Perpetual Fixations

 

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Breakdown & Its Discontents

https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care/

https://www.telegraph.co.uk/health-fitness/body/i-was-an-nhs-psychologist—but-i-suffered-from-depression/

https://www.psychologytoday.com/us/blog/campus-confidential-coping-college/201604/depressed-psychologists

 

The Phenomenology of BPD

 

https://themighty.com/2018/07/code-words-dont-leave-me-borderline-personality-disorder-bpd/

View story at Medium.com

https://www.bustle.com/p/11-little-tips-for-spotting-borderline-personality-disorder-in-yourself-54305

https://themighty.com/2018/03/bpd-borderline-personality-disorder-self-sabotage/

https://www.psychologytoday.com/us/blog/fulfillment-any-age/201810/borderline-personality-and-the-struggle-connect

View story at Medium.com

https://themighty.com/2018/01/borderline-personality-disorder-bpd-embarrassing-symptoms/

https://hellogiggles.com/lifestyle/health-fitness/women-borderline-personality-disorder/

 

Chaos and Elucidation: The Borderline Kōan

 

Disclaimer: The following material was written for therapists trying to identify and manage clients with Borderline Personality Disorder while illustrating some consequences that may occur during clinical practice. Furthermore, the following hypothetical situation in no way suggests that all Borderlines are similar regarding presentation, cognition, or behavioral responses. This essay is not intended as a support resource or treatment recommendation for those suffering from Borderline Personality Disorder; it represents an experiential and educational guide to inform and protect therapists. Despite some of the behavioral depictions, occasional humor, and seemingly derogatory vernacular, there is no motivation by the author to show prejudice or discriminate against this controversial mental health population. Borderline Personality Disorder is a serious mental illness that affects the person suffering from it, in most cases, as much as it affects those who interact with them. Borderline behavior is simply a dysregulated means of survival, but therapists must learn how to recognize and survive the onslaught of such behaviors.

Chaos is the score upon which reality is written. — Henry Miller

Although therapists may have the necessary academic background to assess Borderline Personality Disorder (BPD) from a vignette, questionnaire, or comprehensive case study, they may not have worked with enough varieties of BPD clients in a clinical setting to identify the full range of behavioral manifestations. The DSM-IV and DSM-5, with their checklists of infamous Borderline traits and diagnostic features, cannot begin to capture the experiential dynamics of being in a more direct relationship with a BPD individual (the World Health Organization’s ICD-10 defines BPD as Emotionally Unstable Personality Disorder). The complexity of this personality disorder is sometimes incapable of being detected by even the most seasoned clinicians until a specific behavioral pattern over time suggests a definitive pathology. The danger of normalization and misdiagnosis is common with Borderlines because of the protean nature of this biosocial disorder and its wide array of individualized features. According to the article Subtypes of borderline personality disorder patients a cluster-analytic approach from the journal Borderline Personality Disorder and Emotion Dysregulation, 2017: “The BPD population is notably heterogeneous from a descriptive and theoretical perspective. Two hundred fifty-six possible combinations of criteria may yield the same diagnosis. Hence, two patients with a diagnosis of BPD may have only one diagnostic criterion in common.” Correspondingly, a dimensional-based severity scale for BPD should include categories for mildly disturbed, moderately disturbed, and severely disturbed (in addition to Theodore Millon’s 4 BPD subtypes: discouraged, impulsive, petulant, and self-destructive). Regarding functionality, some Borderlines are very self-sufficient, whereas others can be completely dependent. As a characterological disorder, the symptoms of BPD are often camouflaged by the client’s Delphic presentation, thereby making the prospects of a conclusive diagnosis even more troublesome. Overall, Borderline Personality Disorder should be considered on a broad psychiatric spectrum rather than relying on common caricatures, stereotypes, or hyperbolized Hollywood depictions. But even with all of these stipulations and appraisals taken into consideration, to creatively paraphrase Richard Feynman: If you think you understand Borderline Personality Disorder, you don’t understand Borderline Personality Disorder.

In terms of an accessible two-tier classification system, BPD “first impressions” could be recognized as either Authoritarian or Vulnerable.

Authoritarian BPD. Interpersonal disposition: Self-sufficient, dominant, intense, intrusive, demanding, presumptive, irritable, over-involved, impatient, pessimistic, interfering, easily angered, stubborn, critical, paranoid, and jealous. Rationale: “I have needs for stability, predictability, and approval that were not met during childhood, therefore I must be in charge to survive.” Objective: Control of self, others, and their environment.

Vulnerable BPD. Interpersonal disposition: Dependent, charming, emotionally coercive, desperate, mercurial, seductive, playful, hapless, duplicitous, suspicious, fearful, loving, deceptively docile, hypersensitive, desultory, easily disappointed, childlike, vindictive, and envious. Rationale: “I have needs for safety, validation, and intimacy that were not met during childhood, therefore I must be taken care of to survive.” Objective: Control of self, others, and their environment.

It should be understood that these rudimentary classifications are not mutually exclusive. For example, a Vulnerable BPD could easily switch into an Authoritarian BPD, given the volatility of their internal barometer and the right circumstances. However, general appearances indicate a default tendency towards either one disposition or the other, and both classifications maintain fantasies of omnipotence to offset feelings of deep insecurity. For purposes of this essay, the author will focus on clinical encounters with the Vulnerable BPD. A more descriptive archetypal rubric is supplied by Christine Ann Lawson in her popular book Understanding the Borderline Mother.

A conceptual view of BPD is noted by Robert B. Shulman, “The characteristics of the borderline personality include a marked and persistent identity disturbance, chronic feelings of emptiness and boredom, and intense unstable personal relationships. The borderline tends to have difficulty tolerating being alone, and will fear abandonment. They are highly impulsive, and may engage in self-mutilating behavior, have recurring suicidal threats, and manipulate others to meet their immediate needs. The borderline also tends toward having an intense unstable affect mood, display inappropriate anger, have perceptual distortions, and under great stress may depersonalize. They see the self as justified; since they feel intolerably bad, they are entitled to go by impulse instead of common sense, and entitled to soothe themselves. Their fictitious goal is to do whatever they want as they cannot be happy by how others do it. Their methods are protean, and include splitting, primitive idealization, projective identification, denial, and devaluation. The borderline personality is not a cooperator. Their impairments include affective instability, anxiety and panic, and engaging in self-harmful behaviors. These impairments may cause significant interference in social or occupational functioning. Because the borderline uses others to meet their needs, they can often be the ‘problematic patient’ that medical offices dread.”

The ways that Borderline Personality Disorder can present itself are sundry, but the traits reliably surface whenever sufficient stressors are involved in the person’s life. The problem is that notable levels of stress may not emerge in therapy sessions as they would in a family context, romantic relationship, or adverse situation. In many cases, the BPD’s affable demeanor, charm, sense of style, and energetic magnetism—as presented in a structured setting—can create the illusion of normalcy (apparent competence) for an extended period of time before things begin to unravel. But, to be sure, this commonly misunderstood disorder is a far cry from the “worried well” going through a seasonal spell. As clinical misinterpretation progresses, the caregiver may end up pouring the equivalent of co-dependent jet fuel on the client’s emotional reasoning by gradually supporting their distorted views of reality, or by feeling compelled to gratify their assorted requests for special favors. BPDs could be thought of as emotionally unstable individuals with maladaptive software programs when it comes to navigating interpersonal relationships—akin to a faulty GPS. Unfortunately, BPDs are not responsive to most forms of traditional psychotherapy and, therefore, must be willing to submit to specifically designed, intensive treatment programs (i.e., DBT, MBT, IFS, schema therapy) that usually require many years of attendance before adequate insight is developed.

The challenge for clinicians is when an undiagnosed or misdiagnosed BPD presents in multiple sessions with no conspicuous traits or affective instability. Furthermore, the elusiveness of this disorder will often escape the radar of the client’s previous clinicians because of the BPD’s ability to superficially present themselves as calm, reasonable, and well-adjusted during most clinical interactions. In the same way, BPDs can appear very functional and cognitively copacetic when engaged with specific activities that allow for structure, affirmation, control, and unambiguous results. If affective dysregulation is admitted by the client, it’s often misdiagnosed as Bipolar Disorder or minimized as situational anxiety and depression. Despite a plethora of comorbid considerations, a contradictory or confusing diagnostic history might well suggest that the client is suffering from pervasive patterns of psychic disturbance that transcend Axis I considerations. However, due to time constraints and other factors involved with high-maintenance clinical work, reliance on the assessments of previous caretakers often remains unquestioned. Likewise, it’s sometimes assumed that the client has been an innocent bystander of chaotic family circumstances—surrounded by personality disordered individuals, rather than being a card-carrying member themselves. In other words, objectivity can easily be lost if a clinical confirmation bias exists in thinking that the client is an unfortunate victim of bad luck instead of being a potential culprit (this bias does not dispute victimization in childhood). Whenever such a misguided conclusion becomes diagnostically solidified, the lost-in-translation therapist assumes the position of a detective chasing down the wrong suspects. In these circumstances, understanding the multi-generational pervasiveness of BPD in families is of key importance (early diagnosis of Borderline Personality Disorder is crucial for a favorable treatment prognosis). Because of the public and mental health stigma surrounding Borderline Personality Disorder, medication management is often chosen as the sine qua non for treating affective symptoms rather than subjecting the client to a series of more intensive evaluations. However, psychotropic medication is only supplemental (at best) and not effective for managing the nucleus of this multi-layered disorder.

