed with the patient, which they would very much like to do. So, I
may take a phone call every night, but I may limit it to ten minutes or fifteen minutes,
because that‘s the limit of what I‘m going to do, and I let the patient know that. So, every
night they may call me, and every night I may talk to them for ten or fifteen minutes.

You would be amazed at the difference it makes if you are willing to adapt to the patient,
number one. Number two, you know what your limitations are, and you‘re clear with the
patient about your limitations. That makes a big difference if you say, ―No, I am unable
to do that,‖ versus saying, ―No, that‘s inappropriate.‖ It‘s completely different. I don‘t
think therapists tend to get into trouble with patients when they say, ―No, I can‘t do that,
I‘m unwilling to do that.‖ You get into trouble with patients when the patient puts some
strain on you that you can‘t handle, and you blame the patient for that, where you say,
―That‘s inappropriate.‖

There‘s nothing inappropriate about my patient wanting to call me and talk to me and
keep me on the phone all night. There‘s nothing inappropriate about the patient wanting
me to be with them 24/7. That is what they feel the need for. That is the kind of
relationship that they really do need. That doesn‘t mean that I have to meet it. The
distinction is between the validity of their need and my ability to meet it, and as long as
I‘m clear to them that I‘m unable to do that, you would be amazed at how well the

34
borderline patient takes that, because they know that that‘s a real limitation of mine. I‘m
expressing who I am to them. I am not hiding behind something else.
They also know that I am willing to make certain sacrifices for them, that there are
certain things I‘m willing to do.

In one of my more dramatic examples of this, I had this one patient, whom I wrote about
in my book, who, like all borderline patients, was extremely demanding in conventional
terms. She basically wanted to have an infant/mother relationship with me, and as things
developed -- I can‘t go into details in this context but it‘s in the chapter -- but as things
developed, as her relationship with me evolved, she became more and more regressed, in
conventional terms. She brought in an afghan. She brought her chair close to mine. She
would sit and sleep, she would curl up, she would bring in cake that she baked for us to
share. She needed to be nurtured, and I was willing to do all of that. It didn‘t violate any
sense of myself to adjust myself to doing this, to allow her to form the kind of
relationship she needed. But, at a certain point, she then asked me to hug her, and that I
was unwilling to do. I draw the line at physical contact. Now, maybe some therapists
would do that. I do not do that. And so, I told her that no, I am willing to ―hold her,‖ and
I‘ve been ―holding her,‖ but not in that way, and that I feared for my own sanity if I
would do that. That would be something that I didn‘t feel like I could handle, and I told
her that. She did not fall apart in response to that. She appreciated the honesty of it, and
we were able to find ways for her to be nurtured and held in the way that she could, and
that I could. That‘s really what it‘s all about.

So, the therapist‘s limitations are who the therapist is, and often I think it‘s the deepest
expression of our own subjectivity. That‘s not a problem; it abets the treatment a great
deal. The reason it abets the treatment is because when I said to this patient, ―No, I am
unwilling to do that; I fear for my own sanity,‖ she was rubbing up against my own
subjectivity. This was the first experience she had of me as a separate person.

That‘s ultimately what the patient has to learn to handle, that other people have
subjectivities of their own. Not, just handle it, not just adjust to it and tolerate it as a
necessary evil, but ultimately to appreciate it, and to appreciate that that‘s what a
relationship is all about. It‘s not all about sameness, it‘s about appreciating difference.

I‘m making a couple of points here. When people talk about setting limits, I don‘t
believe in setting limits in some artificially imposed way as though there‘s some rule out
there. There isn‘t any rule out there. The limits are the limits of the therapist as a person.
Number one, that‘s real, it‘s not artificial, that means the therapist is not hiding behind it
even. Number two, it‘s beneficial to the patient because then they experience the
limitations as a new level of relating, as something that‘s therapeutically, ultimately, very
useful to them. It doesn‘t help them at all to say, ―No, that‘s not what therapy is, that‘s
inappropriate,‖ because the therapist is hiding and the patient knows the therapist is
hiding, and it doesn‘t help them enter the world of interpersonal reality. It‘s a protection
against it.

35
So, I‘m making the point that boundaries have to do with the therapist‘s subjectivity, and
we all have different things we tolerate better than others. Number two, I‘m making the
point that the expression of those boundaries, as owned by the therapist as their own
subjectivity, has tremendous therapeutic potential for the patient in introducing them to
the world of inter- subjectivity. But it will only work if the therapist has made clear,
meaningful, and well-intended adaptations to the patient‘s needs. You can‘t just in the
first day, or first week, or first month say, ―Now here are the rules: you can‘t do this, you
can‘t do that.‖ That doesn‘t mean anything to the person, okay? That‘s only rejecting.
That only tells them you don‘t want any part of them, you don‘t want them inside you.
Those kinds of expressions of subjectivity only work after the patient feels the kind of
connection with you that they need. Then they can handle those things.

ALEXANDER: Even in the very first session, the patient has to know this session is
going to last, we will meet X number of times, and we will meet for forty-five minutes, or
fifty minutes, or sixty, or whatever, and there is a fee.

SUMMERS: Right

ALEXANDER: Now, maybe if you‘re in an agency, that fee is set up ahead of time in
the business office, and the length of sessions is set up, but if not, if you‘re not in a
setting where somebody else does that for you, you still have to do that and right there,
aren‘t you saying, ―There are limits and there are boundaries?‖ And the reality is, ―You
have to pay.‖

SUMMERS: Right, but those types of realistic concerns, of course, are set up right
away. What I was talking about, maybe I didn‘t make it clear enough, what I‘m talking
about is that you can‘t start early on with the person, before you‘ve really formed a
connection, to say, ―No I‘m not going do this for you, I‘m not going do that for you.‖
The realistic boundaries of the situation, which are fairly minimal, but very realistic and
often very difficult for the borderline patient, are there from the beginning. They have to
be acknowledged from the beginning: there is a certain length of time to the session;
there is a certain fee, how the fee has to be paid. Borderline patients often have a great
deal of difficulty with that.

I, anyway, feel like I want to keep those to a minimum and I want to make them clear
right from the beginning, because all therapy whether it‘s with a borderline or anybody
else, is based on what I call, ―transitional space.‖ Transitional space means two things: it
means it has a boundary, it has a defined limit to it; and, within those limits, it is open. It
is open for the patient to use as they need, in the same way that the child uses a
transitional object. They use it in their own way. They give it their own meaning, but
they still have to find the teddy bear, they have to find the blanket. It‘s a real object, but
it‘s treated as though it isn‘t.

Therapy is the same way. There are these real limitations, but the patient has to create
and will create their own meaning from it. So, those kinds of boundaries have to be made
clear from the beginning, and often with a borderline patient, they feel that is insufficient.

36
Usually, that kind of insufficiency isn‘t something they feel from the first session; that‘s
something that evolves as they begin to feel affectively connected with you. Then that‘s
where you get the demands to continue on.

Like the patient I just mentioned, the session would end, and then she would say, she‘s
not leaving. She was not going to leave, she was going to stay. At that point, the forty-
five minutes becomes an issue. The first session of course, I told her how long the
sessions would be, payment, and those kinds of things. That wasn‘t an issue that seemed
fine to her, right. But when the relationship evolved to the point that the underlying need
for a fused relationship came out, then forty-five minutes meant nothing. That was just
an imposition of a hostile reality that she couldn‘t deal with. So...

ALEXANDER: How did you deal with that?

SUMMERS: Usually, the patient isn‘t going to respond to that in the first session,
they‘re going respond to it when the underlying needs, the kind of relationship they want,
begin to evolve.

ALEXANDER: So, how did you deal with it?

SUMMERS: At that point?

ALEXANDER: Yes.

SUMMERS: Well, at that point, I told her that she had to leave. She kept saying,
―I‘m not leaving.‖ I‘d say, ―I feel I‘m being put in a very difficult spot here, because I‘m
afraid if I tell you to leave, that you‘ll feel rejected. I‘m afraid in some unconscious way,
you might be setting me up to say that to you, so that you‘ll feel rejected by me, and I
certainly don‘t want to reject you, but on the other hand, I have somebody else waiting
out there, and I can‘t let you interfere with their needs.‖ ―I‘m not leaving,‖ is what she
says. So, finally it gets to the point of the patient‘s absolutely refusing to leave, and I
insist that they have to leave, and they say they‘re not going to, what I finally said to her
is, ―I‘m going to have to call the police; you‘re leaving me no choice,‖ at which point,
she bolts out of the room. But, I felt like I had no choice at that point.

So, you have some leverage there because it was clear from the first session that it was
going to be forty-five minutes; it always has been. But, very little leverage with the
borderline patient, because that doesn‘t really mean too much to them. All she knew at
that point is that she needed me to be there with her, and anything else is just a hostile
interference. What she was doing, of course, was setting me up to be the paranoid object
who‘s only rejecting of her, which is what she fully expects and she will arrange, because
by arranging that, and getting me to reject her, then there‘s a distance and then that
relieves the anxiety of being too close with the merger connection. That‘s the only way
they know how to separate, through some sort of hostile attraction. Either the patient has
to be hostile, or I have to be hostile. So, when she comes back for the next session, that‘s
what I talk to her about: ―You get scared by being so close, and you don‘t know how to

37
separate except either to make me bad and get you enraged at me, or make me bad in a
way where I have to reject you, in which case you get enraged at me.‖ So, either way,
she does.

ALEXANDER: Do you think that you can have more than one or two patients like this?

SUMMERS: Well that‘s a very, very good question. This is something I‘ve learned
by the school of hard knocks. When I was young and naive and less experienced, I
basically took in whoever came across my door. Whoever knocked on my door could
come in, and you know it was a first come, first served basis. But, I learned through
experiences like the one I just described and the availability that‘s required for a
borderline patient, that I would have no life if I saw -- like at one point I actually had, if
you can believe it, six borderline patients simultaneously. I knew then that I wasn‘t
going to kick anybody out, but I was also going to have to limit the number of borderline
patients I saw at a time.

Now, how many you can see depends on your own tolerance level. The experience that
I‘ve had tells me that depending on how much each person needs, how many phone calls
they need, how much work there is outside of the session, I can have two or three at a
time and that‘s it. I will not have more than three borderline patients, and I have in fact,
had people come, who clearly would need the kind of treatment that I‘m describing here
and I have said ―No, I can‘t do it‖ and I explain to them why. I‘d say that I am not able at
this point to give you what you need, and I think it‘s very important that they understand
that it‘s my limitation that I can not do that. It‘s not that what they need is inappropriate
or wrong, it‘s that my practice is in such a state that I can‘t do that. If I have three
borderline patients, I‘m not going to take another one. I‘ve learned that from the school
of hard knocks.

ALEXANDER: The sixty-four thousand dollar question is how do you know at the
beginning so you can protect yourself?

SUMMERS: Well, yes, and that it‘s not obviously a very easy thing to determine, but
the criteria I use go back to my definition of what the borderline personality is. Why are
they so difficult? Why do they drain so many resources? It‘s because they form these
fused attachments. If they attach at all, they tend to form this fusion in which self and
object tend to merge and that‘s why they drain so many resources. Then, the recognition
of me as a therapist as a separate person is not only unacceptable, but extremely
threatening. It threatens such sense of self as they have.

What I try to do early on is get a sense of people‘s history of interpersonal relationships.

Well, I won‘t pretend that there‘s a quick, easy way to do it.
The best criteria that I have is the history of their relationships. If I get a history of either
non-attachment or this kind of intensive attachment where they have great difficulty
getting out of things that are clearly not working for them but they seem to be drawn by
forces they can‘t control to sustain things that clearly are destructive, defective and are
clearly not working, then you begin to get a sense of somebody who tends to form fusion

38
in relationships. Once you really fuse in a relationship, you really can‘t get out of it. No
matter how bad you might know it is for you, to get out of it is too threatening.

So, that‘s my basic criteria. I don‘t go into a lot of complicated assessments of ego
functioning and defenses because a lot of those things you‘ll see in people with a variety
of different kinds of character disorders. I stick with my decisive criterion of what makes
somebody a borderline or not, what I call the ―pathic/demonic criterion,‖ which is a
tendency to fuse in close relationships. So, if you make affective contact, you fuse or you
don‘t make affective contact at all. And by the history of those relationships, by what‘s
going on with them in that way, I try to get a sense of whether I think this person is a
borderline personality or not.

Often, I can tell even in the beginning by the way they attach to me. I mean, I‘ve had
patients where after the first session, they‘re calling me and clearly beginning to form this
intensity of attachment after one session. Well then, it becomes pretty easy, I mean, it
becomes very clear right away that this is somebody who is what I would call a
borderline,‖ which is that they immediately, if they make affective contact, they tend to
lose that sense of self and I become a part of them. And so that‘s what I look for.

ALEXANDER: Is there anything in the presenting problem that might give you a clue?

SUMMERS: No, because, well, it might give you a clue. Yes, it might give you a
clue is right, but, nothing in the presenting problem that would be a decisive indicator.
The presenting problem could be a drinking problem, could be drugs, could be
depression, could be difficulty in relationships, and that would be true of somebody who
could be a borderline personality, it could be a variety of other kinds of character logical
patterns: narcissistic personalities; passive aggressive personalities; dependent, infantile
personalities. None of those things make for the decisive criteria.

But they do give a clue. Any of those things I mentioned can be a manifestation of a
borderline personality structure. Substance abuse, for example, can be an indication of
such a structure because the substance forms the substitute for the relationship that‘s
missing. It‘s in the ―being high‖ that the patient gets a sense of fusion, but it‘s also true
that a lot of other people have substance abuse problems where the substances perform
other functions, such as drowning out painful affects, where it‘s not an underlying
borderline personality structure. So, yes, many symptoms can give clues, but no
symptom will be decisive.

ALEXANDER: Well, now let‘s go to the other end, which is termination. How do you
know when the person is better, or is ready to stop?

SUMMERS: Well.

ALEXANDER: If ever?

39
SUMMERS: First of all, with a borderline personality, often the most difficult issue
is termination, because of the nature of the disorder. The nature of the attachment is such
that, of course, what the patient most fears is abandonment, the ending of the relationship.
Consequently, often, and this is very common with borderline personalities, they‘re afraid
of getting better. It‘s one of the greatest threats they can face. Why? ―Because, if I get
better then therapy is over, and you‘re going to tell me it‘s over, right? And that‘s the
end.‖ So, since that‘s always the anxiety, I always find that the worst thing I can do is to
recommend that, ―Oh, maybe we‘re at a point now where we can think of cutting down,‖
because what it does is it confirms the worst fears they‘ve had all along, which is that as
soon as they get better, you‘ll leave them.

This is why borderline personalities are often so addicted to misery, because in the
misery, they feel that you‘ll continue to stay connected with them. But, as soon as there
is any sense of happiness in their life, they become immediately afraid of the separation.
That‘s what happiness means actually to them: it means separation, it means loss.

The last thing you want to do is to make a suggestion like that, so, I never offer that. My
feeling always with the borderline is that I‘m there, and I‘m willing to be there for as long
as they need me, and they let me know when they feel they can begin to separate. They
don‘t do that by suggesting the ending of the relationship; they do it by the lessening of
the attachment. They begin to do other things in their lives and form other connections,
other relationships. Other things become meaningful, and the therapeutic relationship
becomes relatively less meaningful. Then, they usually begin to cut down frequency of
sessions, and they begin to talk about things that are more like, let‘s say, what more
neurotic or higher level patients tend to talk about. So, it‘s the importance of the
relationship that diminishes as they get better, and they will naturally, on their own, get to
a point where they say, ―Ah, you know I think maybe we can start thinking about I don‘t
really need to be here so much.‖ But, by then, they‘ve formed other relationships; they
have other things in their lives. So, really, you can tell that when the intensity of the
relationship is reduced.

But, that doesn‘t mean that -- I don‘t think I‘ve ever had a borderline patient where I
have suggested that we think about the ending. They will bring it up quite because they
don‘t need the relationship as much; it becomes a natural part of the evolution of the
getting better. You can not separate the termination phase from the treatment with a
borderline patient. You can with many other patients, but with the borderline patient, it‘s
the nature of the attachment that‘s been the issue all along. So, the giving up of the
attachment is the most difficult thing that they do. They have to be able to do it
themselves at their own pace, which comes naturally from the reduced intensity, which
comes from getting better, the growth of the self, and the forming attachment to other
things in their lives.

ALEXANDER: What if they form other fused relationships? Could that happen?

SUMMERS: Well, it could, and of course, often does, and then you‘re just really in
the middle of the same work with them. If they form other fused relationships, then,

40
obviously, they haven‘t resolved the one with you, and it‘s still very much the same kind
of thing. You continue to operate with them as you always have, where you maintain the
availability for their fused attachment with you.

Usually, if they form other fused attachments, it means that they don‘t feel the full depth
that they need. There‘s some sense of needing to defend against the intensity of the
relationship with the therapist, because they don‘t totally trust it, it‘s not safe enough. So,
you would address it that way. You‘re in the middle of the therapeutic process then.
When the therapeutic relationship really takes hold, and they feel the sense of fusion, that
they have a piece of themselves invested in you, then the relationships they form with
other people will not have that sense of fusion because, they don‘t need it. They don‘t
need it elsewhere. So, the other relationships they form tend to have less investment,
which is good, because you don‘t want them to fuse with other people, you want them to
have an investment with another person as a person.

I guess what I‘m saying is if that happens, I look at is as there‘s something that‘s not
getting met in the therapeutic relationship, and usually it‘s they‘re afraid to fully invest in
it because it‘s so terribly threatening and frightening because it puts all their eggs in that
one basket. That‘s what they are so afraid to do, but that‘s what they have to do, and you
just keep working with that.

But, I would like to say more about the therapeutic action with borderlines because I‘ve
said some things about it, but I don‘t know that I really gotten quite to the core of it. I
think I‘ve sort of left it at the point of saying that the patient needs an adaptation, which
they do and they need the experience of the limitations of that, which they do. Then I
think what happens is this: with every borderline patient I‘ve ever treated, and some
were more hostile and negative and paranoid than others and some were more on the
merger side than others, but with all of them, there was a constant inability to tolerate the
relationship on either side. If they feel close that threatens the sense of self, if they push
away, they feel abandoned and bereft, or attacked, you know, one or the other. It‘s either
you‘re trying to kill me, or you‘ve abandoned me and left me alone to die.

I think where the therapeutic action lies, more than anything else, is in the therapist‘s
ability to process that oscillation. This is what drives every therapist, myself included, so
nuts in treating such patients. It‘s that you feel like you can‘t win. Whatever you do is
wrong. But, then I think what you have to realize is that this tightrope you‘re on, where
you‘re always falling off on one side or the other, that‘s the tightrope on which the
patients lives. You are, in a sense, empathically resonating with the very structure of the
patient‘s pathology. This is what it‘s like to be the patient. Feeling like you could never
win is exactly how they feel. Nothing is ever good enough, nothing is ever right. You
have to continually process that so that the transformational possibilities rely as much on
the processing of the therapist‘s countertransference as in anything else.

I mean, there is always countertransference. We have to deal with it with every patient.
But, the importance of it, the crucial nature of it, I think, is something that is specific for
the treatment of the borderlines. More than any other patient, countertransference is the

41
central issue. Because of the intensity of the connection they need and their inability to
handle that intensity, you inevitably feel both sides of it. So, you have to continually
process your own experience and realize that when you feel connected, that‘s so
threatening that the patient is going to have to push it away. When they feel as it‘s all
over and they‘re bereaved, it‘s not working and so on, that‘s their way of creating their
needed distance, and you have to say that to the patient at certain points.

But, even more important than saying it is knowing that, and knowing that you are there
and you will continually be there throughout the vascillation. So, when a patient assaults
you with these paranoid attacks, ―You‘re trying to kill me, you hate me,‖ etc. etc, the
important thing there is to continually be there. It‘s an emotional availability.

What I tell a patient is, ―Of course, you think I‘m trying to kill you. You can‘t
understand why I wouldn‘t meet this need unless I was trying to damage you. That‘s the
only way it makes any sense to you‖. Of course, the borderline will say, ―Yes, exactly!
So why the hell are you doing it? Why don‘t you meet it?‖ That‘s where you‘ve got to
say, ―I think this is the kind of relationship you need, but I‘m not always able to do it in
that way. Here‘s another way I can do it.‖

But, what I‘m trying to emphasize is this: more important than the words, the content of
what you say, is your willingness to be continually emotionally available, to continually
form that relationship, that you are forming and maintaining and sustaining the
relationship, even when the patient feels it‘s over. That‘s what it depends on. If the
mother has a screaming baby in her arms, to throw it away retraumatizes the baby, even
to the point of permanent damage. But what a good mother does is she holds the baby,
rocks the baby, and soothes the baby until the baby calms down. The mother sustains the
relationship, and it‘s the same way with the borderline. The therapist has to sustain the
relationship.

I think many of the psychotherapies of borderline patients fall to ruin at the point at
which the patient may well be saying, ―This is over, this is worthless, you only hate me
etc. etc.‖ The therapist thinks, ―You know, I‘ve been trying and trying. The patient
thinks I hate them and they‘re not getting any better. We better go to hospitalization or
medication or send them to somewhere else.‖ That‘s where is gets ruined. The therapist
doesn‘t see that that whole experience is exactly what the process is about. It doesn‘t
mean that the therapy is over. In a sense, it means the therapy is working, because it‘s
exactly what has to happen. The patient has to know that your emotional availability is
there, no matter how much they hate you. You have to survive the hatred.

Of course, this is a Winnecottian concept, that the only way the person can ever realize
that you are a separate person is if you survive their hatred. They will destroy you, over
and over and over, and you have to come back and survive it. That‘s what Winnecott
pointed out happens with the baby. When the mother survives the baby‘s hatred, the
child becomes aware, ―Oh, this person exists outside of my control.‖ So, by your
continued availability, your survival of the aggression and the hatred, the patient becomes
aware that you are, number one, there for them, that you can survive it, and number two,

42
that you are a separate person. So, it has tremendous therapeutic benefit in terms of
helping them achieve a new level of intersubjectivity. So, I think it‘s based more on that,
more on the continued availability despite the ups and downs of the relationship and the
patient‘s hatred and distancing as on anything else.

The thing I think is most important, and I try to tell therapists when I supervise them with
borderlines is, ―Don‘t take the patient‘s bait. Don‘t go along with, ‗Yes maybe we‘ll get
you another therapist, you‘re unhappy here.‘‖ It‘s your continued emotional availability
upon which therapeutic action rests.

ALEXANDER: Dr. Summers, reality rears its head.

SUMMERS: The limitations of reality

ALEXANDER: The limitations of reality. Again, a remarkable interview.

SUMMERS: Well, thank you so much. I enjoyed doing it very much. I appreciate
your asking me to do this. Obviously I love to talk about this kind of topic. I wish we
had more time; I have a lot more I could say, but I think I did get across some of the basic
points.

This concludes our interview with Frank Summers. To order Dr. Summer‘s book,
Transcending the Self: an Object Relations Model of Psychoanalytic Therapy, contact
the Analytic Press www.analyticpress.com.

I must say here that the opinions expressed by our speakers are theirs alone, and do not
necessarily reflect the opinion of On Good Authority.

Until next time, this is Barbara Alexander, thank you for listening.

43
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview 4: “BORDERLINE MARRIAGES”

CHARLES McCORMACK, MSW

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Charles McCormack, MSW

6525 N. Charles Street, #239
Towson, MD 21204
410.938.8499
[email protected]

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You will be reading or

listening to Interview 4 of ON GOOD AUTHORITY‘s program about ―The Borderline
Personality Disorder (BPD).‖

In this interview, we will be exploring treatment of Borderline couples from the object
relations perspective. Anyone doing marital therapy knows that there are couples, and
there are couples! The normal/neurotic couple rapidly incorporates the therapist‘s
suggestions and help with communication and conflict resolution issues. On the other
hand, the personality-disordered marriage seems impervious to change and in fact, seems
to get worse in treatment.

In work with individuals having BPD, the therapeutic goal is not insight per se, but also
the facilitation of new relationships. This also holds true with couples. Through the
relationship with the therapist, the couple is helped to relinquish pathological relational
patterns and replace them with others based on the patient‘s authentic experience.

In Charles McCormack‘s book, wonderfully titled Treating Borderline States in

Marriage: Dealing with Ruthless Aggression, Severe Resistance and Oppositionalism, he
describes marriage as containing both the dream and the nightmare of the couple‘s way of
being in a relationship. The couple presents a tangle which all three – couple plus
therapist -- in the room must work to sort out.

44
Charles McCormack, MSW, BCD, is on the teaching and supervisory faculty of
Sheppard-Pratt Hospital in Baltimore, and is a guest faculty member of the Washington
School of Psychiatry‘s Psychoanalytic Object Relations Family and Couples Therapy
Training Program. He has presented numerous papers and workshops in the United
States and Canada on the treatment of ―difficult to treat‖ individuals, couples, and
families. In 1994, Mr. McCormack was named Clinician of the Year by the Maryland
Society of Clinical Social Workers. He currently supervises and maintains a private
practice in Baltimore.

In this interview, Mr. McCormack refers to the movie, ―You Can Count on Me.‖

ALEXANDER: Mr. McCormick, the title of your book, with its subtitle I
love, which is ―Dealing with Dealing with Ruthless Aggression, Severe Resistance and
Oppositionalism,‖ just spoke right to my heart about marriages and couples that I have
worked with over the years, and your book comes very close to answering the eternal
mystery about why some couples stay together. So, what I would like to start with is your
definition of the personality disordered marriage, especially the borderline marriage.

McCORMACK: The keystone to the personality disordered marriage is really

the borderline state and that is something none of us are immune from it; we can all
experience it. It is like we were having temper tantrums at home with our kids or yelling
at our spouse or that kind of thing. It is basically marked by the goal of selling an agenda
rather than in service in understanding anything. Whereas normal neurotics can regress
to borderline states, personality disordered individuals, because of their developmental
deficits, actually dwell there.

Personality disordered relationships are marked by one or both spouses dwelling in the
borderline state. This is similar to Melanie Klein‘s notion about the paranoid schizoid
position. What that entails is that people in the pre-oedipal condition don‘t relate to
others as separate cells with legitimate needs of their own, but more as what Stolorow
called ―a primitive self object‖ or what Bailant called ―a primary object,‖ the function of
which is to maintain or re-cohere the sense of self. So each spouse will relate to the
other in the ―usage‖ fashion, rather than an actual relationship fashion.

For example, I had one patient -- this was a couple that actually didn‘t work out well in
terms of the couple staying together, but it worked out well actually in terms of their
leading to separation -- and in that, the wife would repeatedly wake the husband up at 3
or 4 a.m. in the morning because she was anxious and wanted to be held. This was
alright for once or twice, but she would do this night after night after night and would not
let go of that until he would give in He would accede to her wish to be held and the
holding could go on for 30 minutes to two or three hours. Even though he would sit here
in the office and tell her how enraged he was about that, she couldn‘t hear that at all. She
just kept telling him that he didn‘t really know how he felt, that he really loved her and
that when he was holding her, that is what he was communicating to her. So her whole
focus was on using him to hold her and maintain or re-cohere or help her deal with her

45
sense of anxiety, rather than any recognition of what impact that might have on him. In
other words, she lacked a capacity for empathy. So, that is a more primitive, personality
disordered relationship and that is how the people use each other for that function rather
than being more separate and autonomous in relationship to another person who is
relatively separate and autonomous.

ALEXANDER: In that example you gave, what would have kept that man in the
marriage up to that point. Had they been married a long time?

