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I Hate You—
Don’t Leave Me
UNDERSTANDING THE
BORDERLINE PERSONALITY
COMPLETELY REVISED AND UPDATED
Jerold J. Kreisman, MD, and Hal Straus
A Perigee Book
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“I Hate You—Don’t Leave Me was the rst book to introduce BPD
to the public. We are all indebted to Dr. Kreisman for his pioneering
efforts to raise awareness of this painful mental disorder. As research
and treatment have advanced so much since then, we welcome this
needed update to what is now a classic text.”
—Valerie Porr, MA, president and founder of Treatment and Research
Advancements National Association for Personality Disorder, and
author of Overcoming BPD
“Dr. Kreisman and Hal Straus have thoroughly revised their twenty-
year classic to include the latest advances in therapies and medications
while retaining the rich, easy- to-read style of the rst edition. Real- life
case studies and the extensive list of references illuminate our under-
standing of borderline personality not only for the general public but for
professionals as well. This book belongs on the bookshelf of patients,
their friends and family, and for all those who help in their healing.”
—Randi Kreger, author of Stop Walking on Eggshells and
The Essential Family Guide to Borderline Personality Disorder
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9780399536212_IHateYou_FM_pi-xvi.indd iii 16/09/10 7:41 AM
I Hate You—
Don’t Leave Me
UNDERSTANDING THE
BORDERLINE PERSONALITY
COMPLETELY REVISED AND UPDATED
Jerold J. Kreisman, MD, and Hal Straus
A Perigee Book
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A PERIGEE BOOK
Published by the Penguin Group
Penguin Group (USA) Inc.
375 Hudson Street, New York, New York 10014, USA
Penguin Group (Canada), 90 Eglinton Avenue East, Suite 700, Toronto, Ontario M4P 2Y3, Canada
(a division of Pearson Penguin Canada Inc.)
Penguin Books Ltd., 80 Strand, London WC2R 0RL,
England
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Books Ltd.)
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Penguin
Books (South Africa) (Pty.) Ltd., 24 Sturdee Avenue, Rosebank, Johannesburg 2196, South Africa
Penguin Books Ltd., Registered Ofces: 80 Strand, London WC2R 0RL, England
While the author has made every effort to provide accurate telephone numbers and Internet addresses
at the time of publication, neither the publisher nor the author assumes any responsibility for errors
or for changes that occur after publication. Further, the publisher does not have any control over and
does not assume any responsibility for author or third-party websites or their content.
Copyright © 2010 by Jerold J. Kreisman, MD, and Hal Straus
Text design by Tiffany Estreicher
All rights reserved.
No pa rt of th is bo ok may be reproduced , sca nned , or distributed in any printed or ele ctron ic form with-
out permission. Please do not participate in or encourage piracy of copyrighted materials in violation
of the author’s rights. Purchase only authorized editions.
PERIGEE is a registered trademark of Penguin Group (USA) Inc.
The “P” design is a trademark belonging to Penguin Group (USA) Inc.
Library of Congress Cataloging-in-Publication Data
Kreisman, Jerold J. (Jerold Jay)
I hate you—don’t leave me : understanding the borderline personality / Jerold J. Kreisman
and Hal Straus.— Rev. and updated.
p. cm.
“A Perigee book.”
Includes bibliographical references and index.
ISBN 1-101-44168-2
1. Borderline personality disorder. I. Straus, Hal. II. Title.
RC569.5.B67K74 2010
616.85'852 —dc22 2010 029714
Disclaimer: The information in this book is true and correct to the best of our knowledge. The book is
intended only as a general guide to a specic type of personality disorder and is not intended as a replace-
ment for sound medical advice or services from the individual reader’s personal physician. The stories that
begin many chapters, and other case history material throughout the book, have been developed from
composites of several people and do not represent any actual person, living or dead. Any resemblance to
any actual person is unintentional and purely coincidental. All recommendations herein are made without
guarantees by the authors or publisher. The authors and the publisher disclaim all liability, direct or con-
sequential, in connection with the use of any information or suggestion in this book.