Things are not always what they seem. — Phaedrus

BPDs are resource and sympathy acquisition specialists—chameleons of expediency and masters of mimicry with lifestyles that are frequently in dramatic fluctuation. Their stories can be captivating and their charismatic powers of persuasion are often unrivaled. The BPD’s voyage of hardship (unrelenting crises) and methods of retelling are irresistible bait for any caretaker who cares too much. In fact, BPDs are some of the most emotionally convincing interlocutors on the planet. Assessments taken at face value may have therapists believing the client’s victim identity—which can provoke a strong rescue response—thereby enabling an unrealistic, excessive, and unsustainable attachment as the therapeutic alliance develops (after all, it’s considered rude for therapists to openly question the veracity of a purported victim). Keep in mind, the client’s victimology list often includes multiple offenders, in multiple contexts, to be blamed over an extended period of time. For example, BPDs can go from one personal or professional relationship to another while complaining about how they were grievously mistreated during their last encounter (aka “system surfers”). However, a detailed history of the client’s life will undoubtedly reveal significant contradictions while demonstrating evidence for repetition compulsion. In fact, upon closer examination, BPDs have a remarkable capacity to inadvertently exploit others while maintaining an anchored position of victimhood—perpetuating a cycle of victim and rescuer. Consequently, this position abdicates all personal responsibility while justifying the BPD’s impulsive behavior, self-aggrandizement, and mistrust of others (it’s like playing tennis without a net). For example, BPDs can be very disturbed individuals who are exceedingly proficient at persuading their sympathizers that everyone else is disturbed. Other diagnostic misinterpretations may include believing the client to be a mere witness of “crazy makers” rather than investigating the client’s adult contributions to their own psychosocial predicaments. To make matters more convoluted, BPDs sometimes expect professional relationships to be indistinguishable from personal relationships. Therapeutic relationships, in particular, are anticipated by BPDs to become more personal if the clinician’s empathy is to be convincing. However, BPDs interpret the authority of therapists to be another simulacrum of parental judgment with the potential for criticism. Similarly, BPDs will work hard to undermine the therapeutic process to avoid anxiety in the face of uncertainty (the distressing process of change equals an all-too-familiar uncertainty from their childhood).

As expected, the BPD’s history of romantic relationships will appear characteristically unstable, stormy, and varied with evidence of intermittent reinforcement relationships (looking for someone to love, or someone to blame). Likewise, long-term pair bonding is extremely difficult with BPDs because they’re predisposed towards jealousy, chronic irrationality, inclined towards self-sabotage, unable to be emotionally subdued for any substantial period of time, and possess unusual degrees of rejection sensitivity. According to psychotherapist Ross Rosenberg, “Their [Borderlines] romantic relationships begin quickly, intensely, and with a great deal of excitement, euphoria, and sexual chemistry. Their volatile emotions move in one of two directions: love and adoration or hate and destruction. Because this person has had little-to-no experience with healthy relationships, the euphoric ‘perfect love’ feelings that occur in the beginning of the relationship are neither realistic nor lasting. The early euphoric love experience is transient as their psychological fragility leads them to an eventual emotional crash and burn. This black-and-white approach to their romances creates a teeter-totter effect of extreme behavior; they either shower their partner with love and kindness, or rage at them with disgust and violence. Their love/hate processing of relationships places an impossible burden on the partner. Often individuals diagnosed with BPD are preoccupied with real or imagined abandonment, which they frantically try to avoid. The perception of impending separation or rejection can lead to profound changes in the way they think about themselves and others, as well as in their emotional stability and behavior. Whether real or imagined, any reminder causes them to strike back at their romantic partner with rage and aggressive hostility. A mistaken comment, a benign disagreement, or an expression perceived as disappointing can quickly transform their loving feelings toward their ‘soulmate’ into a raging retribution against an enemy.”

BPDs can surreptitiously condition others to respond to their needs through forced teaming, and conscientious therapists may feel heroically compelled to go the extra mile—like a case manager on steroids—as a gesture of loyalty. However, this expectation places too much pressure on therapists to compensate for the BPD’s reported lack of love and support. Unfortunately, the therapist’s valiant rescue attempts will only reinforce the client’s dependence and further vindicate their assertions of distress (BPDs often claim to be mistreated by those who are actually supporting them either financially or emotionally). In short, the therapist might feel obligated to take care of the BPD until the caretaking fuel runs out; but a clinical death trap of Faustian proportions awaits the therapist if they become the client’s “go-to” person (aka “favorite person”). The BPD’s favorite person is based on a fabricated image (the “distorted other”) that places the therapist on a superhuman pedestal designed to serve the unfulfilled needs of the client. As a consequence of forming such an unrealistically constructed ideal, the therapist is unknowingly being subjected to tests and confirmations that either prove or disprove their caretaking worth. Subsequently, the personification of a mythological trope ensues: The therapist, like so many empathic individuals before them, becomes the BPD’s latest knight in shining armor. In this treacherous association, the BPD’s need to feel loved matches perfectly with the therapist’s need to feel needed. Inevitably, the BPD’s performance evaluation of the therapist’s efforts to be an all-encompassing caretaker will result in either effusive praise or devastating disappointment. Since the most significant goal of BPDs is to gain the unequivocal concern of caretakers, this disorder may represent the most challenging condition for clinicians to work with in relation to maintaining professional boundaries.

Givers need to set limits because takers rarely do. — Rachel Wolchin

Therapists may rationalize exceptions to treatment and loosen boundaries as a way of surrendering to the client’s demands for undivided attention, recognizing unresponsiveness to redirection, or to demonstrate solidarity within the therapeutic relationship (BPDs instinctually perceive boundaries as representations of disapproval). It’s a precarious predicament for most clinicians, because BPDs often think of themselves as being owed special privileges via customized experiences that cater to their particular needs. However, not wanting to alienate or hurt the feelings of the client in the short term may result in confusion and resentment for both parties when boundaries are no longer amenable to remediation. If therapy evolves from being professional to becoming more casual, and then to something that resembles a close friendship, it’s only a matter of time before the BPD will initiate further efforts to decimate the remaining power differential. The BPD’s urgency to have their needs prioritized can quickly lead to unforeseen endorsements by a serviceable clinician, such as becoming a full-time apologist, advocate, family interventionist (via triangulation), avenger, personal secretary, friend, and emergency manager. It must be understood that BPDs will elicit strong emotional responses from their caregivers, and these responses are sometimes experienced by therapists as intensified concern (i.e., feelings of pity, outrage, or moral panic). Precipitously, the dynamics of the therapist-client relationship can become progressively organized around the client’s psychopathology instead of being effectively regulated by the therapist. BPDs are in the molding business as they subconsciously search for others who are willing to become malleable acolytes in service of their “id without a grid.” The BPD’s basic message is: If you care for me, you will do something to make it better right now. A therapist’s protective instinct will automatically be innervated by such levels of extreme urgency, because no caregiver wants to be seen as uncaring. Therapists are in a Catch-22 situation. Like the parable of Thales, the therapist can fall into a bottomless well of boundary violations as they focus on attending to the client’s constellation of insurmountable needs. What was once a containable analytic space, is now forever lost in space.

It’s important to be aware of the BPD’s disproportionate requirements for validation, proximity, and reassurance. They can cleverly uncover vulnerabilities in others, such as generosity or agreeableness, to get their emotional needs met—appearing retrospectively as premeditated manipulation, albeit unintentional. Incidentally, the longer a BPD has been undiagnosed and untreated, the more refined their adaptive mechanisms will become in order to secure a corrective relationship. In layman’s terms, a BPD is less interested in change than changing others to obtain what they desire. Similarly, BPDs will capitalize on a caregiver’s commitment to compassion by taking full advantage of every accommodation offered while cataloging these susceptibilities for future interactions. They will subjugate challenging interpersonal encounters because individuation makes them feel uncomfortable and spatial distance is perceived as a sign of rejection. BPDs simultaneously seek and reject help, because accepting help that requires significant change makes them feel out of control. Notice the inherent contradiction: A dependent victim who needs to be in control. Perfectionism, a common BPD attribute, is another manifestation of control that acts as a substitute for external validation. Counterintuitively, perfectionism also serves as a form of self-invalidation, because such unrealistically high standards are self-imposed. The Borderline lives in fear, but control makes them feel safe. BPDs will try to obtain as much control as they are allowed in adulthood to compensate for the lack of control they experienced in childhood. Control of themselves and others is the BPD’s primary method for fear management. Meanwhile, they’ll continue to dispatch a decoy of victimization for maximum effect as they demand unreasonable levels of emotional and/or material support from anyone who gets too close to them. With BPDs, you cannot separate motive from psychopathology; it’s a distinction without a difference. Consequentially, the therapist who accepts the client’s assertions of helplessness at face value is headed for an imminent clinical disaster. The BPD’s victim identity virtually guarantees a more secure attachment to their caregiver, but this attachment is unendurable. Subsequently, the therapist can lose their sense of objectivity by allowing themselves to become influenced by the BPD’s ongoing emotional quagmire.