McCORMACK: They had been married for a while and dated or lived together
for a long time before that, but he also came from an extremely abusive background in
which he was perceived and delineated by his family as selfish and he really held for a
long time, that view of himself. So, that if should pursue a need or a wish of his own,
that would tap into this profound feeling that he was being selfish and he would have to
give himself up to the other to not be selfish, to be a good person, to feel that about
himself, that he was good. You see, his pathology in a sense really fit with her
pathology because she would confirm that for him if he didn‘t hold her and it also
maintained his known relationship in the world, which although very toxic and
unpleasant, is still his organization of self, his sense of identify, his sense of who he is.

A lot of times a major resistance to change is that people don‘t know how to handle good
feelings. They are used to bad feelings and it is kind of like growing up in an aquarium
that has a certain level of acidity to it and even though that may burn the skin, it still is
the familiar and the familiar is equal to ―home,‖ as in ―familial‖ and people will stay
there because they know how that world works.

An example of that is I had one patient, a man who in driving to a birthday party that was
being held for him -- it was his 50th birthday party -- he started getting what he thought
was an anxiety attack and he thought he was having a heart attack and then he pulled off
to the side of the road and then he actually called me from the side of the road after he
had realized that what he was experiencing was ―happy‖ and he didn‘t know what happy
felt like and so it had frightened him in the beginning and then he made the call to me and
was laughing during the call to say that he had realized this is what was called ―happy.‖

ALEXANDER: That is a wonderful example. I love that.

McCORMACK: Just over and over again, these kinds of examples and human
experiences. It is just so poignant, that is what makes the work so rewarding.

ALEXANDER: That‘s what keeps us in it, right? Especially working with

people with borderline personality disorders.

McCORMACK: Yes. One of the great difficulties in working with personality

disordered people, as opposed to normal neurotics is that, personality disordered people
do not hesitate to attack the self of the therapist. So, whereas a normal neurotic may

46
question your credentials and want to know about them, for example, a personality
disordered person can actually attack your competence and call you a charlatan, curse
you, use obscene words towards you and tell you what a low-life you are.

One of the advantages of this -- it is kind of a paradoxical advantage is that it really

confronts the therapist with various aspects of his or own personality so that the therapist
either grows in relationship to themselves or they‘d better get out of the work with
personality disordered people, because those attacks keep on coming.

ALEXANDER: Yes they do. What about the movie (―You Can Count on Me‖)?
Did you think any of the relationships in the movie were borderline relationships?

McCORMACK: Yes, I did actually. I thought the movie was very good.
Sammy, for example, to me, reflected either a high level personality disordered
functioning, or low level normal neurotic functioning, and she would actually transition
between the two.

The reason that I say that is that one of the key characteristics of personality disordered
people is that they lack the capacity to abide with their own experience, to be with their
own experience in service of thinking about whatever thoughts, feelings, and sensations
they are having and in service of learning about what is going on in the moment -- that
they would feel a given way. I call it that ―they don‘t have an ‗I‘ to look at the
experience of the ‗Me.‘‖

Consequently, two things result from that: one is they can‘t learn from experience -- they
just repeat it. Second, since they don‘t have a very well developed capacity for thinking
through experience, the only way they have of dealing with experience is to discharge it,
and that is acting out.

Kernberg highlights four characteristics in the borderline state. The first is identify
diffusion. That refers to the blurring of boundaries between self and other: Who am I?
What is me? What is not me? That is all confused.

Second is the idiosyncratic interpretation of reality. This means that the person is
interpreting events in ways highly peculiar to them-- ways that it would not be shared by
most people of the same culture.

The third characteristic is that they are kind of devoted or entrenched in their own
internal world of, what I call, ―pathological object relationships.‖ That is basically
relationship to others as rejecting or exciting of need, but not fulfilling need.

Then fourth is the reliance of primitive defenses, but all of which distort reality and they
are based on splitting and denial.

Now, in Sammy‘s case, you see, she did a lot of acting out, but she also had curiosity
about herself. So, she would note, for example, ―God, what am I doing? This is crazy,‖

47
and she would make that comment. She was also able to maintain ongoing involvement
in a job. Her acting out also came, it seems to me if I recall correctly, right after the
rather boring stable boyfriend had proposed marriage to her and she went out
immediately and had this affair. So, there is the fear of intimacy and that kind of thing
really scaring her to death and resulting in her discharging the experience by hooking up
with this guy from work. But, she kept observing this within herself, though she didn‘t
really learn from it yet, but it was quite hopeful. As well, she had a great deal of empathy
and appropriate boundaries with her son. So, that showed nice functioning there as well.

Now her brother, Terry -- now Terry was a mess. See, he was a low level personality
disordered person, because all of those characteristics of the borderline state were
manifested in his functioning. He had a repeated confusion of boundaries with his
nephew in the movie. Sometimes he would relate to his nephew as a peer. Sometimes he
was a good father to the nephew, as in the pool hall scene when he lets his nephew take
the winning shot. And yet other times, he relates to his nephew as a betraying parental
figure, so that when he thinks the nephew was told a secret, he relates to him as if that is
an unforgivable sin and completely shuts him out of his life until he learns differently.
So, you can see, he even relates to the nephew sometimes as like a good father. There is
a scene in which he is in the boy‘s bedroom and he tells the boy, ―You know this used to
be my bedroom.‖ The boy, sensing his sadness says, ―Do you want it back?‖ You know,
it was almost like he was fathering Terry. Then, suddenly you have Terry taking the boy
to see his never-before-met biological father a totally inappropriate move on his part --
without exploring it with his sister and then ends up beating up the biological father and
being put in jail. My thought about it was that his nephew‘s biological father was
actually a stand-in for his parents, who died when he was very young and I imagine he
felt abandoned and rejected by them. So, he was beating up this boy‘s father as a stand-
in for his fury and rage at his own parents for being left.

The other thing is that he showed no interest or capacity for self-observation or self-
reflection and he never really took responsibility for anything he did. It was always
somebody else‘s fault, something else brought it on and that is kind of a major
characteristic of more primitive personality disordered functioning -- it is always
somebody else‘s fault. Never any ownership of responsibility for problems in a
relationship.

ALEXANDER: Why do you think that there is such an attraction between a

borderline person and a schizoid person? You know, they seem to go hat and glove
together; then why doesn‘t it work?

McCORMACK: The borderline with the schizoid combination – that‘s when the
borderline, who is more hysteric, up and down, all over the place, really tossed and
turned by the whims of their emotions from moment to moment -- let‘s just say the
borderline is a female, because that is what tends to be the diagnosis, but there are a lot of
male borderlines as well. She looks over at this schizoid guy who has the appearance of
being so stable. So, she relates to him as if he is the mooring and the stability and that
she can borrow from his stability. But at the same time, what soon becomes apparent is

48
that with this schizoid, she can also repeat something of her own history of trauma in
relationships in childhood in which she is unable to form a genuine connection or any
kind of connection with this guy because he‘s schizoid, he‘s aloof, he‘s unavailable. He
never talks about his feelings. He is very focused on reason and logic to the exclusion of
feeling and affect and so on, while, she‘s on the other end of the spectrum. She‘s all
feeling, but with not much capacity for thinking through or reasoning through her own
experience. So, what you have is any time you have feeling without thinking, that‘s just
as crazy as thinking without feeling. So, the two compliment each other, but they
actually never enter into a ―co-mingling‖ relationship -- each learning from the other, you
know, trying to relate to the other. So what they enter into is a ―co-mangling‖
relationship, where it is going to be ―whose relationship is it going to be?‖

Since it‘s a pre-oedipal condition, it is kind of like the child‘s relationship to mother. The
child around the 2-year old level is going to say, ―It‘s my way or not my way.‖ It‘s not
until there is the introduction of a ―third,‖ which is called in the psychoanalytic speak,
―thirdness‖ or ―threeness‖ that the child gets to understand that there is an alternative to
―my way or not my way.‖

If you think about it, a relationship is a ―third‖ because if you and I are in a relationship,
the relationship isn‘t in you, nor is it in me. It‘s a space that both connects and separates
us. So, it is a third entity that connects and separates us. Winnicott called that space ―the
potential space‖ and it allows for the co-mingling of the intrapsyche in external reality so
that you can live a personally and mutually enriching life in relationship to reality.

These folks do not feel that way and don‘t experience that, so what they feel is either it‘s
my way or not my way. I‘m either winning or I‘m losing. So, they‘re always in this co-
mangling relationship to reality in which the focus of the agenda is along an axis of
dominance and submission, as opposed to an access of affiliation and separateness. So,
that is why they get into these huge fights, each is trying to have it their own way and
neither is really interested in learning from the other -- All or nothing thinking, black and
white, and so forth.

ALEXANDER: So, your first example of the woman who wanted to be held in the
middle of the night, that would be...

McCORMACK: She just wanted it her way and that if he satisfies her need, in other
words, helps her to maintain or re-cohere her psychic equilibrium, her feeling okay, then
he‘s good. If he doesn‘t do that, then he‘s bad. She is not able to see that the need-
satisfying husband is the same as the need-frustrating husband. They are parts of every
person and of every relationship, but she is governed more by the experience of the
moment, where there is no history and no future. It‘s just the timelessness of the eternal
moment, and so if you‘re meeting my needs, you‘re good. As soon as you stop meeting
my needs, you‘re bad.

ALEXANDER: In your book, you talked about the how you came to your approach
to work with couples, and that you moved away from the structural and the strategic

49
methods of treatment and into the process-oriented methods and I further wanted to ask
you about what each of those methods consists of and why you found the method that
you talk about in your book -- why you found that so much more beneficial?

McCORMACK: Sure. Actually my formal training was in structural and strategic

family therapies and that I had hired trainers from the Philadelphia Child Guidance Clinic
to come to Shepherd Pratt Hospital where I was working and they did every other week
workshops, four hours a time, where we had a one-way vision room and so on and
brought patients in and live cases. It lasted about three years, that training. Also, we
arranged to have a University of Maryland supervisors -- AMFT-approved supervisors –
who were Strategically oriented come and do some training here for a year or so as well.

So, I really threw myself into that and for a while it was quite empowering, but what I
began to observe, and it wasn‘t only me -- there were like 10 people total in the group
over this period of time -- that after some initial what appeared to be progress, there
would be regress and that after each regress, the ability to make any progress was more
and more difficult to get back to where we had been before.

I actually talked to one of the trainers and he said, ―Well, you know, all of the research
done in structural family therapy had really been like in a six-month time frame, or three
month time frame, so they would end up with these kind of good results, but then the
longitudinal studies weren‘t there‖ and, in fact, in psychoanalytic training, there are a lot
of people from that school that have moved subsequently to psychoanalytic training.

What I found myself confronted with was that I had moved by that time. I had been in a
partial day hospital program and at that time I had moved to long-term inpatient and I
kept bringing the couples and families I was working with to the workshop for
supervision and consultation and training and the trainer started saying to me, ―Stop
bringing these cases. They‘re not good training cases.‖ Yet, this was the population that
I was working with.

So, I was also confronted with another question, in that a lot of structural and strategic
interventions, like a paradoxical intervention, for example, entail putting the patient in a
situation that they find extremely uncomfortable and something about that, you know, the
misery of that situation that results in a change.

But, what I was working with in the long term inpatient unit was people who were
willing to kill themselves. And, when I say long term inpatient, the average length of
stay was 90 days and the mean length of stay was anywhere from one year to five years,
so I really got a chance to work very closely over a 10 year period of time with people
with very, very major life threatening psychopathology. I became intrigued because it
was clear to me that this method wasn‘t working and wasn‘t useful. It was a
psychoanalytically oriented unit, so I was learning by listening. Then, I started going to
the medical library for several years and just in all my spare time reading books and I
ended up writing a paper that was called ―The Borderline/Schizoid Marriage‖ that was
put in the Journal of Marriage and Family Therapy and then invited to give a talk at the

50
Washington School of Psychiatry, and it was only then I realized that what I had written
about was called Object Relations Theory. I didn‘t know about it ahead of time.

ALEXANDER: In the couple with the sleep thing, how would they have been
treated in a Structural or Strategic way and then how would they have been worked with
in an Object Relations way?

McCORMACK: Well, I guess the thing that comes to my mind, and it has been
years since I‘ve used the Structural or Strategic approach, but in my mind, it might be
that I might ask the husband to hold the wife all night every night. So, that what I would
do is amplify the situation so that it became not only aversive to the husband, but
aversive to the wife and so rather than withholding or resisting what she would want, we
would give her more than what she wanted. So that that might then result in her finding
it an aversive experience, rather than a supportive experience.

Here‘s the theory behind the structural and strategic models: it‘s a behavioral theory,
which is that if there is anything such as an ―unconscious,‖ it‘s a black box. Since you
really can‘t know about it, what you do is if you can get the person‘s or the couple‘s
behavior to change, then the unconscious will follow. Again, my experience is you can
get the behaviors to change for a little while, but it doesn‘t stay changed.

Now, how to work with that in terms of a more insight- oriented or object relations model
is really trying to help each spouse look at from the wife‘s perspective, for example, why
was holding so important to her? How did people manage her anxiety in the past, you
know, like when she was younger? Did she have these experiences when younger and
how were they dealt with and what was the experience? Thereby you can start to
identify, basically in retrospective fashion, her family of origin relationship experiences
and why she was missing this internal capacity for self-soothing that she was trying to
get, again, not by developing the capacity for self-soothing, but by using her husband to
soothe her, regardless of what his own needs might be. So it is bringing this to
consciousness, not only intellectual or cognitive consciousness, but also emotional
consciousness, because I do not think that intellectual insight does anything really.
Change requires both cognition as well as the affective memories of those times that are
being played over and over again in the present.

Unfortunately, in this particular case that I have been quoting, this woman had absolutely
no interest in doing any of that kind of work. She was furious and let me know in her
first visit here -- she had had kind of a heap of therapists behind her in her wake -- that
I‘m a social worker, and she told me what pansies social workers are, and anytime I tried
to offer her an empathetic comment, she responded in this very attacking and aggressive
way. Finally, when she left therapy, it became clear as she was walking out the door. It
became clear that she was identifying with her father, who was this very aggressive and
sadistic guy who she kept trying to hold up as this wonderful guy and yet how she
described him and then how she characterized him didn‘t go together; they went opposite
one another. But she was really totally unwilling to look at that. She just wanted what
she wanted when she wanted it.

51
So, from the husband‘s experience, again, it was looking at how he always internalized
the badness of the situation in childhood: that it was his fault and that he was a selfish
guy and it helped him to re-evaluate that whole unconscious basic assumption and helped
him see how he wasn‘t taking his own needs into account. So, in a sense, he was treating
himself as he had been treated and he tried to work with his wife to get her to recognize
that he had needs too, because he really would be able to empathize with hers, but she
wasn‘t able to do it. So, eventually, he left her and that is one of the outcomes that occur
in this kind of thing.

One of the values of couples‘ therapy is that it has a diagnostic value for the participants.
They can get a chance to see how things are going to go and are they going to progress or
not progress or how long would it take and those kinds of things, and thereby they are
able to make decisions for themselves that they otherwise perhaps wouldn‘t have been
able to in terms of living their own life in a healthier way.

ALEXANDER: I‘d like to discuss and ask you about your method of ―changing
first:‖ with couples like this, where they are attacking and it is so difficult, what you
change first is each partner‘s relationship with you -- and then their relationship with each
other.

McCORMACK: Right. What I learned when I first started out really working a lot
more with personality disordered families and couples was that if I let a couple -- be it a
mother/daughter couple, or a husband/wife couple -- just talk to one another, that they
would rapidly go to blame, shame, or attack, or withdrawal types of interaction, that
would then spiral downwards until there was an implosion or an explosion. They‘d rest
up a little bit and then they‘d go through the whole sequence again.

So, what I started doing, and I think actually a lot of therapists do it -- there was never a
name for it before -- is I called it ―the technique of separate dyadic interactions.‖ I
realized that as soon as there is the onset of primitive defenses, that signals the borderline
state and that signals the lack of observing ego and the lack of the capacity to reflect upon
experience. So, what we are watching then in front of us in the couple is just an acting-
out. As long as there is acting out, that is a ―discharge of experience‖ and it interferes
with the ability to learn from experience.

Another experience of acting out is called ―un-remembering.‖ That is, actually

something has been tapped into that threatens the sense of self in the contemporary
situation, but what‘s tapped into is in the Unconscious. So, what I started doing was
when this started to occur in the session, at that moment, I would intervene and then work
with one spouse for a while individually, with the other spouse in the room and go
through what had just happened and help try to understand what it had meant to them.
This impeded the acting out. It also decreased the transference intensity in the room,
because you were relating to me rather than to each other. It also offered what I call ―the
participating spouse,‖ the one I‘m speaking with at the moment, a chance to have a
relationship with an available object, that is the therapist, who actually, rather than being

52
focused on counter-identifying with what he or she is saying, is very much focused on
trying to personally identify with what he or she is saying. So in trying to make sense of
it, the therapist internalizes it and in doing so, that experience, much of which is before
and beyond words, becomes subject to the therapist‘s own inherent organizing tendency
of the self. Then via multiple trial identifications, the therapist shares impression to make
sure that the impressions are accurate or to inform the patient of what he doesn‘t
understand until his genuine sense of understanding emerges. So that patient then has the
experience of being in a real relationship, however briefly, with the therapist and feels
understood.

Then the therapist shifts to what was previously the observing spouse and repeats the
whole process over again, but from only that spouse‘s perspective. When the therapist
shifts from one spouse to the other, the therapist doesn‘t say, ―What do you think about
what your husband or wife was just saying?‖ because that would direct them or channel
them. The therapist asks, ―What have you been thinking about as your husband or wife
and I have been talking?‖ This frees them up to say what really has been on their mind,
they don‘t feel channeled and they start to see that the therapist has only the agenda of
coming to know them and trying to understand them and make sense of their experience.

ALEXANDER: …as opposed to who‘s right or who‘s wrong.

McCORMACK: Exactly. The whole focus is not on changing anything. The whole
focus is on understanding what is going on and understanding what is going on for each
person. In those separate individual interactions, historical information comes up,
memories come up and so on, so that frequently the other spouse might say, ―I never
knew that before. I‘ve never heard that before.‖

There‘s another interesting piece too, which is a direction I‘ve been working on more
recently: if you think about the word ―relationship,‖ what‘s in the word ―relationship‖ is
the word ―relate. ― A real relationship entails the capacity to relate. In other words, it
entails the capacity to identify with the other. Another way of thinking about that is, if I
can personally identify with you, a way of saying that is I can find myself in you, and I
can find parts of your experience in me and through that whole interaction, we‘re both in
the process of developing an evolving internal image of one another.

So, the therapist is kind of this bridge between the two spouses in that he has internal
images and representations of each spouse inside of him or her and he has made room for
both of them simultaneously So the spouses, actually, in their capacity to find themselves
in the therapist and the therapist in them, actually meet up with the other spouse first, in
reality, as opposed to from projections and transference and so on in the mind of the
therapist.

Another part of this is that I really think, although words are essential, words are very
important, but, in another way of thinking about it, words are just a very small part of the
intervention because so much of communication is both before and beyond words.
Therefore, the therapist‘s countertransference is extremely important, because if there is

53
one spouse I like, and the other spouse I don‘t like, they can‘t very well meet up in my
mind as a healthy couple. So, it‘s my job to examine within myself what is it about this
spouse that‘s bothering me or turns me off or repulses me, and then, sometime during the
course of therapy when the timing seems appropriate, explore that behavior that is such a
turn-off with that spouse. Rather than avoid it, you move toward it, so that you can
develop a relationship with the spouse where you like them as a person and they like you
as a person.

What these personality disordered people do is they relate in ―part-to-part‖ fashion, rather
than as whole people and so they will often lead with a part, the function of which is to
keep other people at a distance. So, if you can start to address that or see through that or
beyond that and not just get stuck on that (like equating the tree for the forest), then you
have a real chance to develop what, in object relations theory, is called ―whole object
relationship.‖ It is ―all of my parts‖ in dialogue of one another and all the other person‘s
parts are in relationship to one another rather than split off from one another.

ALEXANDER: But, let‘s say the partner that you don‘t like, and he or she has
presented an unlikeable part of themselves to you. Is what you try to do is go to find
some part of them that you do like?

McCORMACK: Both that -- some part I do like or can respect -- as well as explore
with them, and again, it‘s partly a question of timing, but you have to develop enough of
a relationship to do it so they don‘t feel -- if you do it too soon, they can feel attacked.
But it is very important for the therapist to be aware that there is something going on, to
identify what it is in this person‘s behavior or in way of presenting or relating that is so
obnoxious, for example, and then to explore that with them at some point, because there
will be inconsistencies in it typically.

So, in other words, some guy can act, for example, completely brain dead in the office
and yet at times, you can hear that person, in other parts of their life or thinking, describe
something with some richness and texture to it. So, it is like there are these two different
parts, but they are not connected to one another for some reason.

What I might say to the guy is something like, ―Geez George, you know, a lot of times
we sit here and you act as if you don‘t have a thought in the world and that your mind is
just this ―blank,‖ but it confuses me because you described this or that experience and it
is full of richness and color. I don‘t know how to understand that. Educate me to that.
What‘s that about?‖

ALEXANDER: So then, what will they say? How would they explain it, or would
they say, ―I don‘t know?‖

McCORMACK: Well, often they will say, ―I don‘t know.‖ But, the main thing is if
they can agree that it is true. You see, if they agree that it is true, then you have a
consensual reality to work with and then that becomes a valid topic to be re-examined
throughout the course of therapy until that question is answered.

54
So, in my approach to therapy, the focus isn‘t so much on what is ―the known,‖ but what
is more value is the ―not known,‖ the gaps that create difficulties in making sense of
things.

For example, there was a young man who came to my office -- he was like early 20s --
and he had just made a lot of money the year before. His complaint was, ―You know, I
made all this money, and I‘m really unhappy and I feel depressed because I thought if I
made money, I‘d be happy.‖ So, we explored that for a little while, and then I asked him
about his relationships and he described his current relationship with a woman who he
would get together with unpredictably, because the woman would come over and they
would get together and then she would disappear for a week or two weeks or three weeks
and then they would get back together. So, in this kind of unpredictable and insecure
kind of way, it created this roller coaster ride of a relationship in which the sex was great,
in part because the anxiety was so much, and then the sex would lead to reduction in the
anxiety, in this temporary sense of physical connection and then she would disappear
again. Then, for other relationships in which he had a girlfriend that lived in a different
town and the same kind of thing: they couldn‘t get together reliably, yet he didn‘t want
to move to that town, and she didn‘t want to move to this town.

Then, in further exploration, what came up is that his mother had been a nurse, and she
had chosen, for some reason, from the time that he was age 4, to work the evening shift.
So, this meant that when he got home at night, she was never there, and his father was
aloof and unavailable. So, he was raised essentially by older siblings and every once in a
while, his mother would appear on the scene. It would be a weekend, or holiday, or I
don‘t know if the weekends were even reliable or if she had shifting days off. Then even
when she was there, there was a question of, you know, she‘s working, she has to be
exhausted too and she‘s not always going to be available, so this whole sense angst -- of
trying to make connection with the internal mother, so to speak.

He was reliving this whole thing with each of these women, totally unpredictable when
he would be able to hook up with them. So, it started making sense of what he hadn‘t
focused on before, which he was relating as depression, to not making money and trying
to feel happy because of material world successes. But he couldn‘t feel happy because he
had really no substantial connection with other people in intimate relationships, so that
core self needs were not being met.

That kind of example gets repeated over and over again. Another guy came in and talked
about wanting this warm and fuzzy relationship and I said, ―Well, geez, who doesn‘t?‖
He was very clear that that was what he wanted and he was a therapist and he was talking
about that that was what he wanted, but it turns out that all of the women he was attracted
to were actually very domineering and critical. For example, he would plan a vacation,
pay their way on this vacation as a couple, and if there was a problem at the hotel where
they were staying, the girlfriend would hold him responsible for it. So, she was always
critical of him. It turns out that she was actually a stand-in for his father, who he had a
very warm connection with as he recalled it, until about age 5, 6, or 7 or so on, but as he

55
started to separate and develop a mind of his own in relationship to his dad, his dad
became more and more demanding and critical and wouldn‘t let him do things and
criticized his work and so on. So he had lost this warm and fuzzy relationship and it had
been replaced with this very critical relationship and what he was trying to do was find
these stand-ins for dad, so he could change them from critical back to warm and fuzzy.

I think that is what Freud talks about: the return of the repressed. Until we work it
through, it keeps coming back because we are trying to resolve it or solve it. Freud also
called it the most terrifying of all human experiences, which it is, as well, because of the
ages that it occurred at and the sense of isolation, of loneliness, and the alienation that the
young child feels without the brain capacity -- because the brain is not fully grown until
16 and I‘ve even heard more recent studies saying, the necrotic doesn‘t complete
development until age 30 -- the process of that experience is they internalize it as their
fault and so they are trying to seek redemption and to get love. But, they are attracted to
the same kind of relationship in which they didn‘t feel love because they are trying to
convert it back to a loving relationship, rather than simply finding someone who is
available for love.

Like in that movie, maybe the boyfriend -- he seemed a little boring to me -- but maybe
the boyfriend that was stable was offering love, but it wasn‘t this exciting re-creation and
anxieties and whatnot of more passionate, what one of my patients used to call the
―neurotic click‖ type of relationship.

ALEXANDER: Excellent, really excellent. Mr. McCormick, I‘m just delighted

with this interview. Is there anything that you‘d like to add before we close.

McCORMACK: The thing that I would like to add is that I think it is very important
for therapists to have compassion for themselves in working with personality disordered
people. They have this tendency to bring out the best, as well as the worst in us. It is
important to learn and grow from that, but it is also important in service of learning and
growing to relate to our own experience compassionately so that we can learn and grow
from it, instead of just berate ourselves.

I think sometimes some therapists are very much harmed in working with personality
disordered people, because they get so stirred up and they feel so decimated. I think if
they can try to focus on that and put it in service of learning, get consultation, supervision
or whatever, in service of their own learning and growing, that they will be better off for
it. But the essential feature is to recognize that you‘re going to make mistakes; that‘s part
of the human condition. The repair is learning from them.

ALEXANDER: But, you‘re absolutely right to have compassion for yourself.

McCORMACK: Oh, absolutely. You can‘t do it for them if you can‘t do it for
yourself.

56
ALEXANDER: That‘s right. Thank you so much, Mr. McCormick, it‘s been an
excellent interview.

McCORMACK: Well, I appreciate it.

To order Charles McCormack‘s book, Treating Borderline States in Marriage, contact the
Jason Aronson Press, www.aronson.com.

This concludes our interview with Charles McCormack. We hope you learned from it
and that you enjoyed it.

I must say here that the opinions expressed by our speakers are theirs alone and do not
necessarily reflect the opinion of ON GOOD AUTHORITY. Until next time, this is
Barbara Alexander. Thank you for listening

57
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview #5: “SELF-INJURIOUS BEHAVIOR”

KAREN CONTARIO and WENDY LADER, Ph.D.

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

KAREN CONTARIO
SAFE
C/O Linden Oaks
852 West Street
Naperville, IL 60540
1-800-DONTCUT
[email protected]

WENDY LADER, Ph.D.

SAFE
C/O Linden Oaks
852 West Street
Naperville, IL 60540
1.800.DONTCUT
[email protected]

(to order their book, Bodily Harm, contact the Hyperion Press; 77 W. 66th Street; New
York; NY)

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to

reading interview #5 in our program on the Borderline Personality.