Most Perigee books are available at special quantity discounts for bulk purchases for sales promotions,
premiums, fund-raising, or educational use. Special books, or book excerpts, can also be created to
t specic needs. For details, write: Special Markets, Penguin Group (USA) Inc., 375 Hudson Street,
New York, New York 10014.
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As all things,
still,
for Doody
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CONTENTS
Acknowledgments ix
Preface xi
Note to Reader xv
1.
The World of the Borderline 1
2. Chaos and Emptiness 22
3. Roots of the Borderline Syndrome 54
4. The Borderline Society 74
5. Communicating with the Borderline 101
6. Coping with the Borderline 123
7. Seeking Therapy 142
8. Specic Psychotherapeutic Approaches 176
9. Medications: The Science and the Promise 192
10. Understanding and Healing 204
Appendix A. DSM-IV-TR Classications 223
Appendix B. Evolution of the Borderline Syndrome 229
Resources 241
Notes 247
Index 261
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9780399536212_IHateYou_FM_pi-xvi.indd ix 16/09/10 7:41 AM
ACKNOWLEDGMENTS
The efforts necessary to complete this new edition required both
great assistance and forbearance. Assistance initiated with Bruce
Seymour of Goodeye Photoshare (goodeye-photoshare.com), who
donated much time and effort with technical issues producing
the manuscript. Another dear friend, Eugene Horwitz, massaged
frustrating computer conundrums. My secretaries, Jennifer Jacob
and Cindy Fridley, helped gather articles and books incorporated
into the work. Lynne Klippel, energetic librarian at DePaul Health
Center, St. Louis, tracked down helpful references.
Great forbearance was demonstrated by my partners and staff
of Allied Behavioral Consultants of St. Louis, who allowed me the
freedom to pursue this task. My wife, Judy, and children, Jenny,
Adam, Brett, and Alicia, and the little ones, Owen and Audrey
and a Player to Be Named Later, courageously consented to miss a
few ball games, several plays, and a lot of movies while I indulged
sunny afternoons researching and writing.
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x ACKNOWLEDGMENTS
We wish to thank our agent, Danielle Egan-Miller, at Browne &
Miller Literary Associates, and John Duff and Jeanette Shaw, our
publisher and editor, respectively, at Perigee/Penguin. All played
important roles in shaping the contents of this book.
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PREFACE
When the rst edition of I Hate You—Don’t Leave Me was pub-
lished in 1989, very little information was available to the general
public on the subject of Borderline Personality Disorder. Research
into the causes of, and treatments for, BPD was in its infancy. The
few articles that had appeared in consumer magazines vaguely
outlined the disorder as it began to inltrate the “American con-
sciousness.” There were virtually no books on BPD for the patient
or the patient’s close family and friends. The response to our book,
both in this country and abroad with foreign translations, has been
most gratifying. My intention to produce a work accessible to the
general public, yet functional for professionals with useful refer-
ences, seems to have been ful lled.
To say that a lot has happened in this area over twenty years is
obviously a vast understatement. Several other books on BPD have
been published, including our own Sometimes I Act Crazy (2004),
describing the experience of this illness from the perspectives of
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xii PREFACE
aficted individuals, family members, and treating professionals.
Greater understanding of the etiology, biological, genetic, psy-
chological, and social implications and treatment approaches has
added exponentially to our knowledge. So the challenge of writing
this second edition was to highlight and explain the most impor-
tant advances, present useful, referenced information for the pro-
fessional, and yet manage the length of the book so it can continue
to serve as an engaging introduction to BPD for the lay reader. To
achieve this balance, a few chapters needed only updating, but oth-
ers, especially those on the possible biological and genetic roots of
the syndrome, were extensively rewritten in order to incorporate
the latest scientic research. Additionally, speci c psychothera-
peutic approaches and drug treatments have evolved to such an
extent that it was necessary to include entirely new chapters on
these topics. The book’s reliance on real-life case stories, to give
the reader insight into what life is like for—and with—a border-
line, continues in this edition, though the backdrop of these stories
was altered to reect the changes in American society from one
century to the next. Perhaps the biggest change from the rst edi-
tion is one of overall tone: whereas the prognosis for patients was
understandably bleak two decades ago, it is now (based on numer-
ous longitudinal studies) much more positive.