BPDs may or may not share similarities with those suffering from attention-deficit disorders, but they certainly believe that there’s a deficit of people paying attention to them. Harboring enormous levels of insecurity and self-doubt in relation to their identity versus the identity of others, BPDs experience a sort of “prosopagnosia of the soul” (identity diffusion). Otto Kernberg, a psychiatrist who pioneered a new understanding of Borderline Personality Disorder, believed that pervasive feelings of loneliness and the need to belong to something were the driving forces behind all of the other behaviors associated with BPD. For the BPD, other people can serve as virtual props to help them achieve their impulsive ambitions and to quench their thirst for propinquity. Although therapists learn that successful therapy requires the client to be engaged by building a strong therapeutic alliance, too much obsequious interaction with BPDs will create an avalanche of starry-eyed expectations (ironically, one of the most popular buzz phrases used in clinical settings is patient engagement). The Borderline is an equal-opportunity seeker when gestures of emotional propitiation are on tap. Compliance with the fanciful expectations of the BPD is expected, but expect the BPD to avoid complying to the rules and expectations of others. Over time, trying to successfully manage such interpersonal complexity will feel emotionally draining (this is a telltale sign that someone could be hitting home runs in the Cluster B ballpark). BPDs often expect their therapists to be available at all times and take responsibility for their feelings of desolation. The BPD’s hypersensitivity to criticism and mistrust of others can also make therapy with them exceptionally challenging without triggering their inferiority/superiority complex. Therapists who don’t suspect BPD causality will eventually be caught by surprise, like an off-duty police officer during happy hour, whenever they say or do something “wrong.”

The valence of Borderline Personality Disorder is perennial pathos and emotional instability in fear of abandonment, but keeping these traits from being exposed may prevent or indefinitely postpone diagnosis. Likewise, to appear vulnerable can suggest that there’s something about the person that other people want to protect, although vulnerability among BPDs is seldom revealed as a form of subterfuge. The BPD’s shape-shifting capacity for presenting themselves in a carefully assembled manner, as if they were selectively socialized, effortlessly provocative, neotenic, and demonstrably de rigueur, is a survival-based façade that increases their ability to receive validation from others (especially predominant among BPDs with histrionic traits). If such mesmerizing distractions of presentation are predominant, therapists must learn to ignore the client’s window dressing while paying close attention to the ways in which the office furniture is arranged inside of the building. BPDs may incorporate seduction, entrapment, compelling pleas for assistance, emotional blackmail, and double binds to acquire unambiguous commitment from their caregivers. Just like a live wire requires neutral sources for proper conduction, BPDs crave the reliability and perceived stability of others to resolve feelings of erratic discontent and inner emptiness (the BPD’s capricious identity is a klaxon for therapists who are clinically unprepared to address the monumental task of core restoration without producing enmeshment). BPDs also have a preternatural antenna for spotting those who appear charitable, such as caregivers who are visibly committed to making a difference, and may use flattery via attribute mining to create an atmosphere of disinhibition. Subsequently, therapists can inadvertently exacerbate the needy behavior and obsessive preoccupations of a Borderline, especially if the BPD’s stated concerns are misinterpreted as legitimate personal complaints rather than psychopathological reactions. As a result, the therapist’s temptation to become a “fixer” allows the BPD to avoid being confronted or challenged in ways that could reveal maladaptive patterns of interaction that have been missed by previous clinicians.

Too much self-disclosure and overindulgent styles of caregiving are equally dangerous when working with BPDs. Once the bargaining stage of sacrificing the self for the sake of the other begins (masochistic surrender), the therapist is headed for an impossible task of perpetual mollification. Most therapists do not possess the power of prescription. What do they have instead? The power of conversation, encouragement, and emotional support. However, the very qualities that can make a therapist good at what they do (i.e., being dynamic, attentive, considerate, empathic, and accommodating) are the very qualities that can work against them during interactions with a BPD. For example, volunteering to become a clinical marionette at the BPD’s disposal is a form of professional self-abnegation that can occur gradually as a consequence of trying to please the unpleasable. Whenever the therapist pleases the BPD by reinforcing the client’s cravings for attachment, they will receive very positive feedback … until they inevitably “displease” the client. Similarly, the therapist may be triggered by the BPD’s impatience and intrusiveness that could be reminiscent of responding to demands placed on them by their own family of origin (i.e., if the therapist was raised by a Cluster B parent). In addition, the BPD may unconsciously use the therapist as a self-object for needs unmet in childhood (the perfect mother/father), or fantasies unattainable in adulthood (the perfect partner). Likewise, the therapist may unknowingly be using the client for purposes of correcting former attachments gone awry, or to receive affirmations of caretaking competency. The chemistry of familiarity is a strange brew indeed.

Lookin’ for love in too many faces, searchin’ their eyes and lookin’ for traces. — Johnny Lee

Subconscious transference by the client and countertransference reactions by the therapist will undoubtedly emerge as sessions progress. Additional therapist-client intrigue can occur because of subjective physical allure, shared interests, age compatibility, trauma bonding, cultural upbringing, family of origin similarities, camaraderie, and other forms of overidentification. Similarly, the already intimate nature of one-on-one therapy with clients is exponentially magnified whenever working with Borderlines. Interacting with a BPD is a bewildering lesson in psychological hermeneutics, and understanding what’s really being communicated requires a great deal of careful analysis. For example, idealization (aka “love bombing”) of the clinician is a common phenomenon during various stages of therapy with BPDs. Not surprisingly, most therapists enjoy being admired for their efforts to provide comfort, advice, and reassurance—regardless of the client’s tendentious proclamations. After all, therapists are human beings who have their own needs for validation in an otherwise thankless and emotionally grueling profession. Nonetheless, this “admiration” via idealization may have a trapdoor that includes eroticized transference (an intense, vivid, irrational erotic preoccupation with the therapist characterized by overt, seemingly egosyntonic demands for love and sexual fulfillment to compensate for emotional neglect and abuse in childhood or adulthood). This transference dynamic can intensify because the therapist is literally paid to pay attention to their client through empathic attunement and unconditional positive regard. If, for example, the therapist misinterprets the client’s fixation for genuine appreciation, or if the therapist augments this fixation by also admitting auspicious feelings for the client, the misunderstanding of what is personally conveyed versus what is pathologically motivated could result in a chain of events ending with previously unintended efforts to pacify the BPD’s need for assurance of being loveable. In such cases, the therapist may feel simultaneously drawn to the BPD’s beguiling persona and express malignant eroticized countertransference to acknowledge the client’s amorous disposition, especially if they’re not able to productively displace their own unconscious frustrations (i.e., sexual repression). Fantasies of “making up” for the client’s dismal past can also occur if the therapist’s need to be seen as a paragon of benevolence (aka unobjectionable positive countertransference) is not self-monitored with sufficient reality testing. As therapeutic dialogue resumes, the BPD’s desire for unmitigated acceptance and affection, as expressed in the context of therapy, might become increasingly problematic for an overly restrained therapist who is not effectively managing countertransference reactions. For the BPD, caring is conflated with intimacy. It turns out that Freud was right after all.