A history of self-mutilating behavior is one of the 9 indicators of Borderline Personality

Disorder. Self-injury is one of our society‘s fastest-growing and most disturbing
problems. Alarming and horrifying, self-abuse is a widely misunderstood and
dangerously mistreated psychiatric disorder.

What motivates self-injury? And most puzzling: how is it that things like cutting,
gouging, and burning one‘s body actually make the injurer feel better? And, that being
the case, what possible therapeutic intervention can compete?

58
Increasingly, clinicians recognize the power that can be achieved by combining strategies
and techniques that cut across theoretical models. The two remarkable speakers in this
interview have been doing precisely that in their work with self-injurers. In their book,
Bodily Harm, they describe a course of treatment based of years of experience and
extensive clinical research, as well as compassion, advice, hope, and humor.

In 1985, they founded the first treatment program in the nation specifically for people
who physically harm themselves. Their in-patient and partial hospitalization program
called SAFE, which stands for Self-Abuse Finally Ends, treats clients with respect and
empathy, placing the responsibility for recovery squarely on the patients‘ shoulders.
Their assumption is that successful treatment of self-injurers involves a shift in
responsibility from the therapist to the patient. They use innovative techniques, including
cognitive analytic therapy, to look at the underlying dynamics driving the behavior

But we‘ll let them tell you about it.

Karen Contario is the program director of SAFE Alternatives, in Chicago. The program
was founded by Contario in 1984 as the first outpatient support group for those who
engage in repetitive self-harm behavior. In 1985, she teamed with Wendy Lader to offer
the first structured inpatient program for deliberate self-harm behavior. She is a trained
alcohol and addictions counselor and a certified group facilitator.

Wendy Lader, Ph.D., is the clinical director of SAFE Alternatives. An expert on

women‘s mental health issues, she has treated more self-injurers than anyone else in the
country. She also serves as a consultant to the Women‘s Services at the Loop YWCA in
Chicago. Previously, Dr. Lader was the Director of the Girls‘ Program at Mercy Hospital
and Medical Center in Chicago. She earned her Ph.D. in Clinical Psychology at Nova
University in Florida.

ALEXANDER: We are here now with Dr. Wendy Lader and Ms. Karen Contario and I
would like to have each of them say hello and introduce themselves so that the listeners
can get used to their voices. So, Dr. Lader, would you please go first and say, hi.

LADER: Hi, this is Dr. Wendy Lader, glad to be here.

CONTARIO: Hi, this is Karen Contario.

ALEXANDER: You are co-authors of the superb book entitled, Bodily Harm, and I
would like to go through some of the very important things you talk about in your book.
Let‘s start right at the beginning in terms of just a definition of self-injurious behavior.
One of the things that really took me aback was that you called it, ―the wounding
embrace,‖ and I thought that was just wonderful. So, let‘s talk about that phrase and a
definition of self- injurious behavior.

59
LADER: Basically, the definition we use is the alteration of the body or body
parts, not with the intent of suicide, but with the intent to ameliorate intolerable, or
perceived to be intolerable or intense emotional states. The reason we call it ―the
wounding embrace‖ is because it feels very good. It‘s an immediate sense of relief to the
person who is experiencing it.

CONTARIO: Many people who injure state that they feel ―held‖ by their injury and
such wounding embrace.

ALEXANDER: It‘s so hard for people who have not had experience with this to
understand how something that frightening could actually feel good.

LADER: It is very hard for people to understand. Let‘s face it: all of us, even an
amoeba will revile from pain. Most of us move away from pain, so it is very difficult to
understand how people would move towards it, but if one recalls, the whole idea of the
emotional pain is so intolerable that they would rather deal with the physical, the
physicality than with the emotional side. We also believe that endorphins are released
because a lot of folks don‘t actually feel very much when it is occurring, possibly because
of the intensity of emotion at the same time.

ALEXANDER: So, are you saying that cutting or burning or any of the various forms
that self injurious behavior would take would actually release in the brain the same kind
of chemicals that an antidepressant or that exercise would release?

LADER: Well, think about an automobile accident, or somebody who is in a

horrible accident. There‘s adrenaline racing through the body. There are all kinds of
chemicals racing through the body and sometimes people don‘t even realize that they
have been significantly hurt until they actually see the blood, or somebody says, ―Oh, my
gosh, look what happened.‖

CONTARIO: Or, the person who may accidentally run over a child and pick up the
automobile to release the child from the tire.

ALEXANDER: That‘s right. They are filled with such immediacy of the moment.

CONTARIO: Right.

ALEXANDER: Let‘s talk about the kind of pain that a person would be in, the kind of
emotional pain that they would be in, that this would happen.

CONTARIO: Well, self-injury tends to happen in adolescence. Adolescents are just

emotionally and physically really coming into themselves. Their bodies are changing and
their minds are going from this to that, and it is very confusing for them during that time.

LADER: Adolescence is a time of individuation and separation. So, it is a very

difficult time and one of the main underlying issues is being able to have and feel

60
comfortable having separate emotions. Often anger and sadness are very difficult for
these folks.

CONTARIO: Also, kids, when they experience frustration, it‘s as if it is going to be

like that for the rest of their lives. There is such an exaggeration of what is going on in
their lives. So, at that moment, they truly believe that a separation with a girlfriend or
boyfriend is going to kill them. So, at that moment, everything is so intense, more so
than maybe adults who have had history knowing that we can move past intense
situations.

ALEXANDER: This is where the distortions in thinking come from?

LADER: Adolescence is a hard time for anybody. Clearly, not all adolescents
are going to become self-injurers. So, we have to look at the familial, the biological, as
well as the cultural background of each individual to be able to understand where this
comes from for that individual. But, generally we do look at perceptions, and often
within families, it has to do with communication: being able to communicate directly
thoughts and feelings without censoring them or stuffing them.

ALEXANDER: Have you seen an increase in recent years of self injury?

LADER: I think it‘s a combination. Number one, people know about this more,
so I don‘t think it‘s quite as secretive as it was perhaps a decade ago, but I do also think it
is on the increase. I‘m hearing from more high schools and even junior high schools and
elementary schools that they are seeing more kids and even groups of kids who are
engaging in this behavior.

CONTARIO: When Wendy and I first started looking at this population close to 17
years ago, the average client who would contact us was in their late 20s, early 30s; now it
is late teens, early 20s.

ALEXANDER: Has the body piercing -- the trends toward body piercing, and that it is
sort of, well, not exactly fashionable, but it is sort of a cult thing to do -- has that had an
impact on the self injury?

LADER: I think it‘s the chicken or the egg, which comes first. I don‘t know that
either one has had an impact on the other, but I don‘t think that it is a coincidence that
both of them are on the rise. Why is it that we are focused so in our society on the body?
What is the meaning of that, and I do think in our society that we are very body focused.
I also think that it is on the increase.

The skin is the largest organ of the body and it can be a bulletin board. It is also the
boundary between us and other people. Everything in us is us and everything outside is
somebody else. I think in a world where kids are stealing or believing that they are more
ignored and it is harder to get noticed, I don‘t think that it is surprising that people are

61
starting to write on their bodies, basically, through self injury, tattooing, piercing,
scarification.

ALEXANDER: Well, what would make somebody want to do it?

CONTARIO: Most kids will say that it just happened. There was an impulse. They
may have just broken up, again, with a boyfriend or girlfriend and they saw a knife there
or a razor and they just did it. Then they will say that, for that moment, they felt some
kind of relief.

LADER: However, I don‘t believe that happy and very well adjusted kids self
injure. I don‘t believe it will work for them. So the question is what kinds of kids will
this work for? Generally, I think it is kids who think or feel that they are invisible, that
their experience is unimportant. They don‘t like themselves very much. They don‘t
believe that other people care enough about them to take the time to understand their
experience.

Where that comes from can be many, many different familial and experiential
backgrounds. Often, we find that there is an over parented or an underparented family
situation. In the underparented family situation, kids may have to grow up very fast.
They may have to take on a lot of responsibility, and they may put their own thoughts and
feelings on the back burner: ―Other people in my family have more needs than I do; I
need to take care of them.‖ So, they begin to believe that they shouldn‘t need anything
and feel guilty for needing anything, and therefore individuation and separation equals
annihilation. In other words, ―My family needs me. I can‘t leave them. It‘s dangerous to
leave them. They need me, they‘ll fall apart.‖

With the other kind of family constellation, over-parented, you have parents who may tell
kids what they should be thinking and feeling: ―You‘re either with us or against us. You
don‘t bring that into the house. I‘m the only one that‘s allowed to be angry. Don‘t you
raise your voice to me.‖ There isn‘t allowance for active communication and
individuation and having different kinds of thoughts and feelings from the family. In that
case, separation equals annihilation also because, ―I need them. I can‘t leave them
because they need to tell me how to think and feel.‖ So, you can see in both of these
cases, separation and individuation become a very scary process, almost annihilative.

ALEXANDER: Does it help to think of this in the same way as you would think about
an eating disorder?

LADER: There is a tremendous concomitance between the disorders. Probably

close to 80% of self injurers have a concomitant eating disorder, so the constellations are
very, very similar. Now, that doesn‘t mean that that high a percentage of eating
disordered clients are self-injurers, but the reverse is true: about 80% of self-injurers
have a concomitant eating disorder.

62
ALEXANDER: At some point in the book, you mention that sometimes kids happen on
this accidentally and they find that that helps them feel better. Is that right?

CONTARIO: Many kids report that after some trauma in their life has taken place,
again a breakup with a boyfriend or girlfriend seems to be the most common story that
we hear as to why someone may have just all of a sudden injured.

LADER: But, it is accidental, often. Sometimes it is impulsive, not accidental.

Sometimes it is accidental, but most of the time it is just impulsive and they can‘t tell you
where the impulse came from. They don‘t recall hearing about it, or knowing about it, or
knowing where it came from. As they say, ―It just happened.‖

ALEXANDER: How do you make a distinction between kids who, well, pierce their
naval or double or triple pierce their ears or maybe get a tattoo or two -- how do you
make the distinction between somebody like that and self-injurious behavior? Where do
you draw the line?

LADER: There may be a very thin line between the two. It may be the
motivation and the drive behind it. Now if a child truly wants to do it, and they may not
be the best judge of this but if they are truly doing it just to be in with the in-crowd, it
looks pretty and they are sort of scared of getting it done, they don‘t really want the pain,
that‘s not part of it that they are enjoying or getting any benefit from but they really just
want something on their body because it‘s the in thing, cool thing to do -- that‘s different
than somebody who gets it done and then has almost as an obsessive compulsive desire
for more of them, constantly wants more and more and more. There may be a drive
behind it that‘s unhealthy, very similar to the one for self-injury. Oftentimes, there is
often an enjoyment of the process, and this is a painful process so even though, if it
enjoyable or they don‘t feel anything or experience any pain, they may be having a
problem.

Also, we look at family backgrounds, their self-beliefs. Do they like themselves very
much? Do they have stormy relationships with their peers? Do they have stormy
relationships with their parents and their families? Those are the kinds of things that we
look at to look at the whole syndrome.

ALEXANDER: Could you just give a mini case example of some of the dynamics and
some of the issues that might lead up to a person cutting themselves?

CONTARIO: The severe self injurer often comes from a family where there is a
tremendous amount of perceived and actual real abuse that may have taken place. There
may have been sexual abuse, there may be alcoholism in the family. There is lack of the
child really growing up, often, as Wendy talked earlier about having to take care of
themselves in many ways, and often, maybe having to take care of the drunk father or the
drunk mother. In time, they just begin to not be able to rely on any human being other
than themselves.

63
They often then repeat patterns. They become alcoholic themselves. They may start to
get into relationships that are very destructive, whether they are physically or sexually
destructive, and so then the cycle starts. There is such self-hatred, and then the abuse
starts. They may severely cut themselves where they require a tremendous amount of
stitches. They may burn themselves where skin grafts are required, and we are talking
like hundreds and hundreds and hundreds of scars on their bodies. We have had people
who have amputated a toe, nearly lost most of their skin due to pouring lye or some
burning caustic material on their skin.

LADER: We had one patient -- a good example would be: a woman poured
Dow Oven Cleaner on her arm, got on the phone, called up her girlfriend and was on the
phone for about 20 minutes and until she smelled something burning, she had totally
forgotten that she had poured Dow Oven Cleaner on her arm.

ALEXANDER: That is so hard to understand -- how you could not notice? Are they in a
dissociative state?

LADER: Well, that‘s an interesting question, and, yes, often our folks state that
there is a dissociative type of state going on where their mind and body become separate
entities. There is clearly an analgesic experience where there is a numbing of the body
and there is lack of feeling of what‘s going on and certainly, that could be considered a
dissociation from one‘s body. But, she is on the phone talking and she remembered the
phone call. So, were not talking about dissociation to the point where one doesn‘t know
where they are, although, sometimes that will occur as well.

ALEXANDER: I suppose a differential diagnosis on the more benign kind of self-injury

would be harder to make. I mean that case with the oven cleaner, that‘s a very clear
example of pathological self injury. But, what about when it is closer to the line of
normal? How do you tell?

LADER: Well, it‘s interesting you say ―pathological self injury.‖ Certainly, the
behavior was very dramatic and very severe, but to talk to the woman herself, you would
have no idea. She wasn‘t actively psychotic. She was intelligent, had interpersonal skills
and was enjoyable to be around, so you would have no concept, and that is true for many
self injurers. There are many people that we treat who are lovely people, very cogent
most of the time. But when they go into this experience, this intense emotional
experience, they become so numbed that they are capable of hurting themselves very
dramatically. As a matter of fact, the biggest reason people give us for coming to our
program is that they are afraid that they are going to accidentally kill themselves because
of the inability to stop.

CONTARIO: Yet, interestingly enough, those who have had such severe histories,
and their injury is quite obvious, will be the first to say in group, ―I‘m not as bad as
everyone else. They need to take care of their issues and work on themselves more than I
do.‖

64
ALEXANDER: Well, let‘s go to the subject of treatment. Do you want to tell us about
your program and how you came to start it?

CONTARIO: In 1984, I was doing some course work and needed to come up with
some kind of group. My training was in the substance abuse field and I personally did
not want to try to reinvent the wheel again, so I came across an ad in a newspaper saying
that there is a hospital that treats self injurers. I called the number and I was in contact
with the psychiatrist there. There was no formal program. There was just one patient he
had who was a chronic self injurer. I said, ―I need to run a group. Can I start with this
patient?‖

To make a long story short, I did class on Thursday night, practice what I learned on
Thursday to this one person. After a while, I was not being trained for individual
psychotherapy, so I just went to the local Chicago newspaper and asked them if they
would do a story. They did a story, then Oprah Winfrey picked it up, then Phil Donahue,
and for a year I was running a group with up to about 20 people who self injure, just kind
of making things up as I went along, but, fortunately it seemed to work quite well.
The same psychiatrist then introduced me to Wendy. She was the director of the
women‘s program at this hospital and then we collaborated on designing and
implementing an inpatient treatment program.

ALEXANDER: And the rest is history.

CONTARIO: The rest is history.

ALEXANDER: Do you think that group process works better than individual or do they
give each other new ideas about how to hurt themselves next?

CONTARIO: Not at the Safe Alternatives Program. One thing that we did put in
place was that we ask them not to be specific on how they injured, and I also did that in
the first outpatient group that I ran. I just did not believe that commiserating on how they
injure was going to be effective.

LADER: Basically, the problem is not the injury. We look at it as smoke and
mirrors. The injurer and other people tend to focus on the injury rather than what is
behind the injury. We laugh about it, because when we tell them they can‘t talk about the
kind of injury they do, they say, ―What are we supposed to talk about?‖ We say,

LADER AND CONTARIO (together): ―Bingo.‖

CONTARIO: I‘ll give you a quick example. There was a woman from Canada who
called me a number of years ago and said that she wanted to run a self injury group and
that she is a burner. I said, ―Well, I discourage people who are still injuring from running
self injury groups and she said, ―Oh, no, no, no, I haven‘t injured for three years.‖ I said,
―Well, why do you refer to yourself as a burner then?‖ She said, ―Oh, I don‘t know –
‗cause that‘s what I did.‖

65
We also tell the people that injure that they are far more than just their symptom.
Unfortunately, we live in a culture where everyone is an ―is:‖ ―Hi, I‘m an alcoholic. Hi,
I‘m a drug addict. Hi, I‘m a burner. Hi, I‘m a cutter.‖ These are all just symptoms;
people are far more than just a symptom.

LADER: And that does have to do with our philosophy, which is much more
analytically based, but we do it in a short period of time. Our program is only 30 days.
So, we do basically brief analytic therapy with a strong cognitive behavioral component.

ALEXANDER: Tell me about the treatment process from start to finish.

LADER: The first part of the process is that it is a voluntary treatment. It is a 30

day program that we do as a combination between inpatient and partial hospitalization.
People can be self-referred or they can be referred by a therapist. But the bottom line is
that we screen for motivation. It doesn‘t matter how long they have been injuring or how
severe they have been injuring, but they have to be motivated for treatment.

Number two, they have to be willing to sign a ―no-harm contract,‖ that they won‘t injure
while they are in our program. Now, that‘s not because we believe that ―not injuring‖ for
30 days is a cure. We don‘t believe that. But, we do believe if they are injuring, they are
self-medicating and it is not unlike going into a substance abuse program and drinking all
of the time.

It is very interesting: we don‘t believe that they need self injury to survive. The only
way that they are going to know that is for 30 days not to injure, not to medicate and then
to get to the underlying anxieties and fears and face those directly.

So, the first thing we do is they have to be motivated. They have to talk to us on the
phone. They give us a history and then we talk to their outpatient therapist to make sure
that this is a good time, an appropriate time, and that they are appropriate for our
program. The only thing that we do screen out for is active psychosis -- they can‘t be
actively psychotic, although many of our folks have some psychotic features, and they
can‘t be actively suicidal. They can‘t be motivated to live if they are actively suicidal.
That‘s a different issue.

ALEXANDER: What kind of motivation do you look for? Motivated for what, is my
question?

LADER: They have to be motivated to live a life different than they are already
living, recognize that there are some losses attached to self-injury, and that while that it
has been a coping strategy that works temporarily, they have to, on some level, recognize
that in the long run, it is self defeating and that they need to do something in a different
manner.

CONTARIO: Also, the motivation has to come from within. It cannot come from
somebody else.

66
LADER: In other words, it can‘t be that they are going to a state hospital if they
don‘t come to us, or that their parents are telling them to, or that their therapist will drop
them. It has got to be from themselves.

ALEXANDER: Those are pretty high expectations.

LADER: Our belief is that people will live up to their expectations. Part of the
problem with folks in this population is that people expect that they are so fragile that
they have no ability. Not only do we not believe that, we know that that is not true.
Now, that‘s not to underestimate the pain, the anguish, and the difficulty that these folks
struggle with. But we do believe that they can live without self injury and that there is a
better way, and we are not going to collude with any other belief.

CONTARIO: We expect the person to be ambivalent. We want some kind of desire

to stop injuring and be able to take a look at themselves at this time in their life. So, it‘s
not as cut and dry, it‘s not as black and white. Our expectations are that they are
motivated for treatment at this time. If not, we tell them, ―Don‘t waste your time; don‘t
waste our time.‖

LADER: Basically, we believe in choices and empowerment. We cannot make

anybody do anything. It has to be their desire, otherwise our program will not work, and
as I said, we take extremely severe, long-standing -- many of our patients have been
hospitalized 50, 100, 200 times. So, it‘s not the severity, but motivation is important.

ALEXANDER: So, they come through the door and they come with the suitcase, is that
right.

CONTARIO: For 30 days. Most of the clients come from around the country and
even outside the country now. When they first get here, they will go through the
admission process, and then meet with the nurse and the nurse will take more of a
physical/social history, and then they will immediately begin jumping in in group. If a
group is starting at that time, they will be introduced into the group. If a group is not
presently taking place, they will be assigned, which they are always assigned, but they
will be assigned to somebody who has already been in the program. That person will go
over all of the expectations, will explain the no-harm contract, the impulse control log,
show them what the writing assignments are, the schedule, and things along that nature.

LADER: One of the things that also makes us different from other units is that
we do not keep away dangerous utensils from the folks who come to our program. They
have access to their shoe laces, they have access to their earrings, they have access to
their jewelry. They can have headphones with wires on them. They can sign out
scissors, they can have razors in the shower. Again, we recognize that we cannot pretend
to protect people 24 hours per day. Nobody really can do that. These are folks who, in
other hospitals, have been in restraints myriads of times, but it is very interesting: when
you take the power struggle away, and say this is your responsibility, not mine, it works.
We have had, probably, in 17 years, ten people go into restraints.

67
CONTARIO: … which is absolutely unheard of!

LADER: We have had no one suicide, and we haven‘t really had major self
injury.

ALEXANDER: How do they do it? What happens once they come in that helps them
stop? Is it the group, the atmosphere, the whole thing about being with other people?
What‘s doing it?

CONTARIO: Yes, I think so, because often times the patient will say that, ―Wow,
I‘m with people who really understand me. I don‘t have to hide my scars. I‘m not being
judged.‖ This makes a tremendous difference. There is such a huge fantasy about what
they are getting into that that helps in a way, and then within the next few days that they
are here, they start to know the other peers and start to hear their sounds and their voice,
and their thoughts and their feelings coming from other people who are choosing to do
something different with their life.

LADER: I think it‘s the whole package. It‘s got to be their decision to come in
the first place, and we have given them some time to think about how difficult what we
are asking them and expecting them to sign is. So, they know that coming in.

Then again, it is that they are meeting other people who are self injuring, maybe for the
first time in their lives. It also is that I believe the impulse control log helps. Our whole
philosophy – we‘re not just saying, ―Stop injuring.‖ We‘re telling them what the goal is.
The goal is to face the discomfort of their feelings and not run away to an act of self
injury. We say, ― It is going to be tough, and it is going to be painful, and it is going to
be difficult, but you have a whole bunch of us, staff, and peers around you, to help
support you and understand and validate that we know that this is very difficult and very
hard for you.‖

ALEXANDER: Let‘s say there is a person for whom something comes up in their group
session or in their individual session that makes them incredibly anxious and then brings
them great pain -- the sort of thing that they would ordinarily cut themselves. What do
they do at that moment when they are just really wanting to cut or burn or whatever it is?

LADER: We have an impulse control log that we ask them to fill out every
single time they have an impulse to injure. That‘s designed -- and it‘s basically a
cognitive behavioral tool -- to help them break down a thought from a feeling, from an
action.

A lot of these folks have a hard time differentiating these three things. They think if they
have a feeling, then an action of violence is the same thing; that if one gets angry, they
have to get it out or do something. This is a log that helps them to think through, ―Why
now? Why am I thinking this way now? What am I thinking? What was the precipitant
to this thought? What am I feeling about what is going on? What would I like to show
the world? What am I trying to communicate? What would be different if I did this?

68
What would happen if I didn‘t do this?‖ And then, ―What did you do and what was the
outcome?‖

It helps them, in a state of panic, to be able to think through, ―Why now? Why do I need
to engage in a behavior? Do I really need to engage in a behavior?‖

CONTARIO: They also, amazingly are able to cry for the first time. For the first
time, they will have people listen to really what their pain is all about and oftentimes that
is so foreign. In many hospitals, what they have been told is that if they start to get
agitated in the least little bit, they are offered a medication to stop them from feeling, and
that is what they have learned over time with their self injury: ―Oh, they‘re feeling
something, therefore they can stop how they‘re feeling by injuring.

In our profession, unfortunately, we just keep re-enacting that for them: ―Here, we‘re too
scared about how much you feel. Take something so you don‘t feel so intense.‖ And,
we‘re saying, ―It‘s okay to feel. It‘s horrible, it‘s not the greatest. I wouldn‘t want to feel
what your feeling right now, but it is important that you are able to experience what you
are experiencing and know that you can then tolerate how terrible things are right now.‖

LADER: That‘s not to say that we don‘t use medications. We do use

medications adjunctively, but we want them to also think about the medications they are
taking: do they really need that PRN at that moment, or is there something else that they
can do?

CONTARIO: What we have built into the program is that every time the person asks
for a PRN, they need to fill out a sheet saying why they need this, what could they be
doing differently, are they running away from how they are feeling, are they trying to
medicate how they are feeling?

ALEXANDER: Well, does it happen often that they put in the request or they start to
fill out the form and then they change their minds?

CONTARIO: Some do, sure, because they are so used to assuming that feeling
requires something: whether it is injuring, whether it is a PRN, something needs to
happen and what we are asking them to do is, ―Slow down and let‘s think about what‘s
going on. Let‘s try to understand what‘s so intense.‖ It‘s usually the thinking that gets
them so scared. When they start to feel something, then their minds start taking over:
they‘re going to explode, they‘re going to fall apart, they‘re going to have to start
screaming, and it‘s they who are scaring themselves.

ALEXANDER: How is this the same or different than any of the 12-step programs?

CONTARIO: It‘s a lot different. Although my training was in the substance abuse
field and I use some of the components-- I believe in educating the individual as to what
they are going through -- the biggest difference is that we are not viewing self injury as a
―disease model‖ concept that alcoholism is primary, that it‘s the primary problem where

69
everything that happens from when an alcoholic drinks is secondary. We look at the self
injury as purely a secondary result where what‘s primary is the underlying issue that they
need to deal with. We don‘t look at this as, ―Once won, always won.‖ We look at this as
a symptom, as a way of coping that was learned and that can be unlearned.

LADER: We also do not believe in a ―powerless model‖ -- that ―I am powerless

to do anything,‖ which goes along with the disease model. We do believe that people can
make a choice and do something different and that is a core component to our treatment.

ALEXANDER: So, now, the analytic part. We‘ve talked a little bit about the cognitive
part, learning how to recognize how you feel and how you think and the difference
between thinking, feeling, and action. What about the analytic part? How do you
approach that?

CONTARIO: The impulse control log is set up to help the individual look for patterns
in their behavior and then we interpret a lot of the patterns. We ask them to make
interpretations of ―their choices.‖ We interpret a lot of the transference that may take
place between the patient and the therapist or the patient and the peers, ask them to look
at how they are re-enacting their upbringing in the milieu. It‘s not foreign that they may
look at a therapist and absolutely hate that therapist: ―Well, who does that remind you
of?‖ we may ask them, and they say, ―Well, my mother or my father,‖ and to get them to
understand where such a strong reaction is coming from in such a short period of time
that a relationship was forming. Again, people have such intensity, and they may only
met that person for three days and so we ask, ―Where is this intensity coming from?‖ to
help them understand that and then make an interpretation.

LADER: We do believe that their childhood histories are important. There are
many programs that treat folks who self injure or have a borderline personality disorder
in particular that do not believe that these folks are capable of dealing with these issues,
rather than just doing affect management. We do think that they are capable and we
think it‘s imperative, actually, to be able to go back and understand their experiences
from young childhood: how they formed their ideas about themselves in relationship to
other people. So, object relations and the ability to understand those relationships and
where that came from within the family is a very important part of our program.

ALEXANDER: Does it happen often that some patient‘s symptoms actually get worse
once they are in the program?

LADER: In particular, in outpatient therapy, symptoms may get worse before

they get better because there isn‘t quite the holding environment that we are able to
provide inpatient. This is a symptom that is geared to try to maneuver away and to avoid
discomfort of emotion. If we are asking them not to engage in that behavior, the
emotional flooding is going to come in. The patient is going to be very scared of this, so
they might be very anxious, very panicky, might be calling the therapist frequently, might
be engaging in all kinds of impulsive behaviors because for the first time, they are having
to feel. This doesn‘t happen as much in our program behaviorally, although it does

70
emotionally. Emotionally it can be a very difficult few weeks before they are able to put
it together.