And yet, despite these advancements, it is disappointing to
review the preface to the rst edition and recognize that misun-
derstanding and especially stigma still run rampant. BPD remains
an illness that continues to confuse the general public and terrify
many professionals. As recently as 2009, a Time magazine article
reported that “[b]orderlines are the patients psychologists fear
most” and “[m]any therapists have no idea how to treat [them].”
As Marsha Linehan, a leading expert on BPD, noted, “Borderline
individuals are the psychological equivalent of third-degree burn
patients. They simply have, so to speak, no emotional skin. Even
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PREFACE xiii
the slightest touch or movement can create immense suffering.”
1
Nevertheless, development of specic therapies and drugs targeted
at the disorder (see chapters 8 and 9) has provided some relief from
patients’ burdens, and perhaps more important, public aware-
ness of BPD has grown signicantly from what it was in 1989. As
you will see in the Resources section at the end of this book, the
number of books, websites, and support groups has proliferated.
Perhaps the clearest sign of public acknowledgment occurred in
2008, when Congress designated May as “Borderline Personality
Disorder Awareness Month.”
Still, huge challenges remain, especially nancial. Reimburse-
ment for cognitive medical services is shamefully, disproportionately
small. For one hour of psychotherapy, most insurance companies
(as well as Medicare) pay less than 8 percent of the reimbursement
rate allocated for a minor outpatient surgical procedure, such as a
fteen-minute cataract operation. Research for BPD has also been
inadequate. The lifetime prevalence rate of BPD in the population
is twice that of both schizophrenia and bipolar disorder combined,
and yet the National Institute of Mental Health (NIMH) devotes
less than 2 percent of the monies apportioned to the studies of those
illnesses to research on BPD.
2
As our country tries to control health
care costs, we must understand that investment in research will
eventually improve the health of this country and thus lower long-
term health care costs. But we will need to reevaluate the priorities
we place on limited resources, and recognize that rationing may
impact not only delivery of care but also advancements toward a
cure.
Many in the public and professional realm have kindly referred
to the original publication of this book as the “classic” in the eld.
After two decades, it has been a labor of love to revisit our work
and update the voluminous data accumulated during this interval.
It is my hope that by refreshing and refurbishing our original effort
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xiv PREFACE
we can play a small part in rectifying the misunderstandings and
erasing the stigma associated with BPD and retain the honor of
being referenced widely as a primary resource.
—Jerold J. Kreisman, MD
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NOTE TO READER
Most books on health follow a number of style guidelines (for
example, Publication Manual of the American Psychological Asso-
ciation) that are designed to minimize the stigma of disease and to
employ politically correct gender designations. Speci cally, refer-
ring to an individual by an illness (for example, “the schizophrenic
usually has . . .”) is discouraged; instead, reference is made to an
individual who expresses symptoms of the disease (for example,
“the patient diagnosed as a schizophrenic usually has . . .”). Also,
gender-specic pronouns are avoided; instead, sentences are struc-
tured in a passive syntax or use “he/she, him/her” constructions.
Though laudable in some respects, these recommendations
complicate the communication of information. Although we abhor
the implied disrespect and dehumanization of referring to people
by their medical conditions (“Check on the gallbladder in the next
room!”), we have nevertheless chosen, for the sake of clarity and
efciency, to sometimes refer to individuals by their diagnosis.
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xvi NOTE TO READER
For example, we use the term “borderline(s)” as a kind of short-
hand to represent the more precise designation, “human being(s)
who exhibit(s) symptoms consistent with the diagnosis Border-
line Personality Disorder, as dened by the American Psychiat-
ric Association’s Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR).” For the
same reason, we alternate pronouns throughout, rather than bur-
den the reader with the “he/she, him/her” construction. We trust
that the reader will grant us this liberty to streamline the text.
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Chapter One
The World of the Borderline
Everything looked and sounded unreal. Nothing was what it is.
That’s what I wanted—to be alone with myself in another world
where truth is untrue and life can hide from itself.