You are special too, don’t lose yourself. — Ernest Hemingway

BPDs have a unique ability among mental health clients to uncover repressed aspects of the therapist’s self through systematic transference. Once the Kool-Aid of projective identification (to induce the other to become) is properly ingested, the ability to sustain mentalization (separation of identities) quickly evaporates. Therapists may become equally puerile, irrational, and impulsive as they attempt to appear more accessible, trustworthy, and convincing to the BPD via introjection (internalizing various aspects of the client’s attitudes, feelings, and behaviors) and projective counteridentification (endorsing symbolic roles that the BPD avows of disavows via projective identification). The therapist, in essence, becomes whatever the BPD needs them to become in a transmogrifying maze of psychodrama-infused cosplay. For example, this equalization process can cause therapists to regress—literally losing themselves—in order to accommodate the BPD’s regression rather than maintaining a detached objective stance. It’s like host manipulation by parasite—replete with layers of rationalization that succumb to a unique form of subliminal programming. BPDs are hostages of their own impulsivity, but they have an incredible gift for sharing the voltage of those impulses with other potential hostages. Once the defensive sensibilities of the therapist are effectively neutralized, the therapist will no longer think of the client as a subject of observation. “The patient’s use of projective identification exerts subtle and powerful pressure on the analyst to fulfill the patient’s unconscious expectations that are embodied in these fantasies. Thus the impingement upon the analyst’s thinking, feelings, and actions is not an incidental side-effect of the patient’s projections, nor necessarily a manifestation of the analyst’s own conflicts and anxieties, but seems often to be an essential component in the effective use of projective identification by the patient. Therefore, a patient’s projective identification efforts are most likely to bring about some type of result if they affect the therapist. Often, if a patient feels that the therapist ignores these efforts, the patient may redouble them or may give up and try elsewhere, acting out in other relationships. The projective identification mechanism may bring the therapist in touch with core fantasies of a particular type of relationship that lives within the patient’s mental structure. The urge for the therapist is to become an active participant and act out the according feelings and behaviors,” writes Dr. M. Feldman. Similarly, the therapist may project whatever they want to believe about the client rather than scrupulously analyzing the incongruous reality of the client’s psyche. We are now reminded that the sleep of reason really does produce monsters. The psychic fusion of the client and therapist can rapidly morph into a tangled web of quid-pro-quo arrangements to quell the BPD’s urgency for devotion and to satiate their intense yearning for affection (BPDs are extremely adept at attachment seeking, although they simultaneously mistrust attachment). The BPD’s libidinal intrusiveness via eroticized transference can present as a rare, disorienting, and overwhelmingly arousing stimulus for any therapist who is misinterpreting or mismanaging such therapeutically disruptive dynamics. As a result, the therapist might be getting his or her own needs met by feeling indispensable in the face of attending to such unusual and challenging inducements (i.e., falling in love with the idea of making the client feel loved). Likewise, the therapist may confuse responding to the client’s psychopathology with the experience of establishing an unparalleled emotional connection. It’s a textbook example of folie à deux. “Because of the centrality of projective identification in the experience of treating borderline patients, therapists often feel invaded and transformed into someone other than who they are. Attempting to resist this transformative process can be a formidable problem,” says Dr. Glen Gabbard. As Masterson (1976) noted, “Probably the single most difficult skill to acquire in psychotherapy of borderline patients is the ability to recognize and control one’s own identification with their projections.” Rule of thumb: Never go full transference gratification.

BPDs can pressure therapists into becoming “psychosocial saviors” if their purported tales of victimization and historical discrepancies are not thoroughly investigated during earlier stages of the therapeutic relationship. Fear and denial keep the BPD from having to do any of the emotional heavy lifting (experiential avoidance), so they become experts at deflection by reorganizing factual accounts to avoid personal responsibility, blame, or feelings of shame. In other words, giving a BPD the benefit of the doubt may not benefit anyone. As a result, therapists can feel responsible for doing more than they should if they become swept away by the BPD’s fascinating anecdotes of adversity. Unfortunately, the more the therapist does for the client, the more the client will expect from the therapist. In fact, the therapist may be responding like everyone else in the BPD’s immediate circle of acquaintances by attending to the never-ending needs of a desperate foundling who is perpetually searching for a supportive audience. However, the more one tries to solve the BPD’s recurring problems, the more difficult these problems become (aka the tar-baby dilemma). The therapist may unknowingly represent the most recent target in heavy rotation on the BPD’s take-care-of-me carousel. From the American Addiction Centers: “People with BPD have relationship issues with nearly everyone in their lives, and significant relationship issues will often develop with therapists as a result of the therapeutic process of change. The patient may first idolize the therapist and then later totally demonized them (splitting), or may attempt to manipulate different therapists against each other in order to manipulate the overall treatment. Professionals who treat people diagnosed with BPD must be aware of these potentialities and even expect them to occur. Unstable personal relationships within treatment itself as well as outside treatment contribute to the difficulty of helping these individuals adjust.” However, the limited time frame of therapy is generally not equipped to withstand such relentless permutations of stratagem. As a consequence, the therapist may begin entertaining taboo fantasies of attending to the client’s psychosocial “emergencies” outside of a clinical context. Without maintaining boundaries, the therapist will no longer be able to maintain objectivity; without maintaining objectivity, the therapist will forever be trying to extinguish the BPD’s peripheral complaints instead of addressing the client’s core issues. Like a swiftwater first responder, the therapist can float farther and farther down the gauntlet of BPD appeasement until the rescue raft of good intentions finally capsizes. The helping profession of psychotherapy encourages the development of a genuine relationship to help the client, but it’s the professional aspect of the relationship that must remain especially predominant whenever working with Borderlines. In the BPD motorcade, the wheels of impulsivity are always out of brake fluid—it’s like having a hyper-reactive limbic system for an engine without access to a steering mechanism. If the therapist mistakenly hands the car keys of therapy over to the client, the BPD will drive everyone off the nearest cliff with their busload of needs. Meanwhile, the therapist should prepare to be thrown under the bus whenever those “needs” are no longer being gratified.

Addressing the continuous demands of a BPD is like experiencing The Myth of Sisyphus on methamphetamines; it’s utterly exhausting. Since BPDs largely identify with their problems, all efforts towards remediation represent a threat to their problem-ensconced sense of uniqueness. Lacking in object permanence, there are never enough words of reassurance or altruistic gestures to placate the BPD’s need for consolation—you might as well be sweeping a dirt road. In such circumstances, the therapist may find themselves making promises equivalent to the demands of the client in an effort to de-escalate emotional reactivity, to attenuate their impatience, or to continue receiving encomiums as an intrepid caretaker. As this temerarious gambit commences, the BPD will invariably become more dependent on the therapist’s attempts to stabilize their compromised sense of self-worth. Meanwhile, the therapist may become hopelessly addicted to eliciting positive changes in the BPD’s affective state. Interestingly enough, if the therapist exhibits a tendency towards emotional caregiving, they will feel especially vital by succumbing to the BPD’s assertive requests for special consideration. Nonetheless, the BPD’s ability to reshape the therapist into becoming a more responsive caretaker serves as an insurance policy for maintaining centrality. Likewise, the therapist will feel professionally authenticated by the BPD’s gestures of lavish appreciation—willing to risk more and more for the sake of accommodating their client. Therapists can allow BPDs to take advantage of their generosity, because BPDs appeal to those who are trained to be sympathetic. Similarly, therapists suffering from burnout might find themselves sunbathing in the BPD’s expressions of gratitude in order to feel uniquely valued for their many years of providing social services. As one could imagine, it’s easy in these situations for therapists to feel therapeutically revitalized by offering levels of emotional support and resources that are claimed to be unavailable to the client in other contexts. After all, if positive psychology teaches us that finding a sense of meaning and engagement is curative, nothing could feel more meaningful for a caregiver than heroically assisting a client who appears helpless and unambiguously appreciative. However, the BPD’s veneration of the therapist is always contingent on a continuation of appeasement within the therapist-client validation pyramid scheme. No matter how intoxicating the back-and-forth of validation can feel during the ascending honeymoon period, the end result will invariably lead to emotional bankruptcy and disappointment. BPD idealization is a potent dopamine and oxytocin generator, but therapists should be suspicious if they repeatedly become the subject of excessive compliments. Borderlines and assiduous caretakers are lock-and-key participants in therapeutic relationships, but this indelicate union involves countless caveats. BPDs will use their perspicacity based luminol to expose the blood stains of others who are willing to be subservient to their unmet emotional needs. Once the lifeblood of caregiving capitulation is located, the BPD becomes a merger-hungry hemovore of opportunism.

The therapist might regrettably believe that professional boundaries aren’t going to be convincing, manageable, or effective for addressing *this* particular client’s needs. In fact, the therapist may have never encountered a client who is so causally oblivious to personal space and rules of engagement (BPDs are often raised in households without any sense of boundaries). If the therapist is intimidated, bemused, or intrigued by the client’s unusually assertive and impulsive demeanor, a “Borderline Without Borders” predicament will eventually consume the therapeutic frame. Additional fears of being perceived as awkward, uncaring, or inaccessible during therapeutic dialogue may create intense anxiety for the therapist, and exceptions to standards of care are reluctantly made to keep the client engaged (aka VIP syndrome). In some cases, BPDs can cause therapists to feel guilty, self-conscious, and emotionally negligent for upholding professional standards. BPDs also have an aptitude for making other people feel responsible for their feelings, but the gravity of this burden can promptly turn therapists into deferential doormats. The BPD’s intense psychological pull has the magnetic capacity to draw attentive therapists into their kaleidoscopic world of emotional mayhem. Furthermore, an erroneous belief can be endorsed that acquiescence and improvisation must dictate the direction of all future interactions to compensate for the BPD’s unresponsiveness to redirection. In other words, the standard rules of therapist-client interaction become secondary to the changes in the therapist’s subjective interpretations as they are provoked by the experience of working with a BPD. By this point, the overinvolved and emotionally invested therapist has already dug their own clinical grave site. Once a boundary free zone is established, therapists should expect a quick escalation of efforts by the BPD to dominate and control the direction of the therapeutic relationship. Whenever the floodgates of unconditional acceptance open up, BPDs become a Dionysian tornado bent on annihilating the Apollonian structures of psychotherapy and restrictive sensibilities of the clinician. BPDs can be intense, exciting, and fun to work with in therapy, but you must always be aware of the fine print.