ALEXANDER: Can these patients be treated outpatient?

CONTARIO: Most definitely. We take the patient who really cannot handle what is
going on with them on an outpatient basis. We always encourage people to first work
with their therapist as an outpatient. If they find that they are so overwhelmed and the
injuring is to a point where it is just truly interfering with the quality of their life, then we
will encourage them to come in for treatment.

LADER: And that might even be if in a short time, there is a very rapid
escalation going on, and sometimes, when adolescents start, there could be a very rapid
escalation. You don‘t want them putting so many scars on their body. Ours, certainly, is
a much more intensive treatment program.

CONTARIO: And they do go back to their referring therapist when they are done
with the treatment.

LADER: That‘s one of our prerequisites. They have to have an outpatient

therapist before they come in and they have to go back to that therapist upon leaving
treatment with us.

ALEXANDER: Do the patients usually want to do that?

CONTARIO: Oh yes, most of them are very eager to go back to teach their therapist
what they have learned. We get e-mails and calls all of the time saying, ―I told my
therapist this and she is helping me or he is helping me do it that way too,‖ and it is very
exciting to hear in their voice how they are able to aid in their own therapy with their
therapist.

LADER: It is also exciting for the therapists. We get a lot of calls from the
therapists who are extremely pleased because they don‘t have to deal with this ―hostage-
taking‖ behavior anymore. It is very difficult on an outpatient basis to deal with the
underlying issues when one is dealing with one crisis after another. So, basically, we are
hopefully teaching our clients how to be in therapy without engaging in dangerous
behaviors.

ALEXANDER: What strategies are not helpful in dealing with self injurious behavior?

LADER: We‘re not big believers in cathartic methods, in punching pillows, or

hitting things. The reason is that we are helping our folks understand the difference
between a feeling and an action. So, even though it is not dangerous to them to hit a
pillow, it still pairing together, ―I have a feeling and I need to do something violent.‖
This is often one of their worst fears -- that if they have a feeling, they are going to hurt
somebody else and therefore, self injurers would rather hurt themselves. Our point to

71
them is that nobody has to get hurt. You don‘t need to have a physical action. So, we
don‘t believe in cathartic methods.

We also don‘t believe in substitutive behaviors like snapping rubber bands or putting
hands in ice water, because again, that is focusing on the feeling of the behavior rather
than the underlying issue. To me, I would liken that to, ―Well, rather than doing heroin,
why don‘t you drink a beer?‖

CONTARIO: Or, if you have a desire to drink, just go sit in a bar and have a coke.

LADER: So, just because it‘s lesser, it‘s still along the same lines of the same
behavior and the same thinking pattern, and we are trying to break our client‘s habit of
thinking about needing an action rather than sitting with an uncomfortable feeling.

CONTARIO: And, I know that we have had many patients who have been told to do
their hands in ice and they do that, and then when they are done, they still go back to
injuring. So, many have tried the snapping and it‘s like, ―It‘s not the same,‖ and they end
up injuring.

LADER: Well, they can use ice water as a form of injuring. They can almost get
gangrene from putting their hand in ice water. So, philosophically, we don‘t believe in
engaging in behavior when one is having a feeling like that.

The other thing we don‘t believe in is ECT. We think these folks are fragmented enough
and that often, when people don‘t know what to do with the dysphoria and don‘t know
how to treat this behavior, they will throw things at them. They will throw one
medication after another, try to snow them with that, and when that doesn‘t work, they
will use ECT. Although I believe that ECT can be a valuable technique in many
instances, to most self injurers, because this is characterologically disordered, we don‘t
believe that it is generally an efficacious treatment.

We also don‘t believe in hypnotherapy. Again, we want to go with what people do know,
what people do remember. Hypnotherapy for relaxation might be fine, but not for
memory retrieval, because we don‘t know what we are getting and we find that it is very
fragmenting for folks.

Another thing we don‘t believe in is ―parts‖ therapy.

ALEXANDER: What is that?

LADER: That‘s when you say, ―Well, this part of you is the spider woman who
seduces men, and this part of you is the little girl who is very sweet and doesn‘t want to
say ‗no,‘ and this part of you is the aggressor.‖

What we are trying to do is hold the whole person accountable and singular and in their
own body, and we believe that parts therapy can help iatrogenically produce more

72
fragmentation, more splitting off of uncomfortable feelings, and less responsibility:
―Well, that was that part of me; it wasn‘t really me.‖ So, we don‘t believe in parts
therapy. We believe that people should speak about themselves as a singular person.

ALEXANDER: How do the two of you manage to contain your fears or repulsions or
sensation to cringe? I know the two of you have been doing this for a long time, but how
do you manage to do that?

CONTARIO: Well, Wendy, you drink a lot, right, and I snort cocaine!

(laughter)

We have a lot of humor. Our folks come in and they are so, so serious with everything
and for many reasons. You know, they have many reasons to be serious, but what we try
to mirror a lot is not taking themselves so seriously. Wendy and I will banter, we will
have fun with the patients. We encourage them to have fun with us and with their peers
and just in general.

We don‘t personalize their pain. Wendy and I both don‘t personalize it. I think it is the
therapist who hangs on to every word, takes it as if it is literal and, ―Oh, my god, what am
I going to do if I can‘t cure them?‖ We don‘t take responsibility for their failures and we
don‘t take responsibility for their successes. Some people may come in the program and
do great, some people may not. It‘s still the same program. I think that is the hardest
thing for clinicians working with this population: to make sure that they have a life of
their own; that they are not there to rescue or cure this population; that if you provide the
right techniques, treatment, and give them the direction, it is amazing how well these
people will do.

LADER: We also don‘t want to get into the histrionics of the behavior and by
that, I don‘t mean to demean it, but these are folks who believe that they need to turn up
the volume to get other people to see, and basically, we don‘t need to look at that part.
Okay? We want to hear, we want language. We want them to be able to tell us what their
experience is and that is what we are going to listen to and respond to.

CONTARIO: I think it is important for the clinician to be healthy themselves. Too

often, people get into this field to work out something within themselves based on what
they are doing with the patient.

So, supervision is real important. Supervision is essential with our peers, our colleagues.
We have weekly supervision. They bring in their thoughts and their reactions, their
repulsions, their joys, their cares about the patients and we talk about what is going on
with the therapist, why they think that they are reacting this way so that really helps.
Outpatient individual therapists often they don‘t have that kind of connection with other
therapists to help them deal with their own angers, fears and things like that that do arise.

ALEXANDER: Their own transference and countertransference?

73
 CONTARIO: Yes, their transference with the patient. Wendy and I are like an old
married couple, you know. We‘ll finish sentences, we know what each other‘s thoughts
are. We know this population so well and we‘re so comfortable with it, and I think that
that is reflected. I think the patients know that, that we are not going to judge them.
We‘re not scared of them. We really, really believe in their ability to find a productive
life.

ALEXANDER: I‘m so impressed. I‘m so impressed. Well, is there anything else that
either one of you wants to say before we close?

LADER: I think that the most important thing is for therapists to understand and
recognize that this is a population that is engaging in this behavior and that in fact, they
are capable of leading productive and healthy lives. That is very important, because I
think if you don‘t expect that, you will not see that.

CONTARIO: Right, ditto on that.

LADER: Where there is life, there‘s hope.

ALEXANDER: I agree and I thank you both very much.

CONTARIO: Thank you, Barbara.

LADER: Good questions. You‘re a good interviewer.

This concludes our interview with Dr. Wendy Lader and Karen Contario. We hope that
you have learned from it and that you enjoyed it.

Listeners interested in contacting Dr. Lader and Karen Contario may reach them at 800-
DONTCUT; or through their email: [email protected].

To order their book, Bodily Harm, contact the Hyperion Press; 77 W 66th Street; New
York, NY.

I must say here that the opinions expressed by our speakers are theirs alone and do not
necessarily reflect the opinion of On Good Authority.

Until next time, this is Barbara Alexander. Thank you for listening.

74
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview 6: “Impact on Families”

PAUL MASON, MS

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

PAUL MASON, M.S.

Allsaints Healthcare
1320 Wisconsin Avenue
Racine, WI 53403
262-687-7650
[email protected]
(to order a copy of his book, Stop Walking on Eggshells, contact
www.newharbinger.com)

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or

reading interview #6 of our program on the Borderline Personality Disorder.

Paul Mason, MS is the co-author of the best selling book entitled, Stop Walking on
Eggshells: Taking Your Life Back When Someone You Care about Has Borderline
Personality Disorder. This book manages the delicate tasks of appreciating the dilemmas
that families and friends of persons with Borderline Personality face each day, while at
the same time not simply blaming the person with BPD in a simplistic fashion. This self-
help book helps family and friends learn what they can do to cope with Borderline
behavior and take care of themselves.

Mr. Mason, MS is a professional counselor and program manager of the Child and
Adolescent Services at St Luke‘s Hospital and a psychotherapist in private practice at
Psychiatric Services in Racine, Wisconsin. His research on Borderline Personality
Disorder has appeared in the Journal of Clinical Psychology, and he teaches seminars for
mental health professionals on the effects of Borderline Personality Disorder on partners
and family members.

ALEXANDER: Mr. Mason, on page seventy-one of your book you say, ―The
borderline world differs markedly from your own in several ways. People with

75
borderline personality may unconsciously revise facts in order to justify their feelings,‖
and I think this is one of the most frustrating things for people.

MASON: Yes, you‘re absolutely right. It can be incredibly confusing. It doesn‘t

seem to make a lot of sense to those people who are in a relationship with somebody with
B.P.D. The person with the disorder attempts to soothe themselves and tries to quiet
some of the emotions inside of them by recreating facts or actually changing them around
a little bit to make themselves feel not as bad about themselves or perhaps to externalize
the responsibility for some action on to somebody else. I think there‘s a lot of attempt on
their part to try to take care of themselves by doing things like that.

It‘s a very difficult disorder to understand. Even their behaviors and their symptoms are
constantly changing. The moods of people with borderline personality disorder are
erratic, and their personal relationships are so turbulent and their self image is so unstable
that it‘s difficult for other people to understand if there is any predictability to them: at
first I thought there was a concern about depression, but today they look more anxious.
People who are trying to have a relationship with somebody with a disorder are left
feeling pretty confused.

Two of the other things that people with the disorder do that can be pretty confusing for
us is that they‘ll vacillate between intense feelings of emptiness and alternately, feelings
of well being. They‘ll often experience feelings of severe depression and anxiety, they‘ll
have difficulty controlling their anger and they‘ll start taking out and acting out their
anger in the form of temper tantrums. Some of the behaviors that people with B.P.D.
have are constantly changing so much that it‘s very difficult for people to make some
sense out of it. Things are vacillating and changing so much. Again, people with B.P.D.
have strong feelings and beliefs of rejection and abandonment, and they‘re quick to react
to what they might perceive as rejection. When those feelings of rejection become really
strong, they tend to act out against their partners with rage and some of the accusations
that I talk about in the book. It leaves people feeling guilty and confused and almost like
they are in this emotional combat zone.

Also, the way in which they think -- their black and white thinking becomes so confusing
for people. At one moment they‘ll classify somebody as being good and the next moment
they are classifying them as being bad. A person is either for them or against them at any
given time. The same person can be perceived as being kind and supportive at one
moment and then evil and cruel the next, what therapists call, ―splitting.‖ Overall, this
whole volatile style of thinking and relating to others is what makes it so difficult for
others to understand them, and it leaves the loved ones feeling exhausted and very
confused.

ALEXANDER: And, often the therapists too.

MASON: And often the therapists. For me, my interest in working with families
stems from that. When we‘d sit down after the end of a session and process it with a
colleague, or sit in on a treatment team meeting and then begin to talk about how

76
exhausting those sessions are, and then, you begin to think, ―Well what would it be like
to live with that person twenty-four hours a day, seven days a week?‖ And, ―If I‘m as
exhausted as I am and I‘m doing everything I can to be supportive and to be helpful to
that person, what must it be like for family members and loved ones?‖

ALEXANDER: Let‘s talk about what you‘ve learned about how to help families and
individuals cope with the borderline personality. Is there any one most important thing
that you‘ve found to be helpful?

MASON: I don‘t know if there is just one most important thing. For me, I have
looked at about three different things, and they‘re fairly general. The three most
important things that everybody seems to be needing are support, education, and also, I
think, validation.

What I mean by ―support‖ is that they do need support in terms of understanding

strategies that they could do to take care of themselves, how they can develop more
effective strategies for interacting with the person with borderline personality disorder, as
well as who else is out there who can share their experiences, and so support is one of the
number one things that family members need when they come in.

They also really seem to need education. I think that‘s true of anybody who doesn‘t
understand what they might be going through. Partners, family members need the
information about the diagnosis. Especially during those times of intense conflict and
stress, for them to be able to know that the behavior that they‘re encountering actually
has a name, it actually has a label, can be very centering or at least grounding for people,
rather than just constantly being confused by, ―What is this thing that‘s happening to me?
What is going on in my life?‖ So, I think, just being educated about the disorder, being
educated about the treatments that are available and how they can get their loved one into
treatment can be incredible helpful.

Last, and probably as important as any of these things is ―validation.‖ People, I think,
really need to know that they are not to blame for this disorder, that they are not going
crazy, that they are not the villain or the saint that they‘re being described as. I think they
also need to be understood, and validated. That is a very important and significant step in
helping partners and family members overcome those feelings of guilt and isolation and
shame that they often come in with. By using different types of psychotherapies, but
always keeping in mind the issues of support, education, and validation -- that‘s been
what family members have found helpful.

ALEXANDER: Helpful in what way?

MASON: A couple of those things: being able to take care of themselves -- that
they can feel stronger when they go back. Especially if they‘re trying to really build the
relationship and improve the relationship, if they have something to hold on to, if they
understand that this is a ―disorder‖ and they understand that, ―Even though I‘ve been
called these terrible names and I‘ve been told that I‘m all to blame for this disorder, just

77
knowing that that‘s not true and that it‘s part of the disorder helps.‖ It helps them stay
with it and helps them continue to work on the relationship.

I also think, in terms of people who are actually trying to get out of a relationship, it also
can be very helpful and very therapeutic to know that what they‘ve done and what
they‘ve experienced in that relationship is not entirely their fault. Some people obviously
choose to leave a relationship that is too emotionally demanding, and the number of times
I think I‘ve heard people describe it as an emotional combat zone, is really quite
interesting. Some people can stay within that emotional combat zone and really try and
really work on the relationship, and other people, for any number of reasons, need to get
out. All of those things: education, support, and validation can be helpful regardless of if
you‘re staying or going.

ALEXANDER: If a person comes in and you have never met the person that they are
talking about, but they come in and you don‘t know. You don‘t have a diagnosis in front
of you that says that the person is borderline. Now what if the person talking to you is
actually distorting or making the behavior sound more terrible? Would the interventions
you suggest be helpful anyway or does it really matter? In other words, if the family
member, let‘s say, experiences the person in this way, if they feel this helpless or
overwhelmed or exhausted: a.) Can you make a diagnosis based on your patient‘s
exhaustion? and b.) Does it matter?

MASON: It‘s (b) I don‘t think it matters. And, going back to (a), I certainly
wouldn‘t want to try to make a diagnosis based on just a description of a person‘s
experiences. Again, this is not to say that a person‘s experiences aren‘t incredibly
important because sharing their experiences and talking about what it is that could be
helpful or what they could be doing to feel better, or to gain better control in their life is
what they‘re coming in for is. So, I never really discount a person‘s experiences, and I
usually try to work with them regardless of whether or not I know that what they‘re
telling me is accurate or an exaggeration. That holds true when working with a number
of patients with various disorders. You don‘t always know if people with trauma
disorders have really experienced the physical or sexual abuse that they sometimes
describe. But again that becomes an issue, really a moot point because you need to work
with them from where they‘re at right now and that‘s what they are experiencing. So,
that‘s what we work on.

ALEXANDER: Now, as far as the family members go, and I suppose this chapter is
also useful for the therapist, you have a whole chapter on developing a safety plan. You
say that the best thing during a rage, the best thing to do is to temporarily remove
yourself and any children from the situation: ―I will not discuss this further with you if
you continue to yell and scream at me.‖ So, this is a terrific one.

Then you list a whole bunch of things that you do to retreat, as you say, ―to safer
ground,‖ and that, ―It‘s necessary to think through your options and make concrete plans
for the next time that borderline personality partner flies into a rage.‖

78
You have a whole bunch more of these. How did you develop these?

MASON: Well, these really came out of the interviews that we had with family
members and friends, because that was one of the things I was really looking for help
with: what are the things that people have done to protect themselves and take care of
themselves during these rages? We interviewed hundreds of people -- some family
members, some partners -- and within that group of people they were able to share a lot
of things that seemed to work for them. A lot of people that are dealing with this disorder
and the effects of the disorder on them don‘t have a lot of outlets and they don‘t have a
lot of support groups or places that they can turn to get advice on, ―What‘s working for
you, what‘s not working for you.‖ So one of the things we really wanted to do with this
book was be able to take some of the ―best practices,‖ and put them into a list that we
would hope would be helpful to people.

ALEXANDER: Now, the suicide threats are also another scary thing both for the
therapist and for family members. You say in the book that eight to ten percent of all
people with borderline personalities commit suicide, and of the six million people in
North America who have the disorder, 180,000-600,000 will die by their own hands.
You say, ―This number is equivalent to a Titanic sinking every day for four months to a
year.‖

What should you not do when a person is saying, ―You make me want to die?‖

MASON: Well, first and foremost, and therapists have known this for years, is
that we don‘t take suicidal threats lightly. We validate them, we let them know that
we‘re aware. We understand that this is what they‘re experiencing and we‘re not trying to
argue with them or trying to talk them out of that. If a person is experiencing that and is
having that feeling at the time, there‘s nothing else we can do but accept it.
Unfortunately, as family members, there‘s a tendency more to try to argue and talk that
person out of it rather than just acknowledging it and validating it.

The whole concept of validation is so important. Some of the work of Marsha Linehan
on looking into the early experiences of people with the disorder as people who have
lived very invalidating lives or lived in environments which were very invalidating was
very influential in my thinking here: we work with people on what they‘re experiencing
at the time and we don‘t challenge them on that.

There is also, some real caution that we need to take in terms of challenging people on
their threat. Too many times, people may, or people with the disorder may have acted
out their suicidal threat because of being tempted or being told, ―You‘re not going to do
it. You‘ve been all talk and no action and you‘re too scared or you‘re too chicken to do
that.‖ Then, that person leaves them and they go too far, where typically otherwise, they
would make a threat. So, again I really caution family members to refrain from
challenging it or saying to them that you won‘t do it.

79
ALEXANDER: Do you think it‘s reasonable or even possible that a borderline person
could change their behavior and that a family member could help them do that?

MASON: It‘s very reasonable, and very possible that people with borderline
personality disorder can change and they can recover and that assistance can be given by
a family member. Again, I don‘t want to express the belief that a family member holds
the power to be able to change a person with the disorder, because that is clearly not the
case. They might be able to assist by providing a fairly supportive environment, they can
deescalate situations and perhaps can begin to break down some of the black and white
thinking that a person with a disorder has by being able to show that person that, ―No,
they‘re not all good, and they‘re not all bad; there are a lot of grays,‖ and be able to stick
with them through some tough

There is some assistance that a family member can provide. But, in no way would I want
a family member to believe that they hold the power or they hold the key to the recovery
of a person with borderline personality disorder. In terms of looking at the person with
the disorder, it‘s very important for that person to understand that they do hold the key
and that they do have the potential and the internal controls to be able to work toward
recovery. That is something that is very important to instill early on in the therapy
relationship and early on in working with families.

With family members, I‘ve tried to begin by working with them to help them understand
that they can assist, they can support, they can help their loved ones through recovery.
They can provide an environment which is experienced as supportive. They can learn
communication techniques to deescalate situations, and they can also provide evidence to
the person with the disorder that not everybody is either all good or all bad. By being
able to model that, ―Yes, I make mistakes and I‘m not a bad person,‖ and, ―Yes, I can do
some good things but that doesn‘t make me just always a good person,‖ -- being able to
model that and mirror some of that back to the person with the disorder can be very, very
helpful in terms of that person‘s recovery.

But, in no way would I want the family members to believe that they hold the keys to that
person‘s recovery and that if they don‘t do these things or if they choose not to
participate, that they somehow have failed the person with a disorder.

ALEXANDER: This brings me to a very important part of your book which really
surprised me and was wonderfully helpful: the use of the internet as a resource not only
for the borderline personality but for the non-borderline personality, and for therapists as
well. I mean, the wealth and the amount of information on the internet about the
borderline personality is just astonishing.

MASON: For the most part, I feel pretty positive about the information out there
as well, and I think over the past five to six years, there‘s really been a proliferation of
internet sites, as well as internet support groups out there to assist people with
information and to be able to provide support to each other. That‘s true also for a number

80
of other physical and mental illnesses, but there are a number of them out there on
borderline personality disorder.

Many of them, like I said, are very, very good. I think the internet support groups or
what they call, ―mailing lists,‖ also can provide something that we‘ve never been able to
provide before. Essentially, people have access to a support group twenty-four hours a
day, seven days a week, and it‘s highly anonymous. They can log on, they can share
their experiences, they don‘t have to leave their house and they really can learn a lot from
other people who are experiencing the same problem.

My only caution around all of these web sites is that not all of them are out just to
provide education and support and information. There are some that perhaps aren‘t really
doing as much to try to help people as to try to get them to by a book and by pamphlets
and things like that. That‘s going to be true of anything in this nature, but the web sites,
and there are some very good ones out there, can be incredibly helpful to people because
prior to this, they would either have to go to the library and look up this information, or
go to a health sciences library at a near-by university and look for this information, and
usually that information was written in a very clinical or academic manor. It‘s pretty
difficult to read for those people who are even in the field, let alone for the people who
are just looking for some common sense information about the disorder.

So, I think the internet has helped a great deal in that manor. The anonymity has helped
along those lines. People being able to log on to a site and be able to share that, ―This is
what I‘m experiencing,‖ and ―This is what has been helpful,‖ and, ―This is what I‘m
struggling with,‖ and then not having to be victim of stigma or be labeled or classified in
a way that it‘s very negative for them.

We have struggled in the mental health community to really understand this disorder. It‘s
been around for a couple decades now in terms of its current description, but in terms of
our really understanding and accepting the disorder and saying, ―This is a valid
diagnostic category that has treatments available,‖ and that ―I‘m going to be able to make
this diagnosis and confidently talk to my patient about it,‖ -- that has been fairly recent,
I believe.

Often, people have shied away from talking about the diagnosis with patients because
perhaps they didn‘t know that there were effective treatments available or there really
weren‘t any effective treatments available in their community and so, what would be the
point of even discussing the diagnosis because you wouldn‘t be to help them anyhow.
So, the treatment advances and the mental health community as well as the public getting
more comfortable with this disorder is, I think, a real positive trend.

ALEXANDER: Well, I have a couple of more questions for you. This question comes
from a listener Rebecca Vlam. She has noticed that the diagnosis of borderline
personality disorder is increasing, that so many more people are diagnosed with this, and
it seems to her that this diagnosis is the ADHD of the 2000‘s. She asks, ―Has there been

81
any notice of this within the treatment profession community and what if any damage or
damage control has been done?‖ Do you have any thoughts about this?

MASON: Borderline personality disorder itself has had a prevalence rate of about
two percent of the general population. That has been fairly stable for the past couple of
decades. That translates into about five or six million Americans, and there really hasn‘t
been much change along those lines. Back in the early eighties, it was about two percent
and now it‘s about two percent.

Now, the frequency or the perception that there has been an increasing number of people
being diagnosed with the disorder, I think, probably has more to do with our increased
understanding around the illness, almost what I was talking about previously. If there
isn‘t a real clear definition of the disorder and there really isn‘t acceptance in the mental
health community for the disorder, and that if there are not valid and effective treatments,
it‘s not all that useful to give a person that diagnosis. In other words, mental health
professionals probably just avoided making the diagnosis because it had very little value
to the patient, or to the professional.

Now, because it is being treated effectively and people are seeing that it‘s being treated
effectively, people will make the diagnosis more often because they‘re confident in
talking with their patients about what borderline personality disorder means, this is the
treatment for it, and this is the hopeful recovery. Prior to that, and even in the early
1980‘s, I‘m not so sure if we had all that much confidence in being able to say that to a
patient.

ALEXANDER: Is there anything you‘d like to add before we close?

MASON: Well, I am pretty pleased with the amount of attention that borderline
personality disorder is now getting, both by researchers and even in the community. The
public awareness of the disorder is higher than ever before. Within the professional
community it‘s higher than ever before, and that awareness, I think, is absolutely
necessary in order to get funds for research, to learn more effective treatment strategies,
and to just be able to help in a way that we‘ve never been able to help before. I‘m just
pleased to be a part of the process of increasing our knowledge and awareness around
that, and I‘m just really looking forward and hopeful that we‘ll have continued progress
in the field and really help people with this disorder.

ALEXANDER: Mr. Mason, thank you so very much for your time in giving us this
interview.

MASON: Thank you.

This concludes our interview with Paul Mason. We hope you learned from this interview
and that you enjoyed it.

82
To order Paul Mason‘s book, Stop Walking on Eggshells, contact New Harbinger
publications, www.newharbinger.com.

I must say here that the opinions expressed by our speakers are theirs alone and do not
necessarily reflect the opinion of On Good Authority.

Until next time, this is Barbara Alexander, thank you for listening.

83
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview #7: “Education and Crisis Intervention

with Families of Patients Having Borderline Personality Disorder”

VALERIE PORR

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Valerie Porr
TARA (Treatment and Research Advancement Association for Personality Disorders)
23 Greene Street
New York, NY 10013
212.966.6514
[email protected]

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or

reading interview #7 of our program on the Borderline Personality Disorder.

Our speaker, Valerie Porr, is a passionate and tireless advocate for families of and
individuals with borderline personality disorder. Being the relative of a person with
borderline personality disorder, she knows whereof she speaks. In 1995, she founded
TARA APD, which stands for the Treatment and Research Advancement Association for
Personality Disorders. TARA is the only national, nonprofit, educational and advocacy
organization for borderline personality disorder. Its mission is to raise public awareness
of the disorder, increase research funding and ensure availability of evidence-based
treatment and translation of research findings into practice.

(Incidentally, this interview was recorded in the TARA office, so you will occasionally
hear sounds of New York City in the background. )

ALEXANDER: Valerie Porr, we are here to ask you your opinions...

PORR: (laughter)

ALEXANDER: ... your ―very mild opinions‖ about the work that is being done in the
borderline personality disorder arena and what you think therapists need to know most.

84
PORR: In the last, I would say five to ten years, there has been some remarkable
research in the field. The research is done by approximately 50 really brilliant, top
people, each studying their own little area. One problem is that there isn‘t one overriding
theory of what borderline is or isn‘t, but they are chipping away at some of the common
myths about borderline personality disorder.

The second problem is that they have never had any advocacy for borderline personality
disorder. So, consequently, the new research isn‘t out there -- isn‘t out to the public, and
the new methods for treatment are only sort of dribbling into the community mental
health system.

―Borderline‖ went into the textbooks in 1980 and 1982 and it was a product mostly of Dr.
Kernberg, Dr. Masterson, and it was basically totally psychoanalytic. If you read
Kernberg, I don‘t think you could find a better description of borderline personality
disorder than his description. However, the reasons that he comes up with for why the
disorder is what it is, sort of remind me of the ancient Greek astronomer Ptolemy, who
said that the earth was the center of the universe and every time they couldn‘t figure out
the orbit of the sun, they‘d make a little loop in it called an epicycle and they had these
scalloped planetary orbits. That lasted for 2000 years until somebody finally disproved it
-- I think that was Copernicus and I think they put him in jail!