—From Long Day’s Journey into Night, by Eugene O’Neill
Dr. White thought it would all be relatively straightforward. Over
the ve years he had been treating Jennifer, she had few medical
problems. Her stomach complaints were probably due to gastritis,
he thought, so he treated her with antacids. But when her stomach
pains became more intense despite treatment and routine testing
proved normal, Dr. White admitted Jennifer to the hospital.
After a thorough medical workup, Dr. White inquired about
stresses Jennifer might be experiencing at work and home. She read-
ily acknowledged that her job as a personnel manager for a major
corporation was very pressured, but as she put it, “Many people
have pressure jobs.” She also revealed that her home life was more
hectic recently: She was trying to cope with her husband’s busy legal
practice while tending to the responsibilities of being a mother. But
she doubted the connection of these factors to her stomach pains.
When Dr. White recommended that Jennifer seek psychiatric
consultation, she initially resisted. It was only after her discomfort
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2 I HATE YOUDON’T LEAVE ME
turned into stabs of pain that she reluctantly agreed to see the psy-
chiatrist Dr. Gray.
They met a few days later. Jennifer was an attractive blond woman
who appeared younger than her twenty-eight years. She lay in bed
in a hospital room that had been transformed from an anonymous
cubicle into a personalized lair. A stuffed animal sat next to her in
bed and another lay on the nightstand beside several pictures of her
husband and son. Get-well cards were meticulously displayed in a
line along the windowsill, anked by ower arrangements.
At rst, Jennifer was very formal, answering all of Dr. Gray’s
questions with great seriousness. Then she joked about how her job
was “driving me to see a shrink.” The longer she talked, the sadder
she looked. Her voice became less domineering and more childlike.
She told him how a job promotion was exacting more demands—
new responsibilities that were making her feel insecure. Her ve-
year-old son was starting school, which was proving to be a dif cult
separation for both of them. Conicts with Allan, her husband, were
increasing. She described rapid mood swings and trouble sleeping.
Her appetite had steadily decreased and she was losing weight. Her
concentration, energy, and sex drive had all diminished.
Dr. Gray recommended a trial of antidepressant medications,
which improved her gastric symptoms and seemed to normalize
her sleeping patterns. In a few days she was ready for discharge
and agreed to continue outpatient therapy.
Over the following weeks, Jennifer talked more about her
upbringing. Reared in a small town, she was the daughter of a
prominent businessman and his socialite wife. Her father, an elder
in the local church, demanded perfection from his daughter and
her two older brothers, constantly reminding the children that the
community was scrutinizing their behavior. Jennifer’s grades, her
behavior, even her thoughts were never quite good enough. She
feared her father, yet constantly—and unsuccessfully—sought his
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3 THE WORLD OF THE BORDERLINE
approval. Her mother remained passive and detached. Her par-
ents evaluated her friends, often deeming them unacceptable. As a
result, she had few friends and even fewer dates.
Jennifer described her roller-coaster emotions, which seemed
to have worsened when she started college. She began drinking for
the rst time, sometimes to excess. Without warning, she would
feel lonely and depressed and then high with happiness and love.
On occasion, she would burst out in rage against her friends— ts
of anger that she had somehow managed to suppress as a child.
It was about this time that she also began to appreciate the
attention of men, something she had previously always avoided.
Though she enjoyed being desired, she always felt she was “fool-
ing” or tricking them somehow. After she began dating a man, she
would sabotage the relationship by stirring up con ict.
She met Allan as he was completing his law studies. He pur-
sued her relentlessly and refused to be driven away when she tried
to back off. He liked to choose her clothes and advise her on how
to walk, how to talk, and how to eat nutritiously. He insisted she
accompany him to the gym where he frequently worked out.
“Allan gave me an identity,” she explained. He advised her on how
to interact with his society partners and clients, when to be aggressive,
when to be demure. She developed a cast of “repertoire players”—
characters or roles whom she could call to the stage on cue.
They married, at Allan’s insistence, before the end of her junior
year. She quit school and began working as a receptionist, but her
employer recognized her intelligence and promoted her to more
responsible jobs.
At home, however, things began to sour. Allan’s career and his
interest in bodybuilding caused him to spend more time away from
home, which Jennifer hated. Sometimes she would start ghts just
to keep him home a little longer. Frequently, she would provoke him
into hitting her. Afterward she would invite him to make love to her.