Yeah, yeah, my shit’s fucked up; it has to happen to the best of us. — Warren Zevon

A veritable recipe for disaster also awaits the therapist if they are coping with issues of their own, such as work stress, anxiety, compassion fatigue, major life transitions, family issues, marital problems, sociopolitical concerns, and depression. Therapists must suppress their emotional needs due to the nature of their work (it’s all about the needs of their clients), but this occupational disposition can make working with BPDs exponentially more difficult. As a reminder, the therapist’s own unresolved conflicts can become magnified to an enormous extent through transference-induced provocations whenever working with BPDs. A reliable axis of balance for one’s own mental health is always needed before being able to properly notice degrees of imbalance in others. Likewise, losing one’s proverbial mind can sometimes occur as a by-product of working with others who have already “lost” theirs (e.g., vicarious trauma). Therapists need therapists too. Without proper self-care, the ability to care about the cohesiveness of the therapeutic frame will be less significant—resulting in a ripple effect of potential transgressions. Well-Functioning is defined as the enduring quality in the therapist’s professional functioning over time, and in the face of professional and personal stressors (Coster & Scwebel, 1997). Therapists have many factors to contend with in life and practice aside from the dynamics of working with borderline patients. The most common personal problems interfering with therapist well-functioning are emotional exhaustion and fatigue (Mahoney, 1997). To make matters worse, without knowing that the client is a rank-and-file BPD contender, the chances for course correction in therapy become more untenable over time. For the clinician, it may be just another day at the office; but for the BPD, it’s about survival of the neediest. It’s easy for therapists in these situations to become desensitized by their surroundings and fooled by the mask of innocuousness that BPDs can sometimes exhibit. Before too long, the previously unthinkable becomes increasingly thinkable (this is why ongoing supervision and consultation are essential—including the therapist’s willingness to admit a need for such objective interventions). The therapist’s confidence, intellect, and clinical reputation will sometimes not suffice for navigating such challenging and uncharted territory. Without proper training for the early identification and comprehensive management of BPD, the therapist is potentially lost in a sea of misapprehensions and clinical missteps. Working with a misdiagnosed BPD is like conducting therapy in Plato’s Cave, because the client’s fractured identity can often present itself as an enigma. As the therapist’s critical thinking is slowly disabled, the insatiable will of the BPD quickly captures the limelight. In these circumstances, the therapist may become a reluctant participant or a willing accomplice in the BPD’s eternal quest for enmeshment. By this stage in the therapeutic process, a bizarre array of rationalizations are incorporated by the therapist to maintain denial about their growing sense of fear, obligation, and guilt (FOG). Generally speaking, therapists spend their days attempting to transform the lives of their clients, but BPDs are the types of clients who can transform therapists if boundaries are not continually enforced. With BPDs, the Rogerian maxim should be carefully reconsidered with a strong dose of the conditional.

Pervasive patterns of acting out (externalizing) conveniently thwart BPDs from recognizing high levels of neuroticism, or learning to effectively cope with deep emotional wounds. Although thought suppression keeps BPDs from feeling vulnerable, it ultimately prevents self-reflection and results in sensation-seeking behaviors to numb uncomfortable feelings. Borderlines, if they are anything, are invariably misunderstood by others. The BPD believes that other people (aka need-gratifying objects) must acknowledge their persistent feelings of unfulfillment. BPDs are not always looking for solution-based therapy as much as they are looking for someone to methodically attend to their labyrinth of needs (solution implementation is a major obstacle for BPDs due to active passivity). In addition, Borderlines will rely on other adults as parental figures for structure or advice that is seldom integrated in any meaningful sense. If the therapist is not careful, the temptation to violate additional boundaries for the sake of “repairing” the client becomes more likely. Despite their age, BPDs must be approached with adequate restrictions due to their developmental immaturity, lack of insight, and problems with delaying gratification. No therapist wants to infantilize an adult client, but BPDs sometimes require Romper Room referees more than compassionate collaborators. As a defensive reaction, some therapists may become overly rigid to compensate for the Borderline’s defiant insouciance, occasional hostility, and incessant boundary testing. However, being too reserved could also backfire and result in accusations of not caring, coming across as distant, cold, or appearing judgmental. This oleaginous tightrope is even more hazardous if the clinician is unaware that such boundary testing maneuvers are part of the client’s behavioral symptomatology. Given the right combination of variables, caregivers can quickly become collateral damage if they respond according to the BPD’s wishes via operant conditioning rather than containing the analytic frame. What initially seemed like a once-in-a-lifetime opportunity to address an exhilarating clinical challenge, could ultimately result in occupational suicide if accidentally mishandled.

And you may ask yourself, am I right? Am I wrong? And you may say to yourself, ‘My God! What have I done?’ — David Bryne

BPDs will sometimes attach to those who are pragmatically inaccessible, but whenever the attachment is disrupted, the object of love can quickly become the object of aversion. Borderlines view separation as betrayal, and rejection by a caregiver can evoke abandonment rage. Without the guaranteed availability of a compliant object for attachment, the former adoration of the therapist magically evaporates as the BPD’s tempestuous anger begins to surface. Sadly, the therapist may still be enamored with the feelings of idealization that the BPD once provided. The emotionally starved and competitive BPD wants love to be a possession (a relationship style that alternates between gluttony and starvation), whereas the therapist may become delusional and lovesick in their pursuit of healing the client. Paradoxically speaking, attending to the endless needs of a BPD can initially serve as an invigorating portal of escapism for the therapist. The rest of the inconsolable world seems to melt away as the caregiving lens becomes focused on rescuing the unrescuable; but the therapeutic lifeboat may have to hit an iceberg of BPD indignation before the clinician finally comes to their senses. BPDs would prefer a co-dependent relationship instead of a therapeutic relationship, and they’re remarkably proficient in achieving such ends. Unbeknownst to the therapist, the BPD has been beta testing for attachment eligibility by means of continuous emotional cajoling. Any ambiguity of unification is terrifying for the BPD, and the prospect of change is unbearable. BPDs seek stability, routine, predictability, unconditional love, and safety, but it ends up being at the expense of everyone around them. Dr. Perry D. Hoffman, president and co-founder of the National Education Alliance for Borderline Personality Disorder, explained one of the defining aspects of the disorder: “It occurs in the context of relationships. Unlike other psychiatric diagnoses, if you put someone with schizophrenia on an island all by themselves, their mental illness would still be evident. If you put someone with BPD on an island, you wouldn’t necessarily see the symptoms—whatever happens, happens in the context of [interacting] with someone else.” Instead of becoming a storm chaser, it’s better for therapists to understand the nature of the storm.

But then you let me down, when I look around; baby, you just can’t be found. — Madonna