At any rate, Marsha Linehan came along and published her book in 1993. She is a
cognitive therapist, a behavioral therapist, and is absolutely not psychoanalytic.

So, the way I see the field is you have two armed camps, not exactly overflowing with
data. They have a very difficult time getting research funding, so they have not done
studies to verify Linehan‘s method, even though she has some data and Kernberg didn‘t
have any data at all! But, across America, everybody quotes Kernberg. And although his
theory may have some wonderful aspects to it, the way it is quoted, as it dribbles down
through the community mental health people, you wind up with a bunch of knee-jerk
responses to a borderline patient, that in the long run, I think, are stigmatizing, not
helpful, and increases their pain and suffering.

You can‘t help anybody when you dislike them. You can‘t help anyone when you think
they are manipulating you and you certainly can‘t help anyone if you don‘t understand
the biological substrates of what is going on in front of you.

So, what do I think that therapists should know? I think that therapists should know that
Borderline patients do not manipulate you, because they have no impulse control -- and
the definition of manipulation is skillful, artful, planned handling to achieve a result.

Now, how can somebody whose moods ... I‘ve had one girl tell me her moods change 27
times in one day. They are so impulsive that they get into every addictive behavior and
all of this trouble because they are impulsive. Are they really getting up in the morning
and planning out how to bother you? If they call you at 3:00 in the morning, are they
calling you to bother you, or are they calling you because their pain is so intense that they

85
don‘t have the skills to get through the next 5 minutes? So, as soon as you reframe that,
as soon as you change that attitude, you can begin to deal with the patient like a human
being and have some empathy.

Who else has this very same problem? Their parents, their loved ones, their spouses.

I think that this whole issue of manipulation also comes out because of the way
borderline personality disorder presents itself. If somebody who has schizophrenia,
comes into an office of a therapist, you don‘t need seven assessment instruments and you
don‘t need a degree in rocket science. It‘s pretty obvious that somebody has
schizophrenia. When somebody comes in your office and he is a doctor or a lawyer or
she is the head of a big company and she is functioning and there are just these spots in
life that don‘t work and these rage attacks, but other than that, there is a perfectly lovely
person in front of you, and a very high functioning person, why would you believe that
this person has a mental illness? So, if this person is doing these odd behaviors, they
must be doing them on purpose. So, that‘s the first thing that you have to get out of
somebody‘s head if they are going to help them in any way.

The second thing is, and this goes back to my work with families, abuse is not a
prerequisite for borderline. What we have observed with family members from all over
the country from a national help line -- this is how I introduce borderlines to families: I
say, ―Do you have a child, who, when you say, and of course meaning an adult child as
well, ―Pass the butter,‖ the child says to you, ―I‘m not your maid.‖ or ―Why don‘t you
want me to eat?‖ This is what I call a cognitive distortion. They misinterpret what is
said to them. They are hypervigilant, super reactive, high to react, low to return to
baseline, and they misinterpret things.

So, if you say to them, ―Pass the butter‖ and they say ―Why don‘t you want me to eat?,‖
they go to their therapist and they say, ―My mother didn‘t want me to eat‖ or ―My father
didn‘t want me to eat; they wouldn‘t give me the butter.‖

So, it is so skewed and nobody corroborates what is going on. If borderline makes up 2
to 3% of the population, does that mean that borderline parents make up to 2 to 3% of the
abusers in the United States? It‘s ludicrous.

In terms of my own experience on the telephone and ―listening to America,‖ as I call it,
and Latin America, and Australia, and New Zealand -- I don‘t know how they find us, but
they do -- DBT is what works.

ALEXANDER: They call saying what?

PORR: They call asking for support groups. There is not a single support
group that I know of in the whole United States for patients. None.
ALEXANDER: Of face to face, I mean there‘s a lot on the Internet now, right?

PORR: I don‘t trust Internet, but face to face, no. We tried to run one and

86
people don‘t show up. One night, six people showed up and I didn‘t know what to do
with them because the person who was going to lead the group, who was also borderline,
didn‘t show up, so I spent the evening teaching them what I know about borderline, in
terms of the neurobiology and they sat there dumbfounded. At the end of the two hours,
each one of them asked me for a referral.

Now, remember, this is the population that won‘t go into treatment. So, they don‘t go
into treatment because they feel hopeless and they don‘t understand what they have and
they have been to so many therapists that have failed that they think that they can‘t be
treated. When you explain their disorder to them and you explain what it is they have to
do and what the therapist has to do, it is a reframe. Suddenly they all ask for referrals.

So, that was my only experience with really running a support group for patients, but our
organization is just initiating an affiliate for consumers. Families call because they want
treatment for their children. They want to know, ―I don‘t know what‘s wrong with my
child (and when I say ―child,‖ I mean usually an adult). ―I‘ve been to every kind of
doctor, gotten every kind of diagnosis, nothing helped. We don‘t get along. I read this
book, I saw it on the Internet, I found your brochure, or somebody told me, I went to a
lecture,‖ and then we send them an information packet.

And they say, ―I read your literature and this is what my child has, everything fits.‖ This
is heartbreaking, because you‘re talking about people in their 30s and 40s who have been
going to therapists for 20 years. Some of them started in childhood. We just tallied up
the calls: 23% are coming from adolescents.

I believe that borderline is a development disorder and that if you taught families how to
recognize it, you could pick up signs and symptoms in early childhood and do a lot of
intervention, but I seem to be one hand clapping in the wilderness with that one.

So, the parents want a referral and the problem with giving them a referral is that the
person isn‘t going to accept the referral. But you have to try to help whichever way you
can.

In terms of the whole United States, who do you refer to? I mean, people tell you they
treat borderlines, so I say ―How do you treat them.‖ That is a very big way of eliminating
a lot of people. So, in terms of pharmacology, I have to find really super duper people.
In terms of treatment, it‘s very hard to send people to kinds of psychoanalytic treatment
because they really don‘t get better.

The other pattern that we see is people are in therapist for years, and years, and years, and
they don‘t get better. In fact, one man in my family group is in treatment with a very
well known borderline psychoanalyst and he doesn‘t know what to do, because he has
three children and his wife is borderline and the house is just chaotic and he is trying to
figure out how he can create an environment where his children can grow up with some
sanity.

87
And he says, ―What should I do? Should I switch doctors?‖

I said, ―Well, how long have you been going?‖

―A year and a half.‖

―Is there any improvement?‖

―No.‖

I said, ―You‘re in business. What would you do if you were in business and you hired a
consulting firm to solve the problem and it‘s a year and a half and the problem is the
same way?‖

He said, ―I‘d get rid of them.‖

I said, ―Well, you answered your question.‖

You know --- but people don‘t let go of psych people because they don‘t make the same
decisions in the psych world that they do in real life. You see business men and you
know --- they can run General Motors but they don‘t know how to deal with a
psychiatrist, a psychologist, a social worker and they just get completely intimidated. So,
that‘s another problem. So, we try to educate the families so they can make at least an
informed decision.

ALEXANDER: When you make an intervention yourself over the phone, using
DBT, what do you do?

PORR: It‘s kind of an amazing thing that‘s evolved. Sometimes you get a
phone call from someone who is in these crisis modes of a borderline episode, and they
call up because either their therapist has just thrown them out and told them they won‘t
see them anymore, or their husband has left them, or they have gotten evicted, or there‘s
some --- not even really as catastrophic as being evicted --- I mean it‘s just they perceive
a situation as being catastrophic and they, as Marsha Linehan says, ―The problem with
borderline personality disorder is that these are people in excruciating pain and they have
to live with the pain and they don‘t know how.‖ That‘s what we get on the phone.

So, here I get a call from Kansas-- from somebody I‘ve never met in my life, and they‘re
hysterical. So, the first thing that I do is I try mindfulness. I say, ―I know you really
want to tell me what the problem is, and I know you really need help, and I really want to
help you and I can hear your pain; however, you‘re so upset that I can‘t understand you.
How about if we do some deep breathing exercises together and maybe then if you calm
down a little bit, I can hear the problem and find a way to help you?‖
So, we do (demonstrates breathing in, blowing out the air). It‘s extraordinary, but about
six breaths later, they have gone down where you can begin to hear them. Then, as they
escalate in the conversation, you go back to that and do it again.

88
Well, if you can just do some breathing and calm them down, what‘s going on in
America with all these therapists?

So, then you ask, ―What‘s the problem?‖ And the problem is usually presented in
hyperbolic language and Marsha Linehan does this chain analysis and a great deal of
validation.

So, the first thing you say is, ―Oh my God, you must have felt awful, that must have just
been a terrible experience,‖ You validate that whatever they are in pain about is painful.

Then you ask what happened. Then you say, ―What else could you have done?‖

Then they give you the, ―Duh.‖

Then you say, ―Well,‖ and you give them some little hints and then you say, ―Have you
ever been in this type of situation in the past and what happened?‖

You pull out of their memory episodes of similar situations where they‘ve overcome
them.

Like, ―I just broke up with my boyfriend and he never wants to talk to me again.‖

―Did he ever say that to you before?‖

―Yes, he said it last week.‖

―What happened?‖

―He came over the next day.‖

I say, ―Well, you know,‖ you have to kind of develop a scale for them to measure their
own experience by.

―This is the worst day of my life, I‘ve never been through it.‖

―Well, is it as bad as, you know, are your parents living?‖

―Yes, but my father is dead.‖

―Is it as bad as the day your father died?‖

―Oh, no.‖
―So, it‘s not the worst day. It‘s the next to the worst day.‖

And, as you develop a scale with them, they calm down. Then they ask what to do.

89
The problem is it would be wonderful if, when they call up like that, there were a buddy
in the area, there were a support group, there were a TARA chapter. We have eight
affiliates right now, and eight is certainly not enough to handle 2 to 3% of the American
population. There is an organization called Recovery Inc. I wonder if you‘ve ever heard
of it.

ALEXANDER: Sure.

PORR: Recovery, Inc is actually cognitive behavioral therapy in 1940s

language. If there is nothing else available, you can suggest that they go to a Recovery
meeting. Some of them get involved with that and it helps. But, basically, I feel like I‘m
putting my finger in the dike. I mean what can I do for these people? Then, I suggest
that they read, ―I Hate You, Please Don‘t Leave Me.‖ Or, to go out and buy Marsha‘s
Skill Training Manual and start with chapter 7 and start studying the skills. It‘s a very
sad situation.

ALEXANDER: If a therapist were to want to start a support group for families or

for borderline patients, what kind of training do you think that they should get?

PORR: We were trained by Marsha Linehan just in the last year. We went
through DBT intensive therapy. Before we did that, I had been doing groups with DBT,
because I had been exposed to it so much that I thought that I knew some of it, but of
course, by the time I did the intensive, I realized, you know, there was a great deal more
to learn.

We have started both in Philadelphia and New York, a family program for family
members and are sort of developing it as we go along, but it‘s getting there. Whatever
we are doing, it‘s already helping people. It‘s an eight week class and in terms of a
therapist doing this, I will explain what it is we do. It depends upon the therapist‘s
background. If the therapist is psychoanalytic, he should just stay away from the
families, they don‘t need anymore stigma, they don‘t need anymore blame and when your
kid has supersensitivity where: they couldn‘t wear clothing -- it was too itchy; and
everything smelled funny; and light hurt their eyes; and you have a child who is very
supersensitive; who has some very strange things going on with memory and cognition;
who has no impulse control; and who has mood dysregulation that makes bipolar, rapid
cycling look like a placid lake --a family dealing with behavior from this kind of person
doesn‘t know what‘s going on. This has nothing to do with what happened when he was
two.

I don‘t go with the whole attachment theory. I‘ve seen biological studies. To me, they
indicate that attachment is something that develops neurobiologically about 18 months
and some kids just don‘t develop it. It‘s not because they have a lousy mother; it‘s just
that there is some deficit in their brain.

I think that therapists should take a good look at siblings, because when they are blaming
these parents and they are going through all of these theories, there are two other kids in

90
the house who don‘t have these deficits. So, if they want to nit pick and tell me, you
know, ―Well the environment was different because they came along a year later or
earlier,‖ I don‘t go with them. I think you have to really take a look at what‘s wrong with
these kids. Something is wrong with these kids from the get go and unless you put them
in this environmental bubble where there is totally no stress -- you know like those
hyperallergic kids....

ALEXANDER: Bubble boys.

PORR: Well, you want to raise a boy with a potentially borderline person,
maybe that way they would be okay.

The other thing, before I tell you about our classes -- when the people come in for the
class, I give them a family tree, and I list all kinds of traits in layman‘s terms and I ask
them to fill it in. Somebody could tell me that this is not familial, but I don‘t believe it.
You got Uncle Joe is an alcoholic, and Aunt Mary had a terrible temper, and somebody
else was reclusive, and somebody else was a compulsive worrier, a pathological gambler,
or somebody was ... I mean -- it‘s all in the families. But it‘s not all in one person. It‘s a
little of this, and a little of that, and it just gets the critical mass in this one person.

A lot of people have borderline mothers, have borderline children. It runs in families and
I don‘t think they have done nearly enough work yet to see that in an epidemiologic
basis. They have to really study that.

So, what do we do with the families? The first class that we do is an overview of
borderline from MRI studies to drug studies to pictures of the brain. We just acquaint
them with what the disorder is. The aim of that class is to get anger down and empathy
up. Once they just get past that, ―It‘s their fault and they could stop this behavior if they
wanted to,‖ we‘ve already made progress. They usually get that.

The aim of our whole family class is to teach DBT to the families. So in doing this, I
realize that when a therapist is learning DBT, he knows what cognitive behavioral
therapy is, but a PhD in business does not know what cognitive behavioral therapy is.
So, we have to introduce cognition: how you change thinking? So, the way we do that is
a lot of David Burns‘ work -- it‘s like a self-help book on changing things. I have it here,
I don‘t know the exact name. I think it‘s ―The Feeling Good Handbook.‖ We introduce
things like cognitive distortions, just these different concepts, and cognitive distortions
and how to change them.

Now, after the first class, we give them a homework assignment, which is to observe their
family member and see their response to the family member: if they see the behavior we
described in the class and if that stopped their usual response, or if they at least observed
the behavior. So, we get them to really start analyzing the behavior.

The next thing that we do is this work on cognitive behavioral therapy. We ask them to
find the cognitive distortions their loved one is using and that they are using. We try all

91
of the time to make the gap between the borderline person and themselves less profound,
so it‘s not an abyss -- it‘s just an extension of a normal thing that has gone awry. That
also helps with empathy.

Then, you have to teach them things like ―shaping.‖ What is it that a family member
wants when they come into this room?: ―If he‘d only get a job.‖ ―Why didn‘t he
graduate college?‖ ―Why didn‘t they keep that job?‖ ―Why doesn‘t he get married?‖

Well, what difference does it make whether he gets married, whether he keeps the job or
he graduates college, or he gets an apartment? It‘s not going to solve the interpersonal
relationship problems, the emotional dysregulation, the lack of distress tolerance -- it‘s
just not going to happen. So, you have to change the expectations of the families. You
have to get them down. You have to make the family see that if they go through one
dinner without an argument, they‘ve made progress, and that‘s a tough one because, as I
said before, they come in and they look okay.

Of course, these kinds of people have the ability to just turn off the rage attack -- the
troubling behavior in a second. Somebody will walk in the room and they go, ―Hi, how
are you.‖

ALEXANDER: And they won‘t know why the person they just attacked isn‘t
happy with them.

PORR: Perfect. They create, -- ―Pass the butter.‖ ―Why don‘t you want
me to eat?‖ and this person is, like, ―What do you mean I don‘t want you to eat?‖ So,
they don‘t understand why the person is now angry with the. It‘s incredible.

Another example I give the families, is: you‘re on the bow of a ship and you see that
your loved one has fallen into the water, so you want to save them. So, you go and you
get a life preserver and you throw it out to them and they look up at you, and they
scream, ―That‘s the wrong life preserver. You should have thrown the other one.‖ Or,
they say, ―What‘s that? What am I supposed to do with that‖ and so you‘re standing
there totally frustrated. All you want to do is save this person. They‘re too far out for
you to jump in and swim to them. The only thing you can do is try to get them to help
themselves and they don‘t do it. It‘s a very, very frustrating disorder for family members
and the family members truly love them and just don‘t know what to do to help.

So, our second to last lesson we teach them reinforcement, shaping, positive
reinforcement, negative reinforcement, intermittent reinforcement and consistent
reinforcement. It makes a big difference when they have a language to see what they‘re
doing.
It‘s also very hard for the family member to accept that they need to change to help
somebody who is sick because there‘s this righteous indignation.

ALEXANDER: It‘s them.

92
PORR: Right, ―It‘s them not me, why should I change?‖ So, I have my
work cut out for me with these classes, let me tell you. After these classes, I‘m
exhausted.

Well, then the third class was supposed to be validation. Validation is speaking an
emotional language. It‘s relating to the person only through emotional response, paying
no attention to logic.

Well, lo and behold I discovered that families did not know what emotions were. See,
you look surprised. The way we found this out is we would give a homework assignment
and it would say, write a letter to your loved one validating them emotionally and asking
for a change. So, families think that validating emotionally is, ―I‘m so proud of you.‖
And I say, ―Proud isn‘t an emotion.‖ So, you have to really work on the families to
develop a vocabulary for seeing the changes in emotion.

You know, I don‘t know if the families of borderline people don‘t see emotions because
they have problems in that area themselves or that the general population really doesn‘t
understand what emotions are. We don‘t learn these things in school and we should.
Because if you understood how you were thinking when you were in 8th grade, maybe
you could correct it. No one ever teaches you this stuff.

So, we teach the families emotions from Marsha Linehan‘s Skills Training Manual and
then we go into two weeks of validation and we do role playing so that, let‘s say, we have
the families do an exercise. One person talks to the other person, looking at them. The
other person looks at the ceiling, just does everything possible to distract and then we ask
the family member, how that did feel and, of course, it feels awful. Then we reverse
roles and have them do it and then we tell them that people with borderline personality
disorder, they need your total attention. So, if you‘re chopping the tomatoes or cooking
dinner while they‘re telling you what happened that‘s painful, they feel you‘re not
listening and then they‘ve just had this experience. So, we get them to focus. That‘s
already a big step and when they start validating emotions, almost always, the families
come in and report that their loved ones said, ―Oh my god, you finally understand.‖

My favorite story is -- this is a phenomenal story. We had a woman in the group.

They‘re all kind of highly educated, but this woman is a secretary. She‘s never been to
college. She came in because she thought her 23-year-old daughter had borderline. As
she‘s taking the class, she realizes that her three other children have borderline
personality disorder and her ex-husband too. So, she and her husband are separated, but
they still see each other and he‘s disabled. So, she goes to see him every week or two
weeks and helps him around the house. Every time she goes to see her ex-husband, he
says the following to her, ―I never should have married you. You cheated on me when
we were keeping company. You went out with Lou Serone and I never should have
married you. You betrayed me.‖

Her response is, ―What do you mean I betrayed you, I‘ve been faithful.‖

93
And, they‘re at it. They‘re off and running . It‘s Hialeah. So, she repeats this discussion
in the group and I say to her, ―Why didn‘t you validate him.‖

She said ―What do you mean?‖

I said, ―Say to him, ‗God, that must have been awful. You must have felt so terrible.
That must have been so humiliating for you. No wonder you‘ve been angry at me all
these years. If that happened to me I would be angry.‘‖

She said, ―Well, how can I do that? It‘s not true.‖

I said, ―It doesn‘t matter. For him it‘s true. Validate him, see what happens. It can‘t be
any worse than it already is.‖

She goes to the husband and says this. Then, after 37 years of hearing this diatribe at
every occasion that she‘s seen him, he says to her. ―Oh my god, you finally understand.‖
He‘s never brought it up again.

ALEXANDER: That‘s impressive.

PORR: It should be impressive to the doctors that borderline is a cognitive

distortion. They distort what happens and there is some memory deficit where, when it‘s
not resolved, it‘s like a car alarm that goes off over and over again. So, we do two weeks
of validation, though, validation is the common denominator of every class. And then we
do the skills training. Parents, when they know if their children are in DBT, can reinforce
the skills. Parents can do things like -- and spouses -- when they‘re upset.

These are things that I don‘t think even therapists understand. When somebody with
borderline personality disorder is upset, they haven‘t a clue what to do about it. So I go
around the room and I say to the family members, ―What do you do when you‘re upset?‖

―Oh, I run, I have a drink, I play the piano, I sing, I watch television, I read a book, I go
for a walk.‖ You ask a borderline person the same thing, it‘s ―Duhhhh.‖ They don‘t
know what to do.

So what I do on the phone is I give them suggestions. I say, ―Well, where do you live? ...
Oh geez, is that near the beach?

―Yes.‖

―Do you like to walk on the beach?‖

―Oh, yes, I love it.‖

I said, ―Well, why don‘t you go and take a walk on the beach and if you don‘t feel better,
call me back.‖

94
Never hear from them again.

But, you have to remind them of what to do. So, when you work with families, you teach
them to validate, teach them to be the memory. Teach them to remind them how to do
stress tolerance. You give the family something to do to help, so, the family doesn‘t feel
impotent, incompetent, helpless. They can do something to rescue their child without
being an enabler. They can actually find something to do.

So, everybody‘s happy. It decreases the stress in the family almost immediately. They
all report it. For me, it‘s the best part of all of the work that I do, because I get the most
satisfaction out of seeing this change. Something happens. Very often, after this class
the families, the person with borderline asks for a therapist . Whereas, before, they
wouldn‘t consider going, or they‘re ready to give up their old therapist who hasn‘t done
anything for them in three years.

After we do the skills, the last class we do is talk about advocacy so they can have some
hope. So, they have to come in angry, change to empathy and then I got to get them
angry at the system when they leave.

But, the other thing that we do, which came out through my own experience with my own
family member, is we have created a grief ritual, because nowhere does a therapist
address the crushing, incredible grief of having a child with a mental illness. And, that‘s
all across the board: schizophrenia; bipolar; autism; anything. These families are
grieving, even though they don‘t even know that they are. There is no ritual; there‘s no
public acceptance. I think we‘re all in perpetual mourning.

So, we do a ceremony. There‘s a wonderful article by Peggy McGregor on grieving for

the mentally ill child. So, we read it together and then each one of them will express
something that they are grieving for for themselves and the range, I mean, grown men
standing there and crying. Almost every time we have done it, the men cry. I just am
overwhelmed when I see that. And, we light a candle and we talk. Each person says
what they grieve for for their loved one, and for themselves.

Now, where does a family member get a chance to say, ―I grieve because I‘m not going
to have grandchildren; I‘m not going to go to the wedding. I grieve because she‘s never
going to have a whole life. The silliest things, I can‘t walk down the street and go
shopping with her and go in a restaurant and have a meal.

They just sob, and on their evaluations, they write that that is one of the most helpful
things. So, it‘s eight weeks and the families have asked for it to be 12 weeks. So, we are
thinking about that .
Then we did a graduate class and the graduate class is, to me, the most amazing, because,
the graduate class is really a support group. Now they have a language to talk in. They
have skills. They‘re not screaming and yelling and in crisis and they can come in and
share the problems they are having applying the skills and help each other.

95
Whereas if you start a support group for borderline families and they just come in -- I
mean I used to get sick from it. All they would do is, ―I hate my kid,‖ and this, and that,
―I want to throw him out‖ and ―Yes, throw him out.‖ It was so negative that I couldn‘t
bear it.

ALEXANDER: Last thoughts before we close. Anything you want to add -- a final
point?

PORR: Well, I think any therapist that wants to help somebody with
borderline -- it behooves them to study DBT. I find it most effective and wonderful
method and even if the patient isn‘t officially diagnosed, there‘s nothing that you learn in
DBT that‘s harmful. It helps everybody. I think it should be taught in schools. I think
that dropping patients from therapy because they exhibit the symptoms that they came
into therapy to get help with is an outrage. I think the stigma against families -- when
the therapist throws them out and drops them, it‘s the families that pick up the pieces.
That has to be recognized and respected. I think that the psychoanalysts, if they want to
help these people, there‘s a tremendous risk of suicide with these people. They need to
start looking at the biological findings and change what they have been doing. They have
the skills; they don‘t have to do big change. But it‘s an attitudinal change and the
government has to do more research.

And we need family groups. What can I say?

ALEXANDER: If somebody –the therapist -- wants to contact you, how should

they do it?

PORR: 1-888-4-TARA-APD or they can e-mail, it‘s taraapd@ aol.com or

the web site is TARA4BPD.ORG.

ALEXANDER: Thank you very much for this really informative interview.

PORR: Thank you.

To contact Valerie Porr and for information about the work of TARA, call
(212) 966-6514. The web site is TARA4BPD.ORG.

This concludes our interview with Valerie Porr. We hope you learned from it and that
you enjoyed it. I need to say here that the views of our speakers are theirs alone and do
not necessarily reflect the views of ON GOOD AUTHORITY.

Until next time, this is Barbara Alexander. Thank you for listening.

96
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview #8: “Dialectical Behavior Therapy”

Charles Swenson, M.D

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

Charles Swenson, M.D.

56 Main Street #202
Northampton, MA 01060
413.585.9161

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You will be reading or

listening to Interview 8 in ON GOOD AUTHORITY‘s program about ―The Borderline
Personality Disorder.‖

In this interview, we will take a look at a different theoretical and treatment model for
the treatment of Borderline Personality Disorder – Dialectical Behavior Therapy.
Dialectical Behavior Therapy–called DBT–is a comprehensive, cognitive-behavioral
treatment for individuals meeting criteria for borderline personality and suicidal
behaviors. Devised by Marsha Linehan at the University of Washington in Seattle, it
consists of a unique balance of behavioral change and acceptance strategies. Research
has shown that DBT reduces problems common to borderline personality disorder – in
fact DBT is one of only 2 treatments for Borderline Personality Disorder supported by a
randomized clinical trial. This research has shown that DBT has reduced suicidal
episodes, hospitalizations, and dropout from treatment, while reducing anger and
improving social adjustment.

DBT is based on a bio-social theory of borderline personality disorder based on a

synthesis of principles and strategies from behaviorism, Zen, and dialectical philosophy.
Dr. Linehan hypothesizes that the disorder is a consequence of an emotionally vulnerable
individual growing up within a particular set of environmental circumstances which she
refers to as ―The Invalidating Environment.‖ An emotionally vulnerable person in this
sense is someone whose autonomic nervous system reacts excessively to relatively low
levels of stress and takes longer than normal to return to baseline once the stress is
removed.

97
Our speaker now, Charles Swenson, MD, is currently associate professor of clinical
psychiatry at the University of Massachusetts Medical Center and medical director for the
Department of Mental Health in Western Massachusetts. While at the New York
Hospital Cornell Medical Center in White Plains, New York, he directed a
psychoanalytically oriented inpatient program for borderline patients. He later developed
the first DBT multiprogram on the East Coast for borderline personality disorder. Dr.
Swenson was twice named ―Teacher of the Year‖ by psychiatry residents at Cornell. He
publishes and lectures extensively on treatment approaches for borderline patients and
consults widely to systems and providers in implementing and applying DBT.

ALEXANDER: Dr. Swenson, I must confess to you that I know almost nothing about
Dialectical Behavior Therapy and I‘d venture to say that many of our listeners are not
very knowledgeable about it either. So, let‘s start from ground zero and if you could,
please give us an overview about what you think is the most important thing that a
beginning clinician should know about dialectical behavior therapy.