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4 I HATE YOUDON’T LEAVE ME
Jennifer had few friends. She devalued women as gossipy and
uninteresting. She hoped that Scott’s birth, coming two years after
her marriage, would provide the comfort she lacked. She felt her
son would always love her and always be there for her. But the
demands of an infant were overwhelming, and after a while, Jen-
nifer decided to return to work.
Despite frequent praise and successes at work, Jennifer con-
tinued to feel insecure, that she was “faking it.” She became sex-
ually involved with a coworker who was almost forty years her
senior.
“Usually I’m okay,” she told Dr. Gray. “But there’s another side
that takes over and controls me. I’m a good mother. But my other
side makes me a whore; it makes me act crazy!”
Jennifer continued to deride herself, particularly when alone;
during times of solitude, she would feel abandoned, which she
attributed to her own unworthiness. Anxiety would threaten to
overwhelm her unless she found some kind of release. Sometimes
she’d indulge in eating binges, once consuming an entire bowl of
cookie batter. She would spend long hours gazing at pictures of her
son and husband, trying to “keep them alive in my brain.”
Jennifer’s physical appearance at her therapy sessions uctu-
ated dramatically. When coming directly from work, she would
dress in a business suit that exuded maturity and sophistication.
But on days off she showed up in short pants and knee socks, with
her hair in braids; at these appointments she acted like a little girl
with a high-pitched voice and a more limited vocabulary.
Sometimes she would transform right before Dr. Gray’s eyes. She
could be insightful and intelligent, working collaboratively toward
greater self-understanding, and then become a child, coquettish
and seductive, pronouncing herself incapable of functioning in the
adult world. She could be charming and ingratiating or manipula-
tive and hostile. She could storm out of one session, vowing never
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5 THE WORLD OF THE BORDERLINE
to return, and at the next session cower with the fear that Dr. Gray
would refuse to see her again.
Jennifer felt like a child clad in the armor of an adult. She was
perplexed at the respect she received from other adults; she expected
them to see through her disguise at any moment, revealing her as
an empress with no clothes. She needed someone to love and pro-
tect her from the world. She desperately sought closeness, but when
someone came too close, she ran.
Jennifer is aficted with Borderline Personality Disorder (BPD).
She is not alone. Recent studies estimate that 18 million or more
Americans (almost 6 percent of the population) exhibit primary
symptoms of BPD, and many studies suggest this gure is an under-
estimation.
1
Approximately 10 percent of psychiatric outpatients
and 20 percent of inpatients, and between 15 and 25 percent of all
patients seeking psychiatric care, are diagnosed with the disorder.
It is one of the most common of all of the personality disorders.
2,3,4
Yet, despite its prevalence, BPD remains relatively unknown to
the general public. Ask the man on the street about anxiety, depres-
sion, or alcoholism, and he would probably be able to provide a
sketchy, if not technically accurate, description of the illness. Ask
him to dene Borderline Personality Disorder, and he would prob-
ably give you a blank stare. Ask an experienced mental health clini-
cian about the disorder, on the other hand, and you will get a much
different response. She will sigh deeply and exclaim that of all the
psychiatric patients, borderlines are the most difcult, the most
dreaded, and the most to be avoided—more than schizophrenics,
more than alcoholics, more than any other patient. For more than
a decade, BPD has been lurking as a kind of “Third World” of
mental illness—indistinct, massive, and vaguely threatening.
BPD has been underrecognized partly because the diagnosis is
9780399536212_IHateYou_TX_p1-272.indd 6 20/09/10 11:06 AM
6 I HATE YOUDON’T LEAVE ME
still relatively new. For years, “borderline” was used as a catchall
category for patients who did not t more established diagnoses.
People described as “borderline” seemed more ill than neurotics
(who experience severe anxiety secondary to emotional con ict),
yet less ill than psychotics (whose detachment from reality makes
normal functioning impossible).