Because Borderline Personality Disorder is essentially an attachment deficit disorder, the client’s intrusive approval-seeking behavior is often insurmountable. Many BPDs were not paid enough attention to in childhood, so they will endlessly try to compensate for this lack of developmental stimulation with others in adulthood. However, overly attentive responses to the accumulating desires and dependency fantasies of BPDs will incrementally raise the stakes for an unavoidable crash landing. The problem is that therapists have been issued the caregiving equivalent of a pilot’s license and will be held accountable for any loss in therapeutic altitude. However, if the BPD could rewind the tape on the flight recorder, and muster a modicum of self-reflection, they would hear themselves bombarding the analytic cabin space and taking over the control panel. Just as the therapist has misinterpreted the BPD’s behavior and emotional reasoning as situationally justifiable, the BPD will undoubtedly misinterpret the therapist’s efforts towards accommodation and feel betrayed if extravagant caretaking promises aren’t kept. This emotionally sensitive and high-conflict personality type can become extremely volatile if their chosen “protector” appears to have forsaken them on purpose. Unprepared therapists could be sleeping in a clawfoot tub of Cluster B bathwater before waking up to find themselves circling the drain. If the sufferer’s sense of identity is experienced as dependent upon a relationship, you’ve just abrogated their recognition of self. In the end, the BPD will pull the rug of congeniality from underneath their caregiver whenever the gravy train of appeasement goes off the rails (cessation trauma). The BPD’s dichotomy of self will vacillate without warning as the previously dependent victim becomes an avenging victimizer. The former idealization of the therapist has been swiftly replaced by a 180-degree devaluation phase. A critical threshold of stress has been reached, and the Borderline within has been unleashed. What was once an entirely “good” object is now a completely “bad” object (splitting), because there is no middle ground in the BPD’s world of internalized object-representations. An overwhelming desire to feel safe again compels the BPD to bifurcate people, messages, and situations into simple black & white categories. BPDs consistently puts their needs at the forefront, so any sudden reduction in attentiveness (aka narcissistic supply) will always end badly. The resulting devaluation period will likely include displays of intense anger, paranoia, resentment, and vindictive forms of retribution as the client’s self-fulfilling prophecy of abandonment continues unabated. Most disturbingly, BPDs are generally unable to recognize their own instigation and participation during or after such intense interpersonal interactions. “Borderlines display a signature trait, poor observing ego, which is a dense denial of vital aspects of reality and irrationality to a degree that almost has to be seen to be believed,” says Dr. Daniel J. Zimmerman. Identity disturbance is evidenced by the BPD’s intense, yet tumultuous, attachment to their love object. They yearn for affection, yet may eventually wish to destroy the love object, or at least significantly devalue the person’s life. The sadistically gratifying sensation of vengeance makes the BPD’s resentment feel justified as the “bad” parent is symbolically punished in a dramatic fort/da reenactment. Mistrusting the motives of others intensifies whenever the therapist’s priorities stop revolving around the BPD, and the client’s negative overreaction will appear incalculably disproportionate. In order to protect themselves from such unbearable disappointment, the BPD quickly attempts to regain a sense of control over what they perceive to be an invalidating experience (impulsive BPD subtypes with antisocial and narcissistic traits are particularly prone towards destructive recrimination whenever enmeshment is threatened). The angry/impulsive child is experienced by the BPD’s intense rage that is rooted in childhood resentment for not receiving proper parental care. “The spoiler child refuses to grow up, remains dependent in some way on the parent or a parent surrogate, and ruins and/or denigrates everything the parents try to do for them,” states Dr. David M. Allen. “The spoiler role is difficult to maintain, so the child needs to continually practice it with other people. The usual candidates for them to practice on are lovers, spouses, and of course therapists. No one else will continue to put up with them.” The phrase no good deed goes unpunished has come home to roost.

The end may justify the means, as long as there is something that justifies the end. — Leon Trotsky

BPDs can ingeniously reframe events for advantageous purposes, but retrospective discrepancy identification will separate what is true from what is exaggerated, and what is exaggerated from what is false. BPDs are poor historians, because the past is written on the pages of their unpredictable emotions. Without a stable sense of self, it’s difficult to be self-aware enough to follow the arc of chronology. Part of this disorder is the BPD’s inability to think of their agitated behavior, obsession with control, and emotional reasoning as disordered. For the BPD, what “feels right” must be right. BPDs need to experience immediate emotional satisfaction, even if it’s irrational, contradictory, or devastatingly dysfunctional. BPDs do not see their part in causing or contributing to their own problems, because admitting agency requires an uncomfortable awareness of deep emotional wounds. In tandem, therapists will ignite a co-dependent wildfire by soothing rather than carefully analyzing the BPD’s behaviors and thought processes—transforming caregivers into volunteer firefighters searching for the next batch of smoke. Doing too much for the BPD inevitably results in doing unintended harm, simply because the BPD doesn’t know what’s best for them. Remember, BPDs are living in a state of arrested development and can become as emotionally reactive as an unruly toddler whenever confronted with a challenging situation (low frustration tolerance). Likewise, if the therapist is unaware that their client is Borderline, they won’t be focusing on appropriate treatment interventions as they fall more deeply into the impossible position of becoming the client’s designated overseer (i.e., the parentification of the provider). BPDs do not understand the line of demarcation where their needs stop and another person’s needs begin. Normalizing the abnormal, however tempting, is sometimes the most precarious decision a clinician will ever make. “Psychoanalysts view borderline personality as arising from failure by the patient’s mother to foster coherent differentiation between self and object in the first 18 months of life, leading to the development of pathologic ego defenses. The patient does not learn to tolerate negative affects associated with separation; this continues the child’s clinging into adulthood, as if others were desperately needed parts of the self. Sexuality and dependency are confused with aggression. Needs are experienced as rage. Long-term relationships disintegrate because of an inability to find optimal interpersonal distance. Because of inadequate ego mechanisms of defense, there is little ability to master painful feelings or to channel needs or aggression into creative outlets. The patient has a fragmented mental picture of the self and views others as all bad and simultaneously all potent, a chaotic mixture of shameful and grandiose images,” states Dr. James E Groves.

By using whatever means necessary, the focus of all future concerns will be conveniently relocated to the BPD’s elaborate amphitheater of victimhood, thereby disabling all possibility of self-awareness. In the binary world of the BPD, you’re either for them or you’re against them; you’ve either done something for them, or you’ve done something to them. The BPD’s desperate longing to use the therapist for positive mirroring has now created an unexpected house of mirrors effect. It’s a peculiar gambit that occurs subconsciously in the mind of the BPD: “I have successfully transformed you to serve my needs, but I will use this transformation against you for rejecting me.” An old country song creeps into the frame: I turned the tables on you, now I’m eating your food. The thrust and parry of object relations role playing has gone from the victim being rescued by the rescuer, the rescuer being persecuted by the victim, the rescuer persecuting the victim, and the victim taking final revenge by persecuting the rescuer. The Karpman Drama Triangle is being played out by two participants on auto-repeat until the rescuer can no longer afford the electricity bill. Keeping up with the BPD’s endless search for emotional satisfaction is virtually impossible, and making customized adjustments to match these unwavering frenetic desires only indulges the BPD’s intrapsychic regression and malignant fantasies of omnipotence. The therapist, no matter how personally compromised, ethically unmoored, or professionally misguided in their efforts to please the BPD’s demands for attachment, will eventually be considered part of a syndicated rejection conspiracy. What was once an “ideal” caregiver for the clinging child has now become an untrustworthy demon who must be annihilated by the punitive parent. The BPD’s selective memory, polarized thinking, dissociation, cognitive distortions, projection, and capacity for revisionism are the perfect building materials for constructing a thermonuclear firewall of deflection (gaslighting) to make sure that accountability will always be a one-way street. Ambiguity and ambivalence in the face of need consummation will not be tolerated, because the BPD has the market cornered on Lustprinzip (BPDs are walking limbic systems with low emotional flashpoints). It’s not enough for the BPD to be discouraged by unrealized or unrealistic anticipations, such disappointment means that they must spread this surplus of misfortune to their target of opprobrium (talionic revenge). It’s a heads I win, tails you lose situation. Unreasonably impatient in their wishes for unambiguous emotional fulfillment, a familiar pattern is predictably repeated. For the Borderline, the mistakes of others are intentionally designed to cause them pain. After all, it’s what they’ve learned from childhood (i.e., no one cares, love is a cruel illusion, people cannot be trusted, and the world is a dangerous place). Squaring the circle of BPD determinism doesn’t make the circumference any less chaotic.

There’ll be someone else where you used to be; the world don’t care and yet it clings to me. — Tom Waits

What was once believed to be the client’s monogram of victimization is now seen as pervasive patterns of dependence (a likely continuation of learned helplessness). What was formerly considered to be passionate discouragement can now be interpreted as manifestations of impulsivity, low frustration tolerance, sensation seeking, emotional reasoning, and a ubiquitous need for control. Displays of infantile tantrums and coquettishness have been identified as forms of age regression. What was once thought to be situational anxiety is now understood to be unresolvable feelings of inner emptiness, fear, insecurity, and an unstable sense of identity. Demands for validation and intimacy have been providing cover for an overwhelming fear of abandonment. The client’s inability to recognize the independent needs of others is now exposed as solipsism, envy, and inadequate mentalization. Unpredictable mood shifts and angry outbursts are retrospectively linked to the client’s perceived level of gratification or disappointment at any given moment, combined with an extreme sensitivity to criticism. Intense levels of idealization and devaluation are explained by the client’s Manichean mindset and a zero-sum transactional approach to interpersonal relations. BPDs tend to remember others based on their last encounter, namely “the great moment of disappointment.” Everything that was previously done to indulge the BPD will suddenly be forgotten, because holistic integration of experiences do not seem to register for this all-or-nothing competitor. Other people will not be allowed to peacefully go about living their lives when the BPD’s needs are no longer attended to. Quite simply, there will be hell to pay, and the therapist will be left holding the tab. The BPD’s perceptual surveillance kit obsessively scans for imagined slights, disagreements, inconveniences, and potential signs of rejection to maintain their panorama of paranoia (paradoxically, BPDs will often regret or feel embarrassed by such responses after their anger has finally subsided). To be fair, BPDs aren’t aware that these irrational emotional responses are primitive defense mechanisms to avoid feelings of vulnerability, low self-worth, invalidation, and abandonment that were formed during early childhood. And, to be clinically concise, the therapist has royally screwed things up because of an initial failure to see the forest for the trees. The miscalculations and professional catastrophes of the therapist cannot be whitewashed, but a comprehensive investigation of sequential factors can further illuminate the unexpected and bizarre difficulties of working with Borderlines. “The Brutal Clock is a variation of the Brutal Test where the BPD sets up impossible expectations of others. When others are unable to meet the unreasonable expectations, they are punished with emotional abuse, which is justified by the BPD’s sense of being the victim because they did not get what they wanted,” states Dr. Mark Banschick. A final debate remains: Are the Borderline’s cataclysmic reactions to relationship triggers pre-meditated or intentional? No, not in any “normal” sense. However, the incalculable damage left in the wake of their fear-driven rage will be experienced by others as wholly intentional. Hurricanes destroy lives, regardless of the hurricane’s lack of intention.