SWENSON: Well, Barbara, it‘s a treatment that began when Marsha Linehan
approached the problem of suicidal behavior and suicide in the 1970s. She was a well-
trained cognitive behavioral psychologist, and with great enthusiasm, she tried to apply
the principles of behaviorism to the treatment of people who repetitively hurt themselves
or try to kill themselves. In the process of that, she found that standard cognitive
behavioral therapies did not do the trick. She ran into enormous trouble because the
patients who were injuring themselves repeatedly or trying to kill themselves had
multiple problems and a great deal of suffering and long histories of difficulties. She
found in using standard cognitive behavioral approaches that patients felt routinely
invalidated, misunderstood, and pushed around, in a sense.

So, she didn‘t give up the ship, she didn‘t give up cognitive behavioral therapy. She was
convinced that the change-oriented techniques that are the essence of that therapy were
exactly what the patient needed, so she stuck to it, and stuck to it, and stuck to it and
treated patient after patient, with graduate students watching on in her laboratories at the
University of Washington. She would then regroup with them after sessions and try to
figure out what she needed to do to modify standard cognitive behavioral therapy in order
to reach and affect this population. As she did, the treatment gradually changed, so that if
I gave sort of a long sweeping overview of what has happened, you would have to say
that at the core of this therapy is the standard cognitive behavioral therapies, but that they
have been modified.

The main ways that they have been modified are that she has had to add in a very
sophisticated and substantial set of strategies to evaluate clients on a regular basis while
she is trying to get them to change with cognitive behavioral techniques. So, in a sense,
what happened is that she had to balance the push toward changing behavior and the push
toward changing thoughts, and the push towards changing emotional responses, and
balance all of that with a sort of compassion, validation, and being absolutely radically
accepting of the client and what their situation is. This kind of balance and a fluid back

98
and forth between validation and change defines the essence of this therapy.

Finally, just in terms of this overview, the word ―dialectical‖ applies to a number of
things, by now, in this therapy, which is a pretty sophisticated and complex therapy. But
first and foremost, it applies to the balance, the synthesis of trying to change the patient‘s
behavior and trying to radically accept the patient as they are, almost in the same moment
many times. So the ―dialectical‖ in dialectical behavior therapy refers to the attempt to
synthesize the polarities that come about with trying to change and trying to accept the
patient and going back and forth and back and forth and back and forth in order to help
the patient move forward.

So, you have the three fundamental philosophies that underlie dialectical behavior
therapy (DBT), with the three philosophies being number one, behaviorism as a
philosophy; number two, radical acceptance and especially, relying on approaches
borrowed from spiritualism, including Buddhism but also from a number of other
spiritual traditions, the emphasis on ―mindful,‖ ―compassionate,‖ ―being in the moment,‖
radically accepting things as they are.

So, again, Philosophy number one, behaviorism balanced with Philosophy; number two,
which is the concepts and philosophy of mindfulness and acceptance; and Philosophy
number three being dialectics, which is the attempt to integrate the first two philosophies.

But dialectics carries with it itself a set of concepts and strategies within the therapy to try
to be dialectical, to try to synthesize polarities and synthesize black and white into ways
of thinking and feeling that are more balanced then either side of a given black/white
polarization. So, as an overview, that‘s sort of a philosophical overview of where it came
from, how it got to be where it is and what the underpinnings are.

ALEXANDER: I‘d like to ask you about how this does or does not work with, let‘s say,
ego psychology, or self-psychology or the various psychodynamic models. I understand
you were involved with the first inpatient program for Borderlines --a psychodynamic,
long-term, inpatient program, right? You introduced DBT into that program, so I‘m
thinking you would be the best one to tell us about what can be put together and what
can‘t be.

SWENSON: Well, it is true, I was psychoanalytically trained and for many years, I
used psychoanalytic approaches with people with borderline personality disorder. I
directed an inpatient unit that specialized in that and worked a lot with Dr. Otto Kernberg
in the psychoanalytic tradition and I felt very good about what we were doing. At the
same time, over the years, I felt that I ran into serious limitations in the psychoanalytic
approach and it was in that context that I encountered dialectical behavior therapy in the
mid 1980s and began to study it.

I felt that in the psychoanalytic work that my staff and I were doing in the inpatient unit,
we were not offering our patients enough in the way of concrete, practical, hands-on help
in learning how to cope with situations that provoke lots of emotions: with relationships

99
and with conflicts in relationship, and just getting about life and organizing life and
keeping it up even when you are faced with emotional storms. There are lots of things
that most of us do to manage life and manage emotions and manage relationships and I
noticed, over time, that many of our patients were just remarkably deficient or not using
skillful ways of coping with all of these situations. So, I was wondering whether it would
be possible to directly teach those things and reinforce them in our patients‘ lives in
addition to doing the kind of interpretation of underlying intrapsychic phenomenon.

As I went along, I then noticed Linehan‘s work which offered a whole skills training
package directly pointing to this population of people with intense emotions and
dysregulation of behavior as a result of that. So, I started using that skills training
approach and then I started learning about the rest of DBT and learned that, in fact, it
isn‘t just a skills training approach; it‘s a very comprehensive approach that includes a
sophisticated individual psychotherapy in addition to the skills training and in addition to
coaching the patient in the community through telephone calls now and then, when they
need help integrating the new skills that they are learning. So, I started to like the overall
approach, not just the skills training.

A couple of other things that I found useful is that DBT very explicitly integrates a
biological understanding, looking constantly at the latest research on the brain and how
behavior and emotions are regulated, in an attempt to incorporate that into the treatment,
and also looking at the research on PTSD and trauma in the histories of these patients.
Linehan directly attempted to integrate the approach to the traumatic history and PTSD
symptoms into the treatment of borderline personality disorder and I found that very
appealing.

Finally, one thing that has hugely differentiated DBT from most psychoanalytic
approaches is the emphasis from the get-go on empirical validation of the approach. Like
many behavioral treatments, DBT begins with an assumption that you need to measure
the outcomes of your treatment. Linehan published her first randomized controlled trial
demonstrating the success of the treatment in 1991 and now there are six or seven
randomized controlled trials on DBT in the literature. In every one of those trials, they
are starting to see the pattern that DBT really does reduce the target behaviors, which
include suicidal behaviors, keeps people out of hospitals more than the control groups,
and keeps people in therapy. So, I really liked the empirical approach. There was very
little and still is very little empirical validation of the psychoanalytic approach, which has
been used a lot longer. So, I liked all of those things about the behavioral approach and I
felt that it was made sophisticated by balancing it with dialectical approaches and with
approaches based on mindfulness practice and acceptance.

So, there is some overlap, but DBT is probably driven by a more practical, ―Let‘s get this
behavior under control,‖ and ―Let‘s analyze the functions of these behaviors,‖ and ―Let‘s
offer new alternative, skillful ways of being and behaving‖ to replace such behaviors as
suicidal efforts and substance abuse or eating disorders or a lot of other behaviors that
come up in borderline personality disorder.

100
ALEXANDER: Do you know if those changes have been measured over a long period
of time? One of the things that I have been concerned about with DBT is: Are the
changes just kind of short lived or are they enduring over time?

SWENSON: The data so far on Linehan‘s first study -- it‘s a one year treatment, so,
she studied the patients for one year and then there was a follow up study one year later,
after they had finished the one year treatment. The changes that they made sustained
themselves over one more year. In terms of empirical data, that‘s all we‘ve got. That‘s
the best data we‘ve got. It‘s more data than we have about any other approach to
borderline personality disorder, but it‘s still massively deficient. We do not know about
the long haul after a patient receives DBT. The encouraging thing about other cognitive
behavioral approaches is that it looks like the cognitive behavioral approach for, let‘s say,
panic disorder or other anxiety disorders -- when people go through the treatment, they
do often maintain gains and often improve further after the treatment‘s done. But, we
don‘t know that about DBT per se and what we are treating in DBT are very long term
conditions. So, we need that data and we just don‘t have it yet.

ALEXANDER: But, what a great start.

SWENSON: It‘s a great start. We‘re out of the starting booth, but it‘s very hard.
The amount of work to get even one psychotherapy study done, according to really
rigorous methods in science is a very enormous amount of work and it‘s very impressive
that we have six randomized controlled trials. But, now we need more replications of the
original work and we need it to be done in more different places in the world, which is
being done, and we need it to be done over longer periods of time. So, hopefully all of
that will be emerging. There are studies still going on.

ALEXANDER: To go back to the borderline personality disorder, in DBT, is there a

specific theory of causation?

SWENSON: Yes, there is. It‘s very essential to the approach. It is not only used as
the theory in the therapist‘s mind, but, as is more typical of behavioral treatments that are
kind of pragmatic and kind of right out there with the patient, the theory is shared with
the patient, is shared with the family, and is repeatedly referred to during the course of
the treatment.

So, in a nutshell, the theory in DBT of how these behaviors came into being is that it is
considered a Transactional theory. In other words, there are two different qualities or two
different components to the theory: one is a biological component; and the other is social
or environmental. So, it‘s called, in DBT, the biosocial theory of etiology and before I
tell you the theory, the one other thing that is important about the theory is that it‘s just
not to explain the cause, in other words, historically, the cause or etiology of the disorder;
it‘s also used to explain the perpetuation of it: the maintenance of the disorder. Why
doesn‘t it go away from one day to the next? The same forces that historically that
caused it are still there and are perpetuating it, so those forces have to be addressed. So,
the main two forces are biological and social.

101
In the biological one, the theory is that there is difficulty in the patient‘s brain in the
regulation of emotions and regulation, usually, of several emotions like anger, sadness,
shame, fear. Commonly, the patient with borderline personality disorder has a long
history of a vulnerable system regulating emotions. There are now systems in the brain
that are being increasingly understood. Each emotion has somewhat different system, so
that there is difficulty regulating emotions. Once an emotion gets going in the brain of
somebody with borderline personality disorder, it‘s very often hard to bring it under
control. It gets extreme; it gets intense. It‘s hard to bring it back to baseline. In that
way, the patient suffers an enormous amount of distress, pain, fear -- fear of their own
emotions, because they can‘t control their own emotions the way that people who are
functioning better than they are able to do.

And, the biological side is thought to be different in each case. It can be genetically
determined, in part--one could come from a family that has a lot of history of mood
disorders or anxiety disorders, or parents or other family members that have dysregulated
emotional lives. So, it can be genetically determined. It can also be determined by
having a pretty bad set of experiences in early development. The experiences of abuse
or profound rejection and disappointment and separation can sensitize the emotional
system, as has been shown now in research with trauma at almost any age. It actually
changes the brain and those changes remain for a long time. So we think that in people
with borderline personality disorder, the biological component comes from genetic as
well as environmental determinants historically, but what you‘re faced with, when you
have a kid or an adult with borderline personality disorder, is somebody whose brain is
not good at regulating emotions. That‘s one side of the equation.

The other side then is you take that person who is highly sensitive, and highly reactive,
who can‘t get their emotions back to baseline and they are living, of course, in a context
with other people, and if they‘re in a context where the other people routinely (the term
we use is) invalidate the responses of that individual, then there are all kinds of
unfortunate consequences that result eventually in borderline personality disorder.

What I mean by ―invalidate‖ is -- well, really it‘s several features, but the essence of the
idea is that you‘ve got a sensitive, reactive person who‘s having emotional responses in a
family, let‘s say, for instance. And, the family starts to regard those responses as suspect
or as ridiculous or as pathological, or as being trouble and therefore they really don‘t help
the kid understand, accept, make sense of and deal with the natural and perfectly valid,
emotional responses that they are having. Instead, they are blaming and dismissive, and
disregarding and sometimes ignoring, to the point where the kid is living in kind of a
fenced-in area where everything they are saying and doing, unless they‘re just being
quiet, is being put down or dismissed.

The consequences of this for the kid are –now, the kid is a sensitive, reactive, emotionally
vulnerable person who‘s living in an environment that isn‘t taking that into account and
that, in fact, is dismissing it and disregarding it. The kid then themselves start to take in
that attitude of disregarding and dismissing and blaming their own emotional responses
as a way of coping with them, which really doesn‘t do the trick. So, the person keeps

102
having emotional responses and blames themselves. They look for validation. They may
get it somewhere. They often don‘t get it, and they start to look to other people to try to
figure out how to live their lives, because they can‘t trust their own emotional response
system. So, they blame themselves, they invalidate themselves, they don‘t learn more
sophisticated and flexible ways of having emotions and channeling emotions. There are
all kinds of skills involved in doing those things, but you need, first of all, to have
somebody show you those things and you also need to have it happen in a context where
these things are more accepted. So, that‘s it just in a nutshell.

There‘s a lot more to this when one studies the treatment, but as an overview, the theory
is that it‘s this back and forth between the sensitive, biological system and the
invalidating environment that eventually produces the person who uses extreme
behaviors like suicidal behaviors, let‘s say, to regulate their emotional system. Some
people find that if they cut themselves, in a state of heightened tension, distress, anger,
that actually for some physiological reason, self-cutting reduces the stress. So, they start
to cut themselves or they start to envision suicide as a way out of an intolerable situation.
Or, they start to use alcohol or drugs as a way to basically anesthetize themselves so they
can cope with life, given that they don‘t know what to do with these repeatedly difficult
emotions. Or they develop eating disorders, or they develop all kinds of other behaviors
that are the hallmarks of people who are unstable emotionally and end up with borderline
personality disorder.

ALEXANDER: I suppose that positive emotions will count in there too, like love.

SWENSON: Love, yes. Joy, yes. Another interesting emotion that is dysregulated
in people with borderline personality disorder is Interest.

Basically in research on primary emotions that began with the evolutionary research of
Darwin and has been updated over the years and taken to other levels, it‘s been found that
there are three positive emotions like joy and love and interest that are critical in life in
keeping us moving forward, and going and bonding with other people, and feeling like
life is worth it and life is stable and life is fun.

But in the borderline personality disorder, these emotions are often dysregulated as well,
so as soon as somebody, let‘s say, feels joy, there is an immediate mistrust of joy. There
is an immediate fear that can be set off by joy as soon as one realizes one is feeling pretty
good -- sort of like ―When is the other shoe going to drop?‖ When you‘ve lived a life
history like most people with borderline personality disorder, you‘re very suspect and
mistrustful of positive emotions and so those are dysregulated too.

So yes, there are about five or six negative emotions and these three positive emotions.
In different patients, you will find different degrees in which these different emotions are
dysregulated, but by and large, it is a pervasive problem that comes up day in and day
out. It comes up in jobs. It comes up in relationships. It comes up in the family. It
comes up in therapy and it has to be addressed everywhere in order for the person to

103
develop a quality of life that is not based just on escaping and avoiding emotional life all
of the time.

ALEXANDER: With all these different characteristics of the borderline personality,

does that make assessment easier? I think one of the big concerns that therapists have is
that they don‘t want to get into a situation where they have gotten involved with a
borderline personality in their practice, in their work, and they‘re not prepared to deal
with it; they‘re not emotionally prepared or they already have two or three other
borderlines and they are going to get burned out. So how do you judge whether the
person is truly borderline and that you can work with them?

SWENSON: Even with the most careful of approaches, it can be complicated

because often people with borderline personality disorder have a lot of competence in
certain areas. That can include sitting down and talking, and regulating their life for a
while. They also have other disorders, so often, you think, at the beginning, that you are
treating somebody with a bipolar disorder, which is complicated enough to work with
even without borderline personality disorder in addition, or somebody with major
depression or somebody with OCD (Obsessive Compulsive Disorder). All of these
things can go along with borderline personality disorder and so you can think things are
better than they are.

Then, as soon as you get engaged in therapy or more psychiatric treatment, you find that
you are in unbelievably difficult struggles. You‘re frightened. You‘re frustrated. It can
happen fairly quickly because the behaviors can be really difficult. After all, they grew
out of an invalidating environment and this can create the circumstances that make a
therapist feel like being invalidating, feel blaming, feel upset, and feel frightened and
distanced from the patient and so, yes, it is a very important matter to diagnose.

There are tools to do diagnosis. There are tools: there are paper and pencil tools; there
are structured interviews; there are some things just as simple as looking up the
borderline personality disorder in the DSM and going down the characteristics and
talking to the patient about them, if you begin to suspect that a person has some of them.
You can ask former therapists and family members. Because this is a long-standing
disorder – that‘s what makes it a personality disorder, that it goes on for a long time -- it‘s
important in doing a diagnostic assessment that you check with other people who have
known the patient, whether it‘s family, or former therapists, or psychiatrists or programs
and you find out that lo and behold, there have been two or three therapies that ended
unfortunately, and relationships in the family are kind of difficult and intense or very
distant, and you start to see a pattern where the person‘s difficult emotional life has led to
burn-out on the part of other people, and has led to instability in jobs and personal
relationships. You start to inquire about former therapies and how it is they came to a
close and you start to find out that they sometimes came to a close because there were
difficulties emotionally and interpersonally that never were effectively enough addressed
and the person moves on, so you see a pattern of chaos, intensity, instability, reactivity.
You can‘t just see it in an interview. You have to do a structured interview and usually
supplement it by talking to other people.

104
You put together that information and you start to say, ―Aahh.‖ Maybe this person, in
addition to having the Axis I disorder that they have, might also have a personality
disorder and that personality disorder might be borderline personality disorder. As soon
as you realize that, or you suspect that, you start to raise the question of what is this
treatment going to require, because it often requires more. It often requires more time. It
often requires a different approach and it really focuses on the suicidal behaviors and
other dysregulated behaviors in a very focused and forceful way as part of the treatment,
rather than just sitting back and seeing how things unfold, which can really be a problem
with borderline personality disorder. You have to take an active stance towards the
patient and the behaviors that are destroying their lives.

ALEXANDER: That would not be good for a psychodynamic approach. You can‘t just
sit back.

SWENSON: Well, no, but that groups psychodynamic approach is in a broader way
than they deserve. There are psychodynamic approaches that have been adapted to work
with borderline personality disorder that take a very proactive approach to these
problems. For instance, Dr. Kernberg‘s approach, compared to psychoanalysis in its
more standard form, required intense focus on behaviors that appeared to be aggressive or
destructive. It really asked about those and tried to set up contracts with patients that
helped to contain those behaviors. So, the serious psychodynamic approaches for
borderline personality disorder have all had to take into account what I am talking about.
They‘ve all had to make adjustments and they‘ve all had to become more active, directive
at times, and forceful than standard psychoanalytic treatment with people who don‘t have
this disorder. The borderline patient over the years has taught all models to adjust
themselves to the problems, because otherwise they just won‘t work and they die out, and
the therapists just burn out and they stop treating the patients.

ALEXANDER: DBT is so complex. Do you think it would be possible to give any kind
of a clinical example so that we could see the strategies or the target behaviors? Let‘s
take, as an example, how one would deal with, let‘s say, the person who wanted to leave
the therapy session. Let‘s just take that particular thing.

SWENSON: Okay, if you just started with that, let‘s say you had somebody who was
in therapy because they had repeated suicidal behavior requiring some hospitalizations or
some emergency room visits, and sometimes they‘ve threatened to commit suicide or
threatened to hurt themselves at key moments in relationships where it really brings up
the attention of the other person and provides more proximity and more active responses
from the environment, and also gives the person the feeling that they are trying to handle
a desperate situation more actively by threatening suicide. So, let‘s say you have
somebody that has that and maybe has two or three other sets of behaviors that are, you
know, difficult to manage and are hurting their lives.

So, they‘re in therapy and it‘s five minutes left to go in a therapy session and you think
that things are going not too badly, but then, the person says, ―You know, I know it‘s just

105
about time to go and I just want to tell you that I‘m not sure you‘re going to see me
again.‖

The therapist then says, ―What are you talking about?‖

―Well, I don‘t know. I just might not be able to get back here. Who knows what could
happen between now and the next session?‖

It becomes an implicit but obvious threat that ―I might die before next time‖ and at that
point, usually most therapists in that situation suddenly get more active -- it‘s sort of
predictable -- and start to ask questions and are realizing that the session is coming to a
close and the intensity is rising and there is an attempt to end the session, but also
determine whether the patient is suicidal or whether their suicidality is just going to be
during those five minutes. So, that is a very typical situation.

Now, DBT is a behavioral treatment. Let me take a step back. In DBT, the essence of
what you‘re trying to do in addressing lots of behaviors-- whether they happen in the
session or out of the session-- is you need to be able to assess the function of the
behavior. You don‘t know. Some therapists of some certain models might assume that
this behavior is designed to prolong the therapy session, or that it‘s designed to torture the
therapist for not having paid attention earlier in the session, or that it has some intent.

But, I think what you do in the behavioral model is you immediately think, ―AhHa,!
Here‘s a problem behavior.‖

Next thought: ―I wonder what the function of this behavior is?‖

Next thought: ―How do I determine the function of this behavior?‖

In DBT, a standard approach is called ―behavioral analysis,‖ which is to analyze a

behavior with respect to what its function is. By function, I mean, what is maintaining
that behavior?

So, if somebody just did this once in a therapy session, it‘s not such a big problem in the
long run. But, if somebody uses this repeatedly as a way to cope with difficult situations
or with separations or with the ending of sessions, then you‘re going to want to target that
behavior for assessment, to figure out what is driving this behavior. Why is this person
doing this, and not to think that you know ahead of time.

Also, in DBT, you‘ll start thinking, I bet this behavior, this dysfunctional behavior, has at
least, in part, the function of regulating emotions because the core of the theory is that
there is a dysregulated emotional life and this person is probably feeling, somehow, that
some emotion is getting out of control or something is getting dysregulated here, and let‘s
see if we can figure out what the problem is.

You also are very aware in DBT, as a behavioral model, that if, in that situation, you

106
prolong the therapy session, and if that is what the function of the behavior was -- in
other words, if the behavior is going to be reinforced by extending this session a few
minutes -- then you really want to try not to reinforce that behavior. You‘d rather
prolong the session if somebody said, ―Could you please prolong the session?‖ because
that is an effective strategy in life--to ask directly for what you want.

You really don‘t want to prolong the session, but you also have the principle of
determining safety. So, you have to be good at doing a quick suicide assessment and
there are just several questions to ask and several things to consider.

Or, if you know the patient over a longer period of time, you might need to say at that
point, ―Look, in this situation, I could consider extending the session, but you and I both
know by now that if I extend the session, even if this is not what you consciously
intended, it could have the effect of reinforcing this behavior. Here‘s what I think we
should do. Between this session and the next one, I‘d like you to write down a step by
step story of what went on towards the end of this session that might have led you to
make this kind of comment at this point in the session. Let‘s analyze this situation and in
our next session, let‘s take this out and start working on what it is that leads you to do
this, because this is not a functional way to communicate to me.‖

Now you need to do this and at the same time, you need to validate that there is a
background to this, that the person must be feeling pretty upset. You have to put all of
this together in a dialectical way. So, you might say, ―Look you‘re communicating to me
that you might not make it to the next session. You‘re communicating a suicidal thought
to me. So, this suggests to me that you‘re in some kind of pain. There is some problem
here. There‘s something you‘re having trouble with in our session or out of the session.
There‘s something going on here, and am I right to think that you‘re in some distress that
you would be saying that?‖

Now, the person may say yes or no. But I think to communicate the validation that there
is a problem here and not to disregard it, not to dismiss it, and not overreact to it becomes
this balancing act. So, I want to validate the person and then I want to figure out what the
problem is and figure out a way of addressing it that doesn‘t reinforce the behavior. I
might, in the next session, start to teach a more skillful way of coping with anxiety that
emerges with the last five minutes in the session. I might say, ―This is a totally valid
problem. Of course you‘re anxious about leaving the session,‖ if this is what we came up
with. ―Therefore, we need to figure out a way for you to skillfully handle anxiety or fear
at the end of a session when you‘re about to walk out the door. So, let‘s start to talk
about what some of the skills are in the DBT Skills Manual that could help you cope with
those five minutes and the minutes leading up to that and then deal with the rest of things
so that you don‘t get into that situation.‖

So, you‘re blending together validation with problem solving and, in kind of a rigorous
way, you‘re weaving in skills, the use of skills, the idea of skills, and you‘re weaving in
the biosocial theory by assuming that this is a behavior that has arisen to regulate
emotions that are out of control in an environment that typically, in the past, has been

107
invalidating. It might be that the therapy is in some way invalidating. During that
session, for instance, it might be that the therapist missed several cues that the patient was
upset and now the patient is, in a dysfunctional way, communicating this unrecognized
upset toward the end of the session, before they get out of the door. And, it‘s the
therapist‘s last chance to recognize it, validate it, and start to try to help him find a more
functional way to express the problem.

ALEXANDER: How would a person learn how to do DBT? What kind of training is
required?

SWENSON: Well, there are really several steps to the training. It partly depends
upon where somebody is beginning from. If somebody has already been trained pretty
well in cognitive behavioral therapies and therefore knows the bread and butter
techniques, such as cognitive therapy, or the use of exposure treatments, which is a whole
set of treatments for some disorders, or the use of contingencies, which means things like
reinforcement and conditioning and skills training -- if somebody is versed in that whole
way of going about doing treatment, they have a leg up in learning DBT, because now
what they need to learn is how to apply that model to the borderline patient. That
involves learning mindfulness approaches and dialectical approaches and learning the
model and getting supervision. Somebody who is doing that can start out by reading
Linehan‘s book and reading her Skills Training Manual, going to a workshop, let‘s say a
two day standard introductory workshop in DBT.

Another part of DBT that I haven‘t mentioned yet is that you do it with a team of
therapists. There is really no such thing as being a solo therapist doing DBT all by
yourself. DBT assumes that you have a team of people that meet weekly that are
working on applying DBT together. So, one of the wise things to do right from the
beginning is to find a group of people, either in a private practice, or in an agency, or in a
hospital that is going to meet on a regular basis, read the book together, start to think
about what their questions are, go to a workshop, maybe hire an expert DBT trainer to
come and do some consulting or supervision.

Ultimately, there is another step in training that many people choose to take, which is a
10-day workshop where teams come as teams of three or more and participate in a pretty
intensive workshop. You start with five days of instruction and experiential training and
video tapes, and so on, and then you go on your own as a team for six months and you
have homework assignments and you try to apply the treatment. You try to develop DBT
in your practice or your program and then you come back six months later for five more
days where you present your work and there is consulting and teaching based on actual
clinical situations. So, stepwise, people get together as a group, they read, they study
together, they go to workshops. They get supervision or consultation. They might go to
a ten-day workshop. They might go to local DBT programs or regional DBT programs
and sit in and see what they are doing or study what they are doing. That‘s as far as we
have come so far. Then there is individual therapy supervision, after going to ten day
workshops. I think 2000 or 3000 people have been through the ten day training by now
and many, many more than that have gone to workshops. There are programs established

108
in most states in the country, so people can usually look around somewhere in their
region and find DBT programs that they can also go into and learn in.

ALEXANDER: Now, I have a question from a listener that was sent into me for you.
The question is from Dr. Margaret Wool, and she says, ―Please include some integrative
piece on how therapists make a selection of approach or even combine theories for an
eclectic approach to the borderline person. Is that possible?‖

SWENSON: You see, that‘s a very interesting question to me, because that is what,
over the years, I do, having started out as a psychoanalytic therapist, and still preserving
some psychoanalytic type of work in the practice that I have now with some patients. I
actually wrote an article at one point called, ―Kernberg and Linehan: Two Approaches to
the Borderline Patient,‖ where I was comparing and contrasting. I addressed the issue
there of integration.