The disorder also coexists with, and borders on, other mental
illnesses: depression, anxiety, bipolar (manic-depressive) disorder,
schizophrenia, somatization disorder (hypochondriasis), disso-
ciative identity disorder (multiple personality), attention de cit/
hyperactivity disorder (ADHD), post-traumatic stress disorder,
alcoholism, drug abuse (including nicotine dependence), eating
disorders, phobias, obsessive-compulsive disorder, hysteria, socio-
pathy, and other personality disorders.
Though the term borderline was rst coined in the 1930s, the con-
dition was not clearly dened until the 1970s. For years, psychiatrists
could not seem to agree on the separate existence of the syndrome, much
less on the specic symptoms necessary for diagnosis. But as more and
more people began to seek therapy for a unique set of life problems,
the parameters of the disorder crystallized. In 1980, the diagnosis of
Borderline Personality Disorder was rst dened in the American Psy-
chiatric Association’s third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III), the diagnostic “bible” of the
psychiatric profession. Since then, several revisions of the DSM have
been produced, the most recent being DSM-IV-TR, published in 2000.
Though various schools within psychiatry still quarrel over the exact
nature, causes, and treatment of BPD, the disorder is of cially rec-
ognized as a major mental health problem in America today. Indeed,
BPD patients consume a greater percentage of mental health services
than those with just about any other diagnosis.
5,6
Additionally, studies
corroborate that about 90 percent of patients with the BPD diagnosis
also share at least one other major psychiatric diagnosis.
7,8
9780399536212_IHateYou_TX_p1-272.indd 7 20/09/10 11:06 AM
7 THE WORLD OF THE BORDERLINE
In many ways, the borderline syndrome has been to psychiatry
what the virus is to general medicine: an inexact term for a vague
but pernicious illness that is frustrating to treat, difcult to de ne,
and impossible for the doctor to explain adequately to his patient.
Demographic Borders
Who are the borderline people one meets in everyday life?
She is Carol, a friend since grade school. Over a minor slight, she
accuses you of stabbing her in the back and tells you that you were
really never her friend at all. Weeks or months later, Carol calls
back, congenial and blasé, as if nothing had happened between you.
He is Bob, a boss in your ofce. One day, Bob bestows glow-
ing praise on your efforts in a routine assignment; another day, he
berates you for an insignicant error. At times he is reserved and dis-
tant; other times he is suddenly and uproariously “one of the boys.”
She is Arlene, your son’s girlfriend. One week, she is the picture of
preppy; the next, she is the epitome of punk. She breaks up with your
son one night, only to return hours later, pledging endless devotion.
He is Brett, your next-door neighbor. Unable to come to grips
with his collapsing marriage, he denies his wife’s obvious unfaith-
fulness in one breath, and then takes complete blame for it in the
next. He clings desperately to his family, caroming from guilt and
self-loathing to raging attacks on his wife and children who have
so “unfairly” accused him.
If the people in these short proles seem inconsistent, it should not
be surprising—inconsistency is the hallmark of BPD. Unable to toler-
ate paradox, borderlines are walking paradoxes, human catch-22s.
Their inconstancy is a major reason why the mental health profession
has had such dif culty dening a uniform set of criteria for the illness.
If these people seem all too familiar, this also should not be
9780399536212_IHateYou_TX_p1-272.indd 8 20/09/10 11:06 AM
8 I HATE YOUDON’T LEAVE ME
surprising. The chances are good that you have a spouse, relative,
close friend, or coworker who is borderline. Perhaps you know a little
bit about BPD or recognize borderline characteristics within yourself.
Though it is difcult to get a rm grasp on the gures, mental
health professionals generally agree that the number of border-
lines in the general population is growing—and at a rapid pace—
though some observers claim that it is the therapists’ awareness of
the disorder that is growing rather than the number of borderlines.
Is borderline personality really a modern-day “plague,” or is
merely the diagnostic label borderline new? In any event, the disor-
der has provided new insight into the psychological framework of
several related conditions. Numerous studies have linked BPD with
anorexia, bulimia, ADHD, drug addiction, and teenage suicide—all
of which have increased alarmingly over the last decade. Some stud-
ies have uncovered BPD in almost 50 percent of all patients admitted
to a facility for an eating disorder.
9
Other studies have found that
over 50 percent of substance abusers also fulll criteria for BPD.