A useful analogy for therapy-client relations gone wrong with a Borderline is the ebb and flow of symphonic development. In other words, the therapist’s efforts to appease the BPD were constructed from evolving variations on a simple motif: You are worthy of being loved. Unfortunately, for the BPD, proof of love is contingent upon intimacy, and intimacy is conflated with control. However, the tempo of the second movement is similar to that of the first, but subtle changes in dynamism make it more emotionally complicated than it may at first appear. The evolution of this improper saga results in a rapid crescendo of dramatic fusion during the third movement towards an ecstatic final stanza. The orchestra returns to the call and response motif before a final postlude in the fourth movement—descending from the fifth to the third while the ensemble moves stepwise downward in sixths. As with therapy, it is never a single decision, but a series of misguided steps that move incrementally before resulting in a complex web of enmeshment that has to be unraveled as painstakingly as it developed. Unfortunately, the BPD demands loyalty and insists on maintaining the emotional intensity of the third movement. If the magnitude of the emotional bond is not maintained, the performer (therapist) will be punished by the BPD who feels immense anger for the abandonment of such a quixotic attachment. The therapist, who unfortunately became a volunteer performer in the BPD’s theatrical search for true devotion, forfeited the conductor’s role of mediating between order and chaos. As a result, the therapist’s dalliance with clinical consequentialism has ultimately usurped the structure of the compositional (therapeutic) framework, and the disheartened BPD has unleashed a cyclone of emotional turmoil throughout the concert hall.

At the end of the abandonment rainbow, the disillusioned BPD will be encouraged by their sympathetic allies to collect misadventure bonus points while reclaiming victimization. However, the clinician will suffer a much greater loss because professional boundaries were not cautiously maintained *before* sauntering into such an unassailable therapeutic landscape. The path by which any therapist deviates from protocol can only be retraced, fittingly, by understanding how mysterious the realm of human psychology can be during such unorthodox encounters. For historical clarity, the distinction between pervasive patterns of behavior versus circumstantial aberrations must be identified for all participants. Furthermore, the client’s elusive presentation combined with the therapist’s erroneous confirmation bias allowed for clinical rationalizations over time. “We often think of boundary violations and therapist misconduct as being malevolent in nature,” Dr. Bryant Welch writes. “But with a borderline patient a therapist can get into trouble by virtue of his or her wish to help and have a therapeutic effect. Under enormous pressure to prove he or she ‘really cares,’ the therapist is either going to cross boundaries and/or ‘withhold,’ thus becoming a ‘bad object.’ The grounds are fertile for BPD rage and disappointment in either direction.” In essence, boundary violations can emerge in direct proportion to the therapist’s incremental efforts to assuage the BPD’s increasing demands for a secure attachment under the guise of love. To add insult to injury, it can be embarrassing for any therapist to admit that they’ve been emotionally ensnared by a client as a result of something as simple as poor boundary maintenance and basic misunderstandings. The German language contains a splendid word to describe this type of guilt-ridden hindsight: Treppenwitz (a devastating rejoinder thought of only after leaving the bottom of the staircase). No matter how rewarding the process of emotional accommodation can appear in principle, taking extraordinary risks to make the client feel cared for is not the same as encouraging the client to establish their own sense of independence.

Specialized training programs for therapists to rapidly diagnose and facilitate the effective management of BPDs should be mandatory as a preventive measure to avoid Type II errors in assessment. Respecting commonly understood boundaries among consenting adults is usually taken for granted, but it’s not always guaranteed during emotionally complicated and confusing clinical encounters. It’s up to the therapist to understand the importance of defining clear limits at the beginning of therapy, being intrepid in the face of aggressive boundary testing, recognizing clinical shortcomings, admitting to personal issues, seeking outside consultation when necessary, and following ethical guidelines to ensure a professional therapeutic relationship for the sake of the client’s well-being. Similarly, it’s up to the BPD to courageously work on developing autonomy by understanding how a lifetime of overreliance on others has prevented accountability, self-efficacy, self-reflection, veridical congruency, and sustainable growth. In cases involving such ineffectual therapeutic dyads, understanding what went wrong should be given far more significance than determining the correct calculus of blame. We are all products of our genes and our environment. No matter how hard we try to escape our past, we can never fully escape our vulnerabilities. Motivated by clinical misapprehensions, unfounded confidence, and a therapeutic zeal to make a real difference, the imprudent therapist has unintentionally failed the client by becoming an enabler of regressive tendencies rather than remaining a professional guide. When working with well-documented BPDs, analyzing should never yield to appeasement; confronting should never yield to catering, and challenging should never yield to capitulation. When working with an undiagnosed or misdiagnosed BPD, good luck trekking through those enigmatic eggshells (armchair deductions writ large). Ultimately, therapists who are over-committed to pleasing others need to practice saying “no” whenever reactive or induced countertransference becomes overwhelming. Clinicians who work with BPDs must have extensive knowledge of this disorder, adequate experience working with this disorder, and an actual desire to treat those suffering from this disorder. “Working with patients suffering from borderline personality disorders begins with an acceptance that they live in an immature psychological world, fueled by certain constitutional vulnerabilities, where they attempt to shield themselves from conflict and anxiety by splitting the world into all good and all bad. Although this produces an illusory sense of psychological safety, in fact, it renders relationships fragile and chaotic and drives away the very people who are so badly needed to stabilize the patient,” states Dr. Marcia Goin.

Now that my ladder’s gone, I must lie down where all the ladders start, in the foul rag and bone shop of the heart. — W.B. Yeats

For better or worse, the therapist will finally realize that being a caretaker, despite the best of intentions, cannot include the responsibilities of completely taking care of someone, acting as their quintessential love object, surrogate parent, unfaltering friend, or becoming an omnipotent rescuer to voluntarily save them from a lifetime of insufficient nurturing. No single individual can successfully meet all of the emotional and physical needs of another. Likewise, the client should be discouraged from providing non-therapeutic gratification to the therapist by default. The ephemeral anodyne of affection may satisfy desires for validation on both sides of the couch, but the therapist will never be able to find their way back once the process of BPD pacification begins. Co-dependent quicksand is a formidable force.

What’s interesting about Borderline Personality Disorder is that it represents a subset of psychopathologies that can become equally disastrous for the clinician simply as a result of trying to effectively respond to it. Therapists must be very grounded to withstand the stochastic metamorphosis and strenuous provocations involved with BPD psychodynamics. As with all BPD relationships, there are only three options for the therapist to consider: Avoid, challenge, or appease. Furthermore, the power of love is only powerful if the BPD can learn to love themselves while acknowledging the limitations and imperfections of others. It’s not that Borderlines are irredeemably “bad” people or fundamentally unworthy of love, rather, they’re completely baffled by the give-and-take dynamics that are required for healthy relationships. To be clear, BPDs would benefit immensely from stable companionship, but they must first develop the skills that allow for mentalization, individuation, and self-regulation. Therein lies the great Borderline paradox: Part of the solution to a Borderline’s problems is the availability of a meaningful and reciprocal relationship, but part of the reason why this disorder persists is because of their mercurial involvement in relationships. Granted, relationships aren’t easy; hell, they’re not even easy for healthy people. Borderlines split in relationships analogous to the way in which therapists split regarding their opinions about those suffering from this counterintuitive disorder. Nonetheless, silver linings must exist for both the client and the therapist if psychological insights are meant to be realized after such emotionally charged imbroglios. In hindsight, the message and value of compassion should not be contingent on the origins or magnitude of our fragility.

In summation, the therapist was completely flummoxed by the BPD’s presentation management skills, victim identity, apparent competence, emotional coercion, provocative magnetism, idealization transference, and incomparable powers of projective identification when the therapeutic relationship was in its infancy. A gross underestimation of the BPD’s psychic disturbance has resulted in de-pathologizing the profoundly pathological. An erroneous assumption of relative normality was tenaciously defended, and the therapist allowed their own emotions to undermine the protective protocols of professionalism with an emotionally dysregulated client. Instead of detaching and observing, the therapist has deferred and enabled—thus resulting in a perilous indulgence of the client’s internal fantasy structure. Subsequently, the therapist’s shield of reason was systematically broken down by the BPD’s compelling need for reassurance and attachment. What was easily recognized in the client’s orbit of childhood and adult associations was completely unrecognizable in the client until it was too late. Something that should have been so obvious was regrettably overlooked, and the resulting therapist-client enmeshment has taken its tragic toll. The appeasement to this type of dysregulated mindset was preconditioned in childhood based on the therapist’s own dysfunctional upbringing. This uncanny familiarity comes from a complicated dance that was set in motion many years before the clinician and client finally met on that fateful therapeutic stage.