It‘s very complicated, because -- think about it like learning a new language. I‘m in the
middle of learning Spanish now, for instance. At this stage in life, it‘s very challenging
and yet the idea of learning Spanish that really is the state of art -- for lots of good
reasons, and based on research in learning languages -- is the immersion technique. I
mean, you don‘t go in and learn Spanish by having a repeated discussion of how to
integrate this with your English. They don‘t even encourage you to translate. As I learn
Spanish, they are not encouraging us to translate each English word into Spanish. They
are encouraging us to immerse ourselves in Spanish speaking environments and in the
classroom in a Spanish speaking environment and learn the ropes of speaking Spanish.

That‘s what I recommend. There are certainly ways to integrate. We have no data on
whether an integrated model is helpful. There is no development of an integrated model
to really teach. So each person is on their own. But, what I recommend in response to
that kind of question is this: rather than try to integrate from the beginning, go learn the
other model. Learn it in pure form and then, if you‘ve learned it, you are in a position to
think about integrating and think about how it might work for you, because there isn‘t an
integrated model that anybody has put out there that has any empirical validation. So,
integration is almost inevitable. I probably do DBT in a different manner than somebody
who did not have a psychoanalytic background. There are lots of skills I learned in
psychoanalytic work that are transferrable into doing DBT, but also, if I tried from the
beginning to constantly integrate it, I never would have learned DBT.

ALEXANDER: That‘s an excellent point, excellent. Dr. Swenson, we‘ve really run out
of time here. Is there anything you‘d like to add before we close? This is such a big
topic.

SWENSON: It is a big topic. I think this is a reasonable overview. There are lots of
things I could add, but the idea right now I would like to highlight about DBT is that we
are addressing a group of people who suffer immensely and, in fact, in their relationships,
other people suffer too. It‘s a huge problem. It‘s a painful problem. People kill
themselves based on this problem. We are beginning to have a treatment with some

109
empirical validation. I‘m not sure it will, in the long run, be THE treatment. What we
really need out there is people who are doing their treatments to study them and to
document the outcome of their treatment so we can compare them to what is going on in
the studies of DBT. In a spirit of DBT, it would include the idea that if another treatment
came along that better demonstrated itself to be empirically valid, then you would want to
compare it to DBT and if the other one won out, the DBT therapist should shift, so that
the larger commitment of a DBT therapist is to behavioral outcomes and the degree that
behavioral outcomes are achievable in DBT. That really is the essence of why one would
do it and why one would stick with it.

ALEXANDER: Dr. Swenson, thank you so very much.

SWENSON: You‘re welcome.

To contact Dr. Charles Swenson, call 413.585.9161

This concludes our interview with Dr. Charles Swenson. We hope you learned from this
interview and that you enjoyed it.

I must say here that the opinions expressed by our speakers are theirs alone and do not
necessarily reflect the opinion of ON GOOD AUTHORITY.

Until next time, this is Barbara Alexander. Thank you for listening.

110
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview #9: “BORDERLINE MOTHERS”

CHRISTINE LAWSON, Ph.D.

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

CHRISTINE LAWSON, Ph.D.

Suite 50, Boone Woods Office Park
Zionsville, IN 46077
317.873.1080
[email protected]
(to order her book, Understanding the Borderline Mother, contact Jason Aronson Press;
www.aronson.com)

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or

reading interview #9 of our program on the Borderline Personality Disorder (BPD).

It is becoming increasingly clear that BPD emerges from vulnerabilities in brain function
around regulation of affect and impulse control. Although we are only beginning to
understand the biologic aspects of BPD, research shows that the development of this
disorder depends on an interaction of constitutional biologic vulnerabilities with often
adverse environmental circumstances during development. So it is not surprising, then,
that the neurological functioning of children of borderline mothers would be impacted by
deficits in early parenting and by the projection of massive states of confusion and terror
onto these children by these borderline mothers. We‘ll hear about this in this interview.

Christine Lawson, Ph.D., LCSW, received her PhD in Family Studies from Purdue
University. She is the author of a book and numerous articles on the Borderline Mother.
Her book is entitled Understanding the Borderline Mother: Helping her Children
Transcend the Intense, Unpredictable, and Volatile Relationship. Her article, ―Treating
the Borderline Mother: Integrating EMDR with a Family Systems Perspective,‖ appears
in MacFarlane‘s book Family Treatment of Personality Disorders. In her interview with
us, which you will hear next, she explains how she uses EMDR in her therapeutic work.

ALEXANDER: Dr. Lawson, I‘d like to begin by just asking you your thoughts about the
movie, ―You Can Count on Me,‖ and your thoughts about whether the character Laura

111
Linney portrays is a borderline mother or not and then we can go into your descriptions
and your understanding of the borderline mother.

LAWSON: I think that it is an interesting question, because there is a lot of

confusion about borderline traits versus true borderline personality disorder. In that
movie, as I recall, Laura Linny‘s character does not fit my criteria for a borderline mother
because she does not exhibit evidence of splitting, and I think splitting is the most
important indicator of borderline personality disorder. She does not have an extreme
fluctuation in her mood that is triggered by an interaction with her primary attachment
figure. Some people might argue whether there are other parts of her behavior that some
borderline mothers do exhibit. I really cannot think of a specific example, because she
does not have the rage. She has a little bit of a remote relationship with her child, but yet
she is very concerned about his well being. Remember how she left the office to make
sure that he was okay, even though she might get into trouble?

ALEXANDER: You‘re right, that‘s right. She was protective of him. She really tried
to spare him.

LAWSON: His needs, in her mind, were more important than her needs. She had
to work, because she was a single parent, but in many ways, she exhibited that her
priority was his well being and she was very concerned about her brother‘s taking him to
the pool hall and some of those interactions that she was observing between her son and
her brother. So, I would not classify her, at all, really frankly as being a borderline
mother.

ALEXANDER: Let‘s talk about the borderline mother and how you define that. You
have four different types in your book. Let‘s just go through your understanding of the
borderline mother.

LAWSON: Well, we ought to start with the DSM criteria and what we have to
remember as clinicians is that out of that nine criteria, we only need five to make the
diagnosis. But, I think what has happened, just a result of being human as clinicians, is
that the most alarming behavior, which is the suicidality, or suicidal impulses or self-
mutilation, or impulsivity, draws our attention, attracts our attention, elevates our concern
and therefore we associate, almost automatically, that anyone who exhibits those
behaviors is a borderline. Now, that may or may not be true, but what we therefore miss
is that those traits are not exhibited by many, many borderlines.

Jerome Kroll says that there are 56 different combinations of symptom clusters that meet
the criteria for borderline personality disorder. So, you could have any five of those nine
criteria and still meet the diagnosis of borderline personality disorder without having the
most dramatic and obvious symptoms.

That is why I have separated out four different configurations of borderline mothers,
because some do not present as angry and rageful, some do not present as suicidal, some
do not present as being angry and demanding, and there are borderline mothers who are

112
very, very loving and I would say all borderline mothers in one ego state aren‘t loving,
caring mothers. It is their inability to regulate their emotion that creates the
unpredictability in their relationship with others, particularly their children.
As I have sorted through both what I have witnessed clinically in terms of a review of the
literature, I divided the types of borderline mothers into four general categories. Those
categories are based on their underlying dynamics and how they experience themselves.
Actually, for the names of these -- I always get real nervous when I mention these names
because I know they can sound demeaning -- I‘ve used fairy tale kinds of names because
that is how I have heard my borderline mother patients describe themselves. They have
used these terms, and when I‘ve treated their children, whether they have been adult
children or young children, I‘ve heard them use these terms as well. So, I think that
makes it much more understandable to the public and it is certainly not meant to be
demeaning.

Let‘s just start with the ―waif‖ mother, because I think her underlying experience of
herself is the one of victimization and helplessness. I use the parallel of being like
Cinderella to bring that down to earth in a way that people can understand because very
often, the waif mother did have an experience in childhood where she was mistreated,
abused, neglected, much like Cinderella. Unfortunately, what happens is that she tends to
feel so victimized that her defense mechanism was to relinquish hope and to relinquish
control, so in her parenting style with her children, she tends to not be able to set
boundaries, not set structure. She pretty much lets them do whatever they want. She
often -- I mean, very often I have seen this happen -- she ends up feeling abused and
exploited by her own children. Basically her emotional message to her children is that
life is too hard, which it was for her. She projects that through her behavior and then, of
course, tends to be re-victimized a great deal.

The second category is the ―hermit‖ mother. Her underlying and inner experience of
herself is primarily fear. Often these types of women were terrified as children because
somebody she trusted did hurt them, either sexually abuse them or physically abuse them.
They are so vigilant about watching for danger that they very rarely come to therapy.
Now, we hear about them through their adult children who come to us and say things
like, ―My mother is paranoid. My mother doesn‘t trust mental health professionals. My
mother doesn‘t trust anybody. My mother is very jealous of my father.‖ The underlying
theme there is this paranoia and distrust, which is why so few come to therapy.‖

ALEXANDER: Would you say that mothers who are agoraphobic, in other words, who
won‘t leave their homes, would they be …?

LAWSON: It could well be.

ALEXANDER: But, it also might not be that they would be borderline.

LAWSON: Right, we can‘t say conclusively, of course, that that would be true.
There are a lot of things, just post traumatic stress disorder, that could cause agoraphobia.
Again, what you would have to really look at and listen carefully for through the report of

113
a family member is whether or not there is this evidence of splitting. That is what the
common denominator is in all four types of borderline mothers. In my view, if there is
not the perceptual splitting, it‘s not a true borderline patient.

Let me go quickly through the ―queen‖ mother and the ―witch‖ mother.

ALEXANDER: Okay.

LAWSON: The ―queen‖ mother -- her inner experience is one of deprivation and
emptiness. Often her childhood was not so much one of abuse, and this is fascinating to
me, but was one of emotional deprivation. She did not feel loved and in fact was not
truly loved in the way that she needed to be. So, therefore, when we think about it,
anytime we feel truly deprived, the defense against that or the compensation is
entitlement. So, the ―queen‖ has this extraordinary, sometimes outrageous sense of
entitlement and often exploits others without being aware of it, or sometimes is aware of
it and feels completely entitled because, from her perspective, it‘s about her survival and
she does think, ―Well, I have to have this. This is more important to me.‖ Now, she can
also be very vindictive, because she is very determined to have what she needs, and it can
be kind of scary in terms of how far she is willing to go. Sometimes, she assumes the law
doesn‘t apply to her. She doesn‘t have to follow the rules in life, and that can be
dangerous. Her emotional message to her children, basically, is ―life is all about me,‖
because she is feeling that her survival is always, always being threatened.

Finally, the last and most severe form of a borderline mother is the ―witch‖ mother and
the core of the witch is this annihilating rage. Some mothers, and you could think of
these all as being ego states, but the witch particularly is an ego state that can live within
any of the other three character profiles. The queen mother can have an inner rage within
her that when it comes out, she can be experienced as a witch by her children. When the
witch mother is in that state, she is very susceptible to psychosis, to not remembering her
rage, because when rage is that intense, it does impair memory functioning. But, for
children who live with a mother who is in this constant state, it really is like living in an
emotional prison camp. Her emotional message to her children is, ―Life is war.‖

ALEXANDER: I was very fascinated by your comparison of children of borderline

mothers to concentration camp survivors.

LAWSON: That would not be true. I did clarify -- I remember writing that
sentence and being very careful about it, because I said, ―some‖ children.

ALEXANDER: Okay.

LAWSON: This is because children of the waif mother, or the hermit mother are
not likely to feel that way at all.

Now, children of the queen mother may, depending upon how much rage she particularly
has - and no two borderline mothers are the same; these are just general categories to

114
help both the mothers and the children understand their dynamics. But, for children who
have been raised by witch mothers, it is very true that with this emotional experience of
being trapped with a very vindictive and controlling mother, their only options are just
like the options of a concentration camp individuals. I mean, what are they going to do?
They have to submit. It‘s either submission or attack and if a child tends to attack a
parent, like Christina Crawford once did --she writes about it in her book and it is also in
the movie – well, then what happens, of course, is that the mother calls the juvenile
authorities and the child is taken away.

ALEXANDER: This is Joan Crawford, and her daughter, Christina Crawford‘s book,
―Mommy Dearest?‖

LAWSON: Correct.

ALEXANDER: You use a term in your book, ―the borderland,‖ that that is the world
that children of borderline mothers live in. Can you describe that please?

LAWSON: Yes. This is the emotional world that children of borderline mother‘s
grow up in. We have to be careful about not generalizing, because since there are these
four different character profiles that can be very different from one another, we have to
be careful about generalization. But, because splitting is the underlying dynamic, it is the
common denominator between all four types.

What ―borderland‖ is like is this: it is unpredictable, because any individual who suffers
from perceptual splitting is very emotionally unstable because they are reacting to the
moment and they are reacting in a way where they cannot control their emotions, and you
never know when that is going to happen. So, the child doesn‘t know how to predict or
to control or to manage the emotional dysregulation of their mother, their mother‘s
impulsivity, their mother‘s tendency to explode into tirades, or withdraw into depression
and go to bed for several days. The child has no way of controlling that, although every
child, more than anything, needs and wants their mother to be happy, but they don‘t have
the power to do that. So, they are trapped in this emotional world that is not apparent to
anyone outside of the family. I know of some cases where it was not even apparent to the
father because generally fathers are involved in a lot of activities away from the home,
not just work, but very often the father doesn‘t see it, not only because he is never home,
but also because when the father is around, the mother tends to be more focused on the
interaction with the father, so that the conflict will be with him, and less so than with the
child. But, he doesn‘t see what goes on. No one sees what goes on between the mother
and the children.

ALEXANDER: Is this what you call, ―the façade of normalcy?‖

LAWSON: Yes, and in a way that is part of what I am referring to there. The
façade of normalcy is a little misleading in the terms of the word, ―façade,‖ because that
implies that the mother is somehow consciously being deceptive, and I don‘t think that is
always true. It may be true in some cases, but I don‘t think that that is always true. I

115
think what we know about borderline pathology is that borderlines function very well in
structured environments. So, when they are in a setting where they know what their role
is and they know what is expected of them, they feel more secure. They are less likely to
experience something that triggers that emotional dysregulation or rage, so the façade is
sometimes just a result of the setting or the environment that they are in at the moment.

Borderlines can sometimes just be incredibly talented, successful, wonderful, creative,

funny people, charming, endearing and that part of them is just as real as the other part
that other people do not see. So, that is what makes a child feel like, ―Everyone loves my
mother and no one really knows her.‖ So, the child feels hopeless about anyone ever
believing what they might say they have experienced with their mother: that she has this
other side to her that can be very hurtful.

ALEXANDER: How does a child develop in a situation like this, where there is this
emotional invalidating environment? How can the child possibly grow up to be sane?

LAWSON: Yes, that‘s an excellent question, and the first answer is that it depends
upon the nature of the child‘s relationship to the mother. In other words, because the
mother has this process of perceptual splitting going on, if the mother‘s perceptions of
one child are primarily positive, that child has a certain set of traumatic -- it has an impact
on them in a different way, but they are less likely to develop borderline personality
disorder as a result. If the mother‘s perception is a negative split in terms of a negative
view of the child, that child is at very high risk for developing borderline personality
disorder because those negative messages and those negative interactions are internalized
and the child does believe that he or she himself is bad.

Now, there is some recent, excellent, fascinating research on this. Martin Teisher, who
is at McLean Hospital in Boston, has actually looked at the brain waves, brain
functioning, and MRIs of children that experienced abuse, and he is not the only one.
Daniel Shore, and Rene Muller suggested this possibility many years ago.

But, first of all, let me define borderline splitting because it is important to understand
what we are talking about. It is the inability to integrate positive and negative
perceptions. It is either ―all bad,‖ or it‘s ―all good,‖ whether it is an experience, a person,
a place, a thing, a perception of one‘s self in the moment. In the moment, it‘s either all
good or all bad, black or white.

What that results in is intense but contradictory emotional messages. If mother‘s in a

really good mood today because something positive happened and the next second she
gets a phone call from somebody who she felt was critical of her, then she gets in a
horrible mood. She turns to her child. A moment before, she was saying, ―You‘re just
the best child in the world,‖ but then, after she has some experience that triggers this
feeling that, ―Ohhh, this person hates me and I‘m no good,‖ and she turns around and
projects onto the child, shouting something negative, what the child is experiencing is
what many people have written about, Masterson being one of the first. The child
experiences what they call a ―push-pull‖ interpersonal dynamic. The mother will pull the

116
child close emotionally, be loving, caring, and nurturing, which is very sincere. But,
because she cannot regulate her emotions, at other times she will push and reject the child
completely away.

Some mothers, in their despair, will say things, at one moment like, ―You are all I have to
live for. You are wonderful. If it wasn‘t for you, I don‘t know what I would do‖ and
even in the same day, if there had been an experience that triggered the splitting to the
opposite pole, the mother may say, ―You ruined my life. If it wasn‘t for you, I wouldn‘t
have to work so hard. If it wasn‘t for you, my life would be so much easier.‖

ALEXANDER: How can a child survive?

LAWSON: What the research says, is the number one source of resiliency in
children, the number one factor is the conviction of being loved, so the child‘s
relationship with the father is just critically important. If the child has a sense of secure
emotional attachment to a father, or an uncle, or an aunt, or some adult who believes in
the child and gives consistently positive messages, and the child truly feels loved, that
experience can help the child recognize, ―Well, gosh, there must be something wrong
with mom. It doesn‘t mean there is anything wrong with me, because this person loves
me.‖ Now that doesn‘t mean it makes it any easier to live with the ups and downs, but
what children do is they tune it out, they tune mother out after a time. They become
immune to it, so to speak. It‘s a defense mechanism. They quit listening to her negative
messages.

ALEXANDER: Sometimes it seems this mothering can be so bad that you wonder how
the mother doesn‘t lose custody of the child.

LAWSON: That does happen. I‘ve had that happen with a borderline mother I
treated...

ALEXANDER: Where somebody stepped in and said, ―This has got to stop.‖

LAWSON: Well, I had to.

ALEXANDER: Oh, you had to! Well, how did that affect your relationship then with
your patient?

LAWSON: Well, it was really tragic because we weren‘t able to survive that. She
was not able to see the truth of that. She truly loved her children. That is what makes
this so sad. When they are in one state of mind, they truly love their children. I hate to
say, ―they,‖ because everybody is different. Let me just talk about this particular person I
was working with. She was not able to see that, really, in her situation, the best thing she
could do, if she truly loved her children, was to let go of trying to parent them because it
was harming them tremendously.

ALEXANDER: Can a child go beyond the mother in terms of emotional development?

117
LAWSON: Not without therapy. Now, by that I mean, ―Yes, of course.‖ There are
so many people out there that don‘t even know that they had borderline mothers. I mean
this was only classified in 1980 in the DSM. John Gunderson developed the diagnosis
not that long ago really, in my mind. So, they can function, and they can be very
successful.

How they actually feel about themselves is what concerns me because from my
perspective, children who were perceived as ―the good children‖ often continue that role
as adults. They become physicians, doctors, health care providers, wonderful people who
give everything of themselves because that is what they did when they were a child and
they can be very successful. In their intimate relationships, though, it can create a serious
problem, because the child or the adult, by that time, has lost awareness of their own
emotional needs, so letting people get close to them or letting themselves be helped or
recognizing the need for therapy -- they don‘t even recognize it, because they consider
themselves fortunate compared to a sibling who was treated as ―the bad child.‖

ALEXANDER: You talk about the cycle of borderline personality disorder. How can
therapy help the mother and the child, and what kind of therapy would be most helpful,
do you think?

LAWSON: Well, as you probably know, the American Psychiatric Institute

approves currently the Dialectical Behavioral Model, which is Marsha Linehan‘s work,
out of Seattle, which is a very effective treatment model that I think would even be more
powerful if the therapist incorporates the use of EMDR. Now, EMDR is currently a very
controversial treatment technique.

ALEXANDER: It stands for?

LAWSON: Eye Movement Desensitization Reprocessing.

ALEXANDER: And this is where the neurological information that you have found fits
in. So, let‘s go into that.

LAWSON: What Daniel Shore, Martin Teisher, and I believe even Bruce Perry, but
I‘m not quite sure -- I‘m less familiar with his work, but I know he has looked at trauma
in children -- what they suggest is that splitting is the result of an undeveloped corpus
callosum. Now that is the part of the brain that connects the two hemispheres, the right
and the left hemisphere.

That part of the brain is not fully developed when we are born. In the baby, it is not fully
developed. It is usually fully developed by the time a child is 36 months old. What they
believe happens is that early experiences with a mother who alternates between extremes
of love and hate, or push/pull interactions apparently will impair the growth of the neural
networks that are responsible for integrating the child‘s left and right hemispheres.

118
If a mother is sometimes loving but sometimes abusing, what happens is the child
preserves the perception of the mother as good because the child must do that to
psychologically survive, but they internalize a negative perception of themselves. When
the neural connections between the hemispheres are not fully developed like they are
supposed to be when we are 36 months old, the individual is actually trapped in an
emotional world like a 2 year old, emotionally, because they cannot integrate. They
cannot temper their emotions.

I like to draw this analogy: when you run your bath water, what do we do to get it the
right temperature? We have to adjust the hot to the right place, and then we have to
adjust the cold knob to the right place, and then we get to the comfortable temperature
that is right for us.

Well, a borderline functions like an infant in terms of not being able – with their
emotional faucets, the hot is either all the way on or the cold is all the way on. They
can‘t blend the two to temper their emotional state.

Now, there‘s a film, produced by Olive Tree Productions, called ―The Borderline
Syndrome,‖ and it is available through Film Maker‘s Library. You can look it up on the
internet. But, it is so fascinating because they interview borderline patients and this one
patient says that she feels disconnected and explained her need for connection with
someone who possessed insightedness. By that, I think she is referring to someone
whose corpus callosum is fully developed and can temper their emotions. And, you may
notice when you speak with a borderline who is very upset, telling them a different
perspective often calms then because they can‘t see it themselves. They‘re all anger and
all they can think about is anger and everything angry, and everything that has ever
happened to them that has been so unfair. They really do need an attachment with
another person who can help them regulate their emotions. See, I just think this stuff is
fascinating.

ALEXANDER: How does EMDR address that?

LAWSON: Alright. That is a very difficult question to answer, but if those of you
who are listening to this interview want to look up Teisher‘s article, he does the best job
of explaining it, because EMDR is stimulating to both sides of the hemispheres of the
brain.

For instance, I had a patient, a borderline mother who had not experienced trauma in her
life, but she had experienced emotional deprivation. Now, when I use EMDR, you can
do it different ways. You can use the eye movements, which makes the eyes move far to
the right and far to the left, back and forth, back and forth, back and forth, as they are
holding on to a thought and a memory and a feeling they have had about themselves.
They are really just letting associations come to mind. They are just thinking through this
while their eyes are moving back and forth. But, you can also do it with headphones and
tones that alternate from the right, left, right, left. The brain is being stimulated. In other

119
words, the brain is taking in information as it is listening to these tones or moving the
eyes. These are all ways that we take information into our brains, through these senses.

What happens is that over a periods of sets of doing these movements, and over a period
of time of this kind of treatment, which always needs to be incorporated with traditional
therapy -- that is my bias -- the patient is processing his or her own associations and they
are accessing the beliefs that were internalized about themselves from their childhood
experiences, integrating them with the new experiences that they have had as an adult
since that time.

The problem is that all childhood traumatic memories are stored in the posterior right part
of the brain, whereas newer experiences as an adult are on the opposite side of the brain.
So, without EMDR facilitating the patient‘s actual neural connections being developed at
the time they are recalling these memories and this underlying self-belief, I do not believe
that it is possible to reduce the splitting that occurs, which is at the core of the disorder.

ALEXANDER: But with the eye movement exercises, does that really help?

LAWSON: Absolutely. It‘s not a miracle cure. You have to do it over a period of
time. You have to incorporate it with a therapeutic relationship. What fundamentally
changes is how the patient feels about herself and it alters and improves her ability to
regulate her emotions because there is some evidence that suggests that there is actually
growth of neural networks through the corpus callosum.

ALEXANDER: Even after age 20, age 40, age 50?

LAWSON: Yes, this is an old, old belief that‘s been disproven by neuroscientists
now. It used to be thought that you cannot create new brain cells or new networks and
that has been completely disproven by neuroscientists. But, most of us, I‘m in my 50‘s,
almost, don‘t know that because we were taught, in our training, that that was not
possible. But it is. Teisher speaks of that, Daniel Shore speaks of that in his research.
John Ratey has a wonderful book called, ―The User‘s Guide to the Brain‖ that all
therapists really should read because, we know so much more and it is so exciting
because there is so much hope now that there never used to be.

ALEXANDER: I‘d like to just address a movie that we have discussed in the past, the
movie entitled, ―Anywhere But Here.‖

LAWSON: Okay.

ALEXANDER: It is really a good example of a borderline mother and people might

want to rent it on their own and see this mother/daughter relationship. Perhaps you could
just say a few words on why you think that that is such a great example.

LAWSON: It is an example of a ―waif‖ borderline mother, more so, probably, than

the ―queen‖ or the ―hermit.‖ There is a little bit of mixture. There is always overlap.

120
What makes it such a good example is the daughter‘s experience of her mother in terms
of her mother consistently invalidating the daughter‘s needs and feelings, her use of the
threat of abandonment, and she actually abandons the daughter on the side of the road in
the middle of the desert just because the daughter disagreed with her about something.
The mother has a tendency, a pattern of distorting the truth, of impulsivity, buying things
she cannot afford and then not being able to pay the electricity bill. There are just so many
different examples.

I think the most fascinating part of that movie is the mother‘s two interactions with the police
officer. That is just so symbolic of the inability. She runs a stop sign and her whole issue -- she
just rambles on and on and on to the police officer about her problems with her daughter and how
her daughter wants to go to this college and wants to go away. The policeman gives her the
advice that, ―You know, you have to let her go, and I‘m going to let you go,‖ meaning, ―I‘m not
going to give you a ticket for this.‖

That is the fundamental issue between the borderline mother whether it is the queen, the waif, the
witch, whatever: letting the child be herself or himself; being able to tolerate the separateness;
being able to let go without experiencing it as rejection or abandonment. So, that movie is a good
example.

There is an old movie by Joan Crawford that was made in the 1950s and is still available on
video, which is an excellent example of the ―queen‖ borderline mother and, of course, ―Mommy
Dearest‖ is still available on video.

ALEXANDER: Do you recall the name of that old Joan Crawford movie?

LAWSON: It‘s called, ―Queen Bee.‖ Her daughter, Christina, said that it is an accurate
portrayal. She said her mother wasn‘t acting. She said, ―It is an accurate portrayal of my
mother‘s personality.‖

ALEXANDER: Dr. Lawson, are there any final points you would like to make before we stop?

LAWSON: Just that there is hope. I just hope that people do not feel discouraged but that
both borderline mothers and their children can realize that there is help, but that this is still a
relatively new diagnosis. There are therapists who understand it, therapists who are still learning.
We are in a process of still learning and trying to integrate the latest research on brain
functioning, but it is terribly exciting and there are all kinds of reasons to be optimistic.

ALEXANDER: Well, Dr. Lawson, I am very happy with this interview. Thank you very much.

LAWSON: Oh, you‘re so welcome. I‘m so pleased to have the opportunity to teach others
about it. I think it is just really so important.

To order Dr Christine Lawson‘s book, Understanding the Borderline Mother, contact the Jason
Aronson Press, www.aronson.com.

This concludes our interview with Dr. Christine Lawson. We hope you learned from it and that
you enjoyed it.

121
I need to say here that the opinions expressed by our speakers are theirs alone and do not
necessarily reflect the views of On Good Authority.

On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.

122
 © On Good Authority, Inc.