Self-destructive tendencies or suicidal gestures are very common
among borderlines—indeed, they are one of the syndrome’s de ning
criteria. As many as 70 percent of BPD patients attempt suicide. The
incidence of documented death by suicide is about 8 to 10 percent
and even higher for borderline adolescents. A history of previous
suicide attempts, a chaotic family life, and a lack of support systems
increase the likelihood. The risk multiplies even more among bor-
derline patients who also suffer from depressive or manic-depressive
(bipolar) disorders, or from alcoholism or drug abuse.
10,11
How Doctors Diagnose Psychiatric Disease
Before 1980, the previous two editions of the DSM described psy-
chiatric illnesses in descriptive terms. However, DSM-III de ned
9780399536212_IHateYou_TX_p1-272.indd 9 20/09/10 11:06 AM
9 THE WORLD OF THE BORDERLINE
psychiatric disorders along structured, categorical paradigms; that
is, several symptoms have been proposed to be suggestive of a par-
ticular diagnosis, and when a certain number of these criteria are
met, the individual is considered to fulll the categorical require-
ments for diagnosis. Interestingly, in the four revisions of DSM
since 1980, only minor adjustments have been made to the de -
nitional criteria for BPD. As we shall see shortly, nine criteria are
associated with BPD, and an individual qualies for the diagnosis
if he exhibits ve or more of the nine.
The categorical paradigm has stimulated controversy among
psychiatrists, especially regarding the diagnosis of personality
disorders. Unlike most other psychiatric illnesses, personality dis-
orders are generally considered to develop in early adulthood and
to persist for extended periods. These personality traits tend to be
enduring and change only gradually over time. However, the cate-
gorical system of denitions may result in an unrealistically abrupt
diagnostic change. In relation to BPD, a borderline patient who
exhibits ve symptoms of BPD theoretically ceases to be consid-
ered borderline if one symptom changes. Such a precipitous “cure”
seems inconsistent with the concept of personality.
Some researchers have suggested adjusting the DSM to a dimen-
sional approach to diagnosis. Such a model would attempt to deter-
mine what could be called “degrees of borderline,” since clearly some
borderlines function at a higher level than others. These authors sug-
gest that, rather than concluding that an individual is—or is not—
borderline, the disorder should be recognized along a spectrum.
This approach would put different weights on some of the de ning
criteria, depending upon which symptoms are shown by research
to be more prevalent and enduring. Such a method could develop a
representative, “pure” borderline prototype, which could standard-
ize measures based on how closely a patient “matches” the descrip-
tion. A dimensional approach might be used to measure functional
9780399536212_IHateYou_TX_p1-272.indd 10 20/09/10 11:06 AM
10 I HATE YOUDON’T LEAVE ME
impairment. In this way, a higher or lower functioning borderline
would be identied by her ability to manage her usual tasks of liv-
ing. Another methodology would gauge particular traits, such as
impulsivity, novelty-seeking, reward dependence, harm avoidance,
neuroticism (capturing such characteristics as vulnerability to stress,
poor impulse control, anxiety, mood lability, etc.) that have been
associated with BPD.
12,13,14
Such adaptations may more accurately
measure changes and degrees of improvement, rather than merely
determining the presence or absence of the disorder.
To understand the difference between these two de nitional
approaches, consider the way we perceive “gender.” The determi-
nation that one is male or female is a categorical de nition, based
on objective genetic and hormonal factors. Designations of mas-
culinity or femininity, however, are dimensional concepts, in u-
enced by personal, cultural, and other less objective criteria. It is
likely that future iterations of the DSM will incorporate dimen-
sional features of diagnosis.
Diagnosis of BPD
The most recent DSM-IV-TR lists nine categorical criteria for BPD,
ve of which must be present for diagnosis.
15
At rst glance, these
criteria may seem unconnected or only peripherally related. When
explored in depth, however, the nine symptoms are seen to be intri-
cately connected, interacting with each other so that one symptom
sparks the rise of another like the pistons of a combustion engine.
The nine criteria may be summarized as follows (each is described
in depth in chapter 2):
1. Frantic efforts to avoid real or imagined abandonment.
2. Unstable and intense interpersonal relationships.
3. Lack