We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time. — T.S. Eliot

Working through traumatic childhood experiences, and understanding how these events condition our decision making in adulthood, is what matters in the end. Deeply embedded triggers from interacting with our families of origin are reactivated for both the therapist and the client during every therapy session. Many therapists have not done enough exploratory work to properly identify the innumerable faces of transference, or to successfully manage countertransference reactions, and their clients may be equally unaware of the influential depth that these symbolic-based forms of communication have on their own psychological motivations. Misunderstood and mismanaged countertransference reactions are often the Achilles tendon for therapists who become too personally invested in establishing meaningful relationships with their clients. A good question for therapists to consider is why they chose to work in the profession of caregiving. For many, it could be related to the power of human connection, compassion, and not wanting others to feel alone in their experiences. Unsurprisingly, most would agree that this premise embodies the essence of effective altruism. But can such noble aspirations ever become problematic? Are there exceptions? Some clients require impossible standards of connection that can only be assuaged through connecting with themselves. As a final caveat, be careful what you care about.

Stacking a house of unstable cards is naturally going to collapse if you don’t understand the true nature of what you’re stacked up against. The therapist who prematurely folds their boundaries in the face of something they don’t yet comprehend will lose the game every time. Betting against a Borderline’s nature is impossible, because they can always read the hand of accommodation that you’re holding. Even when the mysteries of chaos are finally revealed, the embers from that raging Queen of Hearts will continue to burn.

This should have been a noble creature:
A goodly frame of glorious elements,
Had they been wisely mingled; as it is,
It is an awful chaos—light and darkness,
And mind and dust, and passions and pure thoughts,
Mix’d, and contending without end or order,
All dormant or destructive. — Lord Byron

For more information:

http://www.universitypsychiatry.com/clientuploads/picp/10_PICPs.pdf

https://www.aafp.org/afp/2004/1015/p1505.html

https://www.bpdfamily.com/content/how-borderline-relationship-evolves

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1857277/

https://www.nami.org/Blogs/NAMI-Blog/June-2017/Understanding-Borderline-Personality-Disorder

https://www.ncbi.nlm.nih.gov/pubmed/6846667

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.1a1

http://www.bpdcentral.com/blog/?Fear-Obligation-and-Guilt-FOG-in-High-Conflict-Relationships-36

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330531/

https://www.mentalhelp.net/articles/falling-in-love-with-the-therapist-erotic-transference-and-psychotherapy/

https://nationalpsychologist.com/2014/01/legal-pitfalls-in-treating-borderline-personality-disorder/102395.html

https://www.psychiatrictimes.com/borderline-personality/borderline-personality-disorder-splitting-countertransference-0

https://www.psychologytoday.com/us/blog/fulfillment-any-age/201212/what-you-need-know-about-borderline-personality-disorder

https://www.zurinstitute.com/clinical-updates/borderline-one-away-from-losing-your-license/

https://www.newharbinger.com/psychsolve/borderline-personality-disorder

https://nationalpsychologist.com/2014/01/psychodynamic-dangers-in-treating-bpd/102401.html

 

View story at Medium.com

 

Recommended reading: https://www.amazon.com/Management-Countertransference-Borderline-Patients-Gabbard/dp/0765702630

 

Beyond all Borders

http://www.guidetopsychology.com/bpd.htm

http://outofthefog.website/personality-disorders-1/borderline-mother-types

https://www.psychologytoday.com/us/blog/fulfillment-any-age/201803/the-2-major-challenges-borderline-personality-disorder

https://www.borderlinepersonalitytreatment.com/relationship-with-borderline-personality-disorder.html

https://ebmh.bmj.com/content/18/3/67

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3268672/

 

 

Smoldering Limits

https://www.psychologytoday.com/us/articles/199707/why-shrinks-have-problems

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156844/

https://pdfs.semanticscholar.org/b750/cb9d9ba0d6124b7d0987209444b6d9272eb7.pdf

https://ct.counseling.org/2018/08/the-hurting-counselor/?utm_source=ciaug30&utm_medium=ciaug30&utm_campaign=ciaug30&utm_term=ciaug30&utm_content=ciaug30thehurtingcounselor

https://www.quora.com/Why-do-psychologists-therapists-counselors-quit

 

 

Countertransference & Its Discontents

https://files.eric.ed.gov/fulltext/ED422533.pdf

http://icpla.edu/wp-content/uploads/2012/09/Tansey-M.-Sexual-Attraction-and-the-Phobid-Dread.pdf

https://digitalcommons.pcom.edu/cgi/viewcontent.cgi?article=1064&context=psychology_dissertations

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.1a1

 

 

Psychological Dividends: On the Necessity of Critical Thinking

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Knowledge can produce any change in the universe that’s compatible with its laws. — David Deutsch

Logic is a virtue only when it’s maintained as a method for reasoning. In addition, reasoning is a process rather than an abstraction. In other words, the rigorous application of logic is not exclusive to philosophical idealism.

Knowing how to think is invariably more important than knowing what to think. Processes matter. Likewise, in today’s onslaught of information overload, knowing what to get rid of can be as essential as knowing what to keep  (e.g., a way of scrutinizing the landscape of our mind to eradicate what neuroscientist and psychologist Dean Buonomano described as “brain bugs”).

Formal logic consists of three basic rules of engagement that are operationally independent but mutually cohesive when analyzing propositions to develop a reliable framework of epistemology.

1. Inductive reasoning: Specific premise to a general conclusion.
2. Deductive reasoning: General premise to a specific conclusion.
3. Abductive reasoning: Most likely explanation given all available data.

However, regarding the seemingly infinite abyss of logical fallacies and their increasing regularity in daily conversation, there are five particular travesties of cognition that I encounter as a clinician more than I care to document during any given session. In addition, given today’s inauspicious trend of factual relativity and a blatant disregard for expertise, the need for intellectual vigilance has become something of a moral emergency among those still concerned with the concept of truth.

1. The fallacy of illicit transference is an informal fallacy that is committed when an argument assumes there is no difference between a term in the distributive (referring to every member of a class) and collective (referring to the class itself as a whole) sense. This fallacy occurs within two categorical errors: What is true of the part is true of the whole (composition), or what is true of the whole is true of the part (division).

Examples: {A} This politician in corrupt; therefore all politicians are corrupt (composition). {B} This agency is known for malfeasance; therefore any employee of this agency is untrustworthy (division). * Anomaly hunting is a common, supplemental approach to this fallacy in which an individual searches for confirmation of a belief while ignoring information that refutes their belief.

2. Post hoc, ergo propter hoc is a logical fallacy that infers the premise that if something occurs after an event, it must be caused by the event; used to indicate that a causal relationship has erroneously been assumed from a merely sequential one.

Example: The WTC 7 building in New York City (north of the Twin Towers) was known to contain private, financial banking records and collapsed shortly after the initial 9/11 attacks; therefore an attempted cover-up of fraudulent banking practices explains why 9/11 was an inside job orchestrated by the government via controlled demolition. Obviously, correlation does not prove causation. However, efforts to preoccupy oneself with erroneous associations often persist long after additional evidence has been produced to falsify such claims (e.g., the Backfire Effect).

3. Just-World Hypothesis (aka the Just-World Fallacy) is the assumption that a person’s actions are inherently inclined to bring morally fair and fitting consequences to that person, to the end of all noble actions being eventually rewarded and all evil actions eventually punished.

Example: People get what they deserve. This idea also derives from the presupposition that the world is an “equal playing field,” or that a person has unmitigated free will to “choose otherwise” (also known as a fundamental attribution error).

4. Argumentum ad populum is a logical fallacy that occurs when something is considered to be true or good solely because it is popular.

Example: Millions of people agree with my viewpoint; therefore, it must be right.

5. The Nirvana Fallacy is the informal fallacy of comparing actual things with unrealistic, idealized alternatives. It can also refer to the tendency to assume that there is a perfect solution to a particular problem (e.g., the perfect solution fallacy).

Examples: {A} Seat belts are a bad idea because people are still going to die in car crashes; therefore wearing a seat belt is an unecessary precaution. {B} Either there is a perfect solution to ending gun violence, or we shouldn’t do anything about it at all.

Alleviating the tyranny of confirmation bias prevents us from assuming the answers before investigating the questions. The facile satisfaction of asserting a comfortable narrative to explain complex or uncomfortable circumstances may be alluring, but it’s not a reliable way to understand the world and can result in the collateral damage of equal-opportunity credulity. In contrast, the psychological dividends available from exercising critical thinking skills allow us to remain honest while providing the most effective strategies for comprehending, accepting, and adapting to the nature of reality.

*Recommended reading: Crimes Against Logic by Jamie Whyte