BORDERLINE PERSONALITY DISORDER

Interview #10: “Neuroscience and Medication in

Work with the Borderline Personality Disorder”

LARRY SIEVER, M.D.

Interviewed by Barbara ALEXANDER, LCSW, BCD

(Edited slightly for readability)

LARRY SIEVER, MD
Director, Outpatient Psychiatric Division
Bronx V.A. Medical Center
Bronx, New York
718-584-9000, ext. 5227
[email protected]
(to order his book, New View of Self: How Genes and Neurotransmitters Shape Your
Mind, Personality, and Mental Health, contact amazon.com)

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or

reading interview #11 from our program on the Borderline Personality Disorder.

In this interview, we move to yet another exciting area of study of the borderline
personality disorder – how the brain reacts to stress and trauma, and how these changes
may lead to the development of the borderline personality disorder. While traditionally
grounded in psychodynamic formulations, it has become increasingly clear that BPD
emerges from vulnerabilities in brain function around regulation of affect and impulse
control. Although we are only beginning to understand the biologic aspects of BPD,
research shows that the development of BPD depends on an interaction of constitutional
biologic vulnerabilities with often adverse environmental circumstances during
development.

Then, we will move to the subject of medication for patients with Borderline Personality
Disorder. A study in the Journal of Clinical Psychiatry indicates that the use of
Risperidone at low to moderate doses can improve borderline personality disorder
symptomatology. This is only one of many studies underway in the recent past that begin
to arrive at pharmacological interventions to ease the suffering of the patient with the
Borderline Personality.

123
Larry Siever, MD, author of The New View of Self: How Genes and Neurotransmitters
shape your Mind, Your Personality, and Your Mental Health, is Professor of Psychiatry
at the Mt. Sinai School of Medicine in New York, and Director of the Mental Illness
Research, Education, and Clinical Center at the Bronx VA Medical Center. Researcher
and author of hundreds of articles on neuropsychopharmacology, he believes that
knowledge of the biology of the borderline personality disorder can help us better
understand it and treat it. Yet even though BPD has important neurobiologic
underpinnings that call for pharmacologic intervention, this population tends to be either
over or under-medicated and poses problems with compliance and suicide .

ALEXANDER: Dr. Siever, I have been very intrigued at the notion that there are
biological underpinnings and causes to borderline personality disorder, with all sorts of
new brain research on it and this is why we‘re talking to you today. So, what do you
think are the main things we should know?

SIEVER: Well, first, the idea that there is a biology to borderline personality
disorder makes a lot of sense if you just think of the fundamentals of how the brain
works, genetics, and how it‘s shaped by environment. We know that the brain, like every
other part of the body, has its individual signature for each person that is, in part, genetic
but in part is shaped by the experiences in the environment they have. So, there‘s a
biology to borderline personality disorder in the same sense that there‘s a biology to
everybody in their personality and we‘re all unique in our own ways. We see this in eye
color, hair color. Obviously these kind of attributes are different for everybody. They
certainly could be shaped by environment as well as by genetics, but genetics gives us the
template.

So, the real question is what is the nature of any kind of biologic or temperamental
underpinnings that might provide a susceptibility to some of the problems of borderline
personality disorder? In other words we know, okay, the brain has to be involved, there‘s
got to be a biology. But can we learn anything about the biology to help us help people
with this disorder cope better with their vulnerability?

This is really kind of a vulnerability model. It‘s not a deficit model, and I think, in that
sense, is compatible with psychodynamic models because a lot of the behavior that a
person who has this disorder displays are ways that they have learned to cope with
underlying feelings of vulnerability around an extreme emotional sensitivity that they
have, a sensitivity to disappointment, loss or frustration, a tendency they have to seek
action-oriented or often even aggressive solutions to these problems. But, they are
attempts to cope and adapt with these vulnerabilities and we believe that actually defining
them can help us intervene more effectively. Certainly, if we know the brains systems
and their biology that are involved, we might be able to have better pharmacologic
intervention, but also that this kind of model will help people better cope with their own
vulnerabilities in a way that they may live their lives in more satisfying and productive
ways. But, we have to appreciate how these vulnerabilities drive people to behave

124
repeatedly in ways that we see are maladaptive, but that they feel are really tactics for
survival.

ALEXANDER: For instance?

SIEVER: Well, let‘s look at one dimension that I talked about. Actually, I‘ll
define two that might be based in brain biology but have with them a whole set of
behaviors and defenses and styles of coping that go along with them. One would be the
affective sensitivity that I talked about. In other words, we know there are regions of the
brain, predominately the limbic regions of the brain, that are involved in processing
threatening, fear arousing, anger provoking stimuli in the environment, and they generate
a response which may be a behavior like fleeing, withdrawing, maybe lashing out, it may
be aggressive, etc.

But, what happens if the gain on their emotional sensitivity is set a little higher than
most? Everybody does have their own temperament and you can see in babies, for
example, some just seem calm and imperturbable, some are very sensitive to noise,
sounds, and in fact, many family members of borderlines have told me observationally
that they notice their kids were very sensitive to loud noises, sounds. It can happen in a
lot of kids, and certainly is not any specific predictor, but it is a kind of retrospect
observation.

Certainly to separations, frustrations, some kids are going to be little more responsive
than others. That‘s in the range of individual differences, but if it gets to an extreme, then
that‘s going to color the way people have interpersonal relationships -- the way they
relate parents, to peers, because they are going to be buffeted about a little more by the
ups and downs, the vicissitudes of daily relationships. In the person with borderline
personality disorder, that‘s coupled with the tendency to deal with frustration or
disappointment by some kind of action, by some kind of impulsive action or aggressive
action. We do know regions of the brain that are involved with that, for example the
prefrontal cortex, particularly orbital frontal cortex, which play a comodulatory role for
these emotions in the generation of aggression or other behavior that comes from them.
These regions suppress, under situations of intense emotional stimulation, the emergence
of unwanted behavior, such as aggression, that might have negative social consequences.

What we have tried to do is understand these brain systems better using genetic, imaging,
behavioral, neuroscience, or affective neuroscience strategies to begin to define how
these systems work, and what some of the differences might be. It‘s not hard to imagine
that somebody who is much more sensitive emotionally and who tends to translate that
into action is going to develop a different repertoire of coping styles than somebody who
may be unflappable and not easily provoked to action.

Hypothetically, you could imagine an infant who is, in fact, easily upset when mother left
or when they were in some kind of internal distress. You can also imagine that parents
may have a tough time coping with these kinds of behaviors. So, while we often think of
the role of the parent -- certainly in schizophrenia, there was the idea that there was a

125
―schizophrenogenic mother‖ -- then people discovered that there‘s something actually
about the person who developed schizophrenia and about their brain development that
may be different, and it‘s not really just a question of getting a bad deal from mom or
something the parents did.

I think that we are coming to the same kind of conclusions around borderline personality
disorder, not necessarily that parents or family or other people don‘t play a role. In fact,
obviously, because all of these patterns are played out in the context of interpersonal
relationships, the interpersonal environment is a critical piece in the development of the
person who develops this disorder.

But, this is not a blank slate. In other words, a child who cries for extended periods of
time, is hard to soothe, has precursors of what we might see later as temper tantrums,
may challenge even the best intentioned and most able of parents who are going to either,
for example, try to indulge the child and maybe at other times, just get fed up and don‘t
respond because they‘re overwhelmed. At other times they may become angry. These
are all natural tendencies when faced with the kind of challenge that a kid who‘s
inconsolable presents.

On the other hand, from the child‘s point of view, a behaviorist might say, ―Well, they‘re
getting intermittent reinforcement. Sometimes they get what they want from tantrums,
sometimes they don‘t.‖ The child‘s sense though is that there are some inconsolable
regions of negative emotion or affect they get stuck in that are intensely distressing and
that they‘re intensely fearful of. This is part of the fear of abandonment etc.

Their way of coping with it is like this primitive tantrum we talked about that might get
them some solace, help from the environment. There might be some relief. At least it‘s
the only way they know to handle it because they‘re faced with what seems, to a child at
least, to be overwhelmingly difficult feelings of despair, or aloneness or whatever
negative feelings are involved. These feelings can be described eloquently by people
who struggle with them, and I‘m sure most people who work with these patients have
heard these kinds of experiences. So, this is a pattern that might develop. Obviously it
takes on a particular connotation when kids become mobile, when they become
motorically active, where they can use aggression as a way of dealing with distress.

People who have these predispositions say that they are not people who are prone to
withdraw, like the shy kid who is very inhibited and who will tend to react to their
affective sensitivities by moving away, who want excessive assurance of acceptance
before they go into situation, and who act to forestall rejection.

In contrast, the person who is more impulsive with this affective sensitivity, like the
borderline, is going to act as a consequence of being upset or hurt, rather than in
anticipation of it. They go into situations that get them into trouble, maybe embarking on
a relationship for example, where there are many warning signals that it‘s not going to be
a promising one but yet seems very seductive and offers them some nurturance.

126
For example, sometimes they‘ll get involved with men who may be sociopathic or
abusive to women. Then, what happens is they hit the inevitable frustration, the end of
the relationship, and they‘re devastated. Then they try to restore their wounded self-
esteem, their affective state, back to some kind of relief from this intense personal pain
by doing things. The kind of things they might be do, about which we‘d say, ―Gee, these
are not adaptive ways of coping,‖ do provide them with sort of familiar landmarks of
relief, for example, going out and abusing a drug that will get them high, or drinking,
engaging in reckless behavior, driving recklessly, binge eating, plunging promiscuously
into another sexual relationship, or even sort of more strikingly pathologic kinds of
behaviors like self-injurious behaviors, sometimes burning or cutting themselves, which,
in a funny way provides them a certain kind of numbness or relief, and also channels that
aggression and anger at themselves into concrete behavior.

So, we look at all these things and say, ―Gee, these are not really reasonable ways to act
under these situations. Why don‘t you try to do something more adaptive?‖

But, these adaptive mechanisms imply a certain measure of self-affective regulation that
these people just really don‘t feel they have or haven‘t developed sufficiently to maintain.
So, what they experience as the only way they know how to survive, we see as
maladaptive, and behaviors that we see as manipulative. They‘ll act in ways to get their
therapist ---. For example, people like yourself who work with these kind of people in
longer-term therapy know that subject to a vacation or separation, they may get very
upset. They act in a way, maybe it‘s a suicide attempt, or a threat of that, to get other
people involved again, like the tantrum or the cry for help. Now we see this as they‘re
manipulating other people. But they don‘t have the internal regulation of affects.

Think about this in the sense of what does it mean for somebody to be intensely
vulnerable to disappointment or loss? What does it do to the relationships they have with
people they depend on, particularly when they are more vulnerable, at an early age? It
means that they‘re going to depend on the other person who is providing a nurturing
relationship with them even for maintenance of self-esteem or emotional homeostasis.
Not only are they going to say, as if in a mature relationship, ―This person is important to
me,‖ they can‘t feel good unless they have some security that that person is going to
remain available to them.

Of course, that means they are going to be exquisitely vulnerable to vicissitudes in

relationships, and the kind of behaviors that we see as hallmarks of abusive or neglectful
behaviors, which they experience, whether or not this represents true abuse, which
certainly occurs in many instances so that these people are more scarred or sensitive to it,
or it‘s a perception of events that others might not see in quite the same way, still, their
experience is that they are dependent on other people and have to, in order to control their
own feelings, make other people behave in certain ways.

In a sense, to them, the regulation of their self-esteem and emotional homeostasis means
that other people have to behave in certain ways. Therefore, they see their actions as
really just oriented towards regulating their own affects, and if that means acting in such

127
a way that the therapist is going to have to respond to their suicide threat, that‘s just part
of their internal homeostasis for survival. That‘s hard for other people, even therapists to
understand, so we say, ―Well, these people are manipulative, they‘re difficult, they are
controlling,‖ but they are doing it in the service of maintaining emotional self-esteem.

ALEXANDER: What we, as therapists, might see as an inability to learn from

experience -- well, it is an inability to learn from experience. But it‘s more than that, is
that right?

SIEVER: Well, an inability to learn from experience obviously happens in some

fashion or other to anybody who gets stuck, and that brings them into some kind of
therapy or treatment. So, what we‘re trying to do is characterize particular
vulnerabilities. I mean, an extreme form of ―you can‘t learn…‖ would be Alzheimer‘s
disease. That‘s a true memory problem, right?

ALEXANDER: Yes.

SIEVER: Alright. I don‘t know if you saw, ―Memento,‖ a movie about

somebody who had a short term memory learning deficit. Well, these are neurologic
extremes where you actually can‘t take in information. For the borderline individual, the
issue more is that yes, cognitively, they‘re pretty intact, except we think that in the
context of these intense affects, there can be cognitive misrepresentations. The affects so
dominate the behaviors under these kind of special circumstance, and the patterns these
people develop become so deeply ingrained that without some kind of break from this
impulsive-aggressive kind of behavior, or some kind of increased or enhanced
modulation of these emotions, it‘s very difficult for people to change their strategies of
behavior. Indeed, these vulnerabilities are impediments to their learning better ways of
coping.

Now, if you think about the various kinds of interventions we might use for this disorder,
they‘re really all aimed around addressing that. For example, we have done a lot of
studies on the brain and neurotransmitter systems like the serotonin system, which is
modulating some of those prefrontal cortical regions I talked about, for example, the
orbital frontal cortex. I don‘t know if you are familiar with the story of Phineas Gage,
who was a railroad worker?

ALEXANDER: No.

SIEVER: He had a tamping rod go through his skull in an accident, while he was
working on laying down some rails. It went right through the top of his head, just above
his eye, where orbital frontal cortex is. He had been a very stable, calm, solid citizen
type of guy, who after that, became irascible, erratic, impulsive, difficult, unreliable. A
team of neurologists in Iowa have reconstructed that the damage was to the orbital frontal
cortex and related areas.

128
There have been numbers of studies of people who have legions to this area and it seems
to have some role in modulating emotions and mediating social judgments. It is heavily
modulated by serotonin. Serotonin, if you‘re not familiar with it, is the chemical in the
brain that Prozac works on -- that‘s plain to say now -- or any of the ―selective serotonin
reuptake inhibitors‖ (we call them), any of these antidepressant medications, which
actually help with impulsivity and obsessions etc.

In fact, we found in people who are borderline who have a lot of these impulsive
aggressive behaviors, serotonin is not as effective in facilitating the action of this
modulatory or inhibitory region. So, if we look at that region as providing the brakes and
the regulation of these intense affects, then serotonin could be the brake fluid, and it‘s not
working quite so well. The brakes aren‘t working quite so well, and if you enhance
serotonin, maybe you could help people modulate their feelings better. So the serotonin
reuptake inhibitors actually seem to be helpful in reducing impulsive aggression in people
who have these kinds of recurrent problems.

Some of the mood stabilizers which are helpful for bipolar disorder, which actually help
maintain equilibrium in some of these limbic regions that I talked about that are
responsible for modulating the brain‘s response to emotionally charged stimuli, are
actually stabilized, with the resultant calming of behavior with some of the mood
stabilizers, which can help, then, in borderline, as well as actual true bipolar illness. So,
that‘s the pharmacologic side. With the pharmacologic side, you can adjust the
thresholds for impulsive behavior or emotional reactivity, at least to the degree that it
becomes more under someone‘s control to deal with these vulnerabilities. So, that‘s one
side of it, and that‘s how knowing about some of these vulnerabilities from a
neurobiologic vantage point can help.

But then, in terms of what one does in the psychotherapy, you have to help people, now
that their thresholds maybe have made a little more manageable, to learn alternative ways
to doing things, to learn from their experience, as you say. There you have a variety of
cognitive behavioral psychotherapies that have been used with people with this disorder.

One of the major techniques that‘s been used in studies you‘re probably familiar with is
dialectical behavioral therapy, which Marsha Linehan has developed. That involves
things like skills training, helping learn alternative ways of coping with these self-
destructive or suicidal ideas or feelings of desperation, and also psychotherapy where
there is validation of these people‘s intense affects and experience and encouragement to
develop other ways of dealing with them. I think she‘s found that‘s probably one of the
key factors, because these people‘s emotional reactivity is, in some ways, very difficult
for other people to emphasize with, to validate. They really become labeled as, ―the
overemotional one,‖ or ―the irrational one.‖ As such, they feel invalidated and feel
outcast and they are set apart in that way. So, that‘s an important ingredient.

I think dynamic psychotherapies more tend to try to chip away at some of the
unconscious assumptions that somebody with these vulnerabilities tends to develop about

129
their world, who they are in relation to other people in the context of these intense affects
and impulsive tendencies.

You can, for example, develop views of one‘s self or other people that, because they are
so emotionally labile and intense, involve intense affective coloring, if you will. For
somebody who is feeling neglected or abandoned, it‘s a state that may carry with it a
whole set of associations, representations of what the world is like that‘s familiar and
recurs every time they get that into state. They may actually use defenses like splitting to
separate out those states of minds from those where they feel nurtured or loved, and they
do that in a dissociative or kind of defensive way.

But, it‘s really kind of a state- dependent learning. We know in psychology paradigms
that if an animal or person is in particular state, they‘ll learn information better in the
context of that state again. In other words, they‘ll remember information learned in that
state when they‘re in the same state in the future. It‘s as if the emotional settings, which
you could think of like the coloration of a movie, are very extreme and intense. There
may be several settings. In one, everything looks sort of jagged in reds and blues and
then in others, things are calmer. They‘ll keep these kinds of emotional settings of their
view of the world kind of apart because they are afraid of being contaminated by the
more negatively charged emotional settings. In therapy, you could try to bring these
kinds of unconscious assumptions about the world to consciousness, and allow them to be
reformed.

ALEXANDER: One thing that has really surprised me is the idea that trauma can
actually change the brain. Is that so, and how does that happen? For instance in the
movie, ―You Can Count on Me,‖ the children in the movie had a double parent loss. I
mean did that actually change their brains?

SIEVER: Well, in a broad sense of course, everything that happens to us that we

can recall, that makes a difference to us, changes our brain. That‘s why what we did or
said on a particular day that we can recall remains as a trace for us. So, all of our
experience effects our brain and changes our brain.

Now, the particular effect that trauma may have that people who study PTSD, for
example, are interested in is this: can a traumatic event actually change the settings in
some of these emotional arousal systems, so that they‘re altered for the future, you see?
That‘s certainly happens in PTSD, that is people have an altered startled response, loud
noises bother them. If they‘ve been, say, combat veterans and they can‘t tolerate -- and
this happens often -- the fireworks on the fourth of July, so in that way not only does
experience change the brain, which it always does, but actually a certain kind of trauma
can change the settings.

Now, the story in borderline: we have collaborated with people like Rachel Yehuda, who
have done a lot of studies in PTSD (Posttraumatic Stress Disorder) and who want to look
at the role of trauma in borderline personality disorder. What we‘ve found is that there is
some comorbidity of the two disorders, but most people who are borderline do not have

130
PTSD, maybe a little less than one third of the examples that we‘ve looked at. Most
don‘t necessarily have abuse. Well, it comes out that a large proportion, maybe a slight
majority had some kind of incident, but it‘s actually no greater in our samples of
borderline than it is for many of the other personality disorders. But, what seems to
happen, what regulates the likelihood of getting a full-blown posttraumatic stress disorder
is if the childhood traumas lead to a greater likelihood of repetitions of having traumas in
adulthood, then that could lead to PTSD. So, we‘ve found relationships of trauma to a
variety of disorders, and there‘s no doubt that they can have effects on the brain, on the
developing brain, and they can have indirect effects by altering behavior patterns that
subject the person to greater likelihood of trauma later on, too. So, they can have
multiple effects. There‘s no doubt the trauma does affect the brain and we‘ve looked at
stress systems like the hypothalamic pituitary axis, like the serotonin. There are
transmitter systems like the norepinephrine system, in both PTSD and borderlines, and
you can find alternations, although they‘re somewhat different in the two disorders.

ALEXANDER: I want to turn to the subject of medications, more specifically, and

biological interventions like ECT. One of our listeners wants me to ask you, this is Dawn
Beckley, she wants to know if electric shock therapy can be used on a person diagnosed
with bipolar borderline personality and obsessive compulsive disorder?

SIEVER: Well, ECT is usually used as an effective treatment, but as a treatment

of last resort, in very refractory depressions, but also in other disorders as well. I don‘t
know if that individual she‘s referring to was in a severe depression, if they‘re bipolar.
It‘s been used in psychosis, schizophrenia, mania, but I would say severe refractory
depression is where it‘s usually used. It‘s not going to change the underpinnings of a
personality disorder per se; it‘s only going to be able to deal with acute state disorders
like a serious depression. I don‘t know about OCD; it‘s not usually used with obsessive
compulsive disorders.

ALEXANDER: What about some other medications? For instance, there‘s a recent
study on the use of Risperidone?

SIEVER: Yes, well the atypical antipsychotic medications, of which

Risperidone is one -- there have been a couple recent studies with Olanzapine, which is
Zyprexa (the brand name), that suggest they can be helpful. Just recently there have been
a couple of double blind studies. One double blind study that was pretty reasonably
scaled found that Olanzapine could be helpful for borderline personality disorder in a
number of the domains in impulsivity, some of the affective lability, the agitation and
anxiety, and the behavioral dyscontrol. So the serotinergic agents seem to be helpful for
maintaining the impulsive aggressions but they may not completely cover the intense
affective lability. The mood stability may be helpful to modulate these intense affects.
The atypical antipsychotics may be helpful, particularly for periods of decompensation or
high stress, and in that context, diminish behavioral dyscontrol as well as dampening
impulsive aggression and often are used for periods of months, maybe a year or more to
kind of dampen a period of intense turbulence.

131
So the main thing, though, I think is that therapists worry about and is probably true that
sometimes there is a tendency to pile medications on more and more because somebody
is having trouble and you add something else, so it is important with somebody with this
disorder, if they do require medications, to reevaluate the medications periodically and
see if they can be reduced in periods of greater stability to some of the core medications
that might be required on a more maintenance basis: for example, somebody who is
bipolar certainly would need to be on maintenance mood stabilizers, and if they ever got
on antidepressants without a mood stabilizer, that would tip them into mania. I‘ve
certainly seen people who have borderline personality disorder who are also bipolar too
and they‘ve gotten off all medications, done okay for a time, then they get depressed,
they get an SSRI, and it switches them into irritable hypomania. Those people obviously
need mood stabilizers if they are ever going to be concurrently treated with
antidepressants for depression.

Now, it‘s an open question as to how long and under what circumstances somebody with
borderline personality disorder needs longer term mood stabilizers. They‘re just
beginning to do controlled studies on all these things in a way that will get us some
answers.

ALEXANDER: I read a quote from a Dr. Paul Markovitz, who said that, ―Medications
are imperative,‖ and that since ―borderline personality disorder is biological, we have to
treat what is physically wrong.‖ Essentially he said, ―You cannot change borderline
personality because it is biochemical and not amenable to thought therapy or talking.‖

SIEVER: Well, I think most people‘s experience is if they have severe forms of
borderline personality disorder, and it is a diagnosis where, in order to meet the criteria
for it, you have to have some pretty serious interpersonal and impulsivity kinds of
disturbances, that the medications, as I mentioned, can be critical in readjusting the
thresholds that make the person less vulnerable. If, though, these are deeply ingrained
patterns of behavior, the medications might help a person learn from experience better,
but in my clinical experience, it seems that they are often stuck enough that therapy can
help them.

On the other hand, even if you change those thresholds, they don‘t easily erase years of
experience of coping with things in these maladaptive ways. That‘s what they know.
That‘s who they are, how they deal with situations, and that‘s not that easy to change.
Even if you can dampen the impulsivity so they are less likely to injure themselves or
behave recklessly, you are still going to have interpersonal relationships disturbance,
probably. That‘s not going to just totally transform itself. That is my experience.

Now, the kind of extensive studies that have started in depression of what is exactly the
role of the medication on psychotherapy and their combinations really haven‘t been done
on a very large scale. I mean there are some large scale studies now about psychotherapy
with meds as part of the treatment, but not the aspect that‘s being looked at, and of course
more medication trials.

132
The guidelines that recently came out from the APA certainly recommend psychotherapy
and also the use of medication as needed. But the disorder has not been around in terms
of being part of the nomenclature for more than about 25-30 years. The term,
―Borderline Syndrome,‖ has been around maybe 40-50 years, so we just don‘t have the
data on it in a variety of ways that we have with some of the other disorders. It‘s also
kind of stigmatized and has traditionally been the realm of psychodynamic theoreticians,
so that the biology had been unappreciated. Then you get the comments you mentioned
that are probably representing some kind of a counterpoint to the purely psychodynamic
point of view.

Clinically we think there is a role for both. Exactly how that works is something that
needs more research.

ALEXANDER: Dr Siever, is there anything else you would like to say before we close,
or final points you would like to make?

SIEVER: Well, just along the lines of what we‘ve been talking about in some of
your final points, I think that what‘s important for people who are suffering from this,
and in my experience doing this kind of research, I have an opportunity to sit down with
them, find out what‘s bugging them, what brought them into our program, but also at the
end to provide a feedback to them of what we learned from our genetic studies, our
imaging studies – I haven‘t really gone into all the details of the multiple kinds of
measures we can get, because some of them are fairly complex biologically and have to
do with how the brain works -- but I do try to explain the results in kind of simple
language to people who I think find it reassuring to know that they are not just ―at fault‖
for some of the vulnerabilities they have, and yet they have to be responsible for
managing them, and that‘s really not that different from somebody who is prone to high
blood pressure, or somebody who is prone to diabetes and high blood sugar – they have
to watch their environment, their diet, they have to know something about their disorder,
they have to know how to deal with it.

I think people with this disorder are similar. They have to understand that okay, maybe
they are easily set off, their trigger to anger is a little lower. Maybe the way they handle
disappointment is a little different, and that has resulted in the way they experience the
world, which is kind of different. They have to learn other ways. They have to be
responsible, in a sense, for managing these vulnerabilities, even though they aren‘t
necessarily to be blamed for having them in the first place.

I think that‘s why people like Marsha Linehan have found that validation is the most
important part of the treatment for someone with this disorder. In a sense, that can even
come from the feedback I may give them, where they say, ―Hey, I can understand that,‖
because some of the kinds of things we might find out about how they process certain
kinds of events or how they cognize them or how their brains work fits with their
experience and they say, ―Okay, now what?‖

133
And we say that we found something, but it‘s not like, ―Well, I‘ve got a chemical
imbalance, there‘s nothing I can do, I just have to take the medication; I‘m fine.‖ It‘s a
vulnerability that plays out in the interpersonal context, and that‘s why there‘s a role for
psychotherapy and that‘s why people need to know something about how they work in
relation to other people and about these vulnerabilities to enable them to change and cope
more effectively. So in a way, I think that neurobiologic modal we work on is a
vulnerability model that actually gives somebody better validation of their own potential
for change and growth in that context, rather than being locked in because their mother
was a certain way to them or because they are genetically going to be some kind of
person for life. Rather, they have vulnerabilities and potentials. They need to work
around the vulnerabilities and maximize their potential.

ALEXANDER: Dr. Siever, thank you very much for a very balanced and informative
interview. We really appreciate it.

SIEVER: Thank you!

To order Dr. Siever‘s book, The New View of Self: How Genes and Neurotransmitters
Shape Your Mind, Your Personality, and Your Mental Health, contact amazon.com.

This concludes our interview with Dr Siever and our program on the Borderline
Personality. We hope you have learned from these interviews and that you enjoyed them.

As always, the opinions of our speakers are theirs alone and do not necessarily reflect the
opinion of On Good Authority.

Until next time, this is Barbara Alexander. Thank you for listening.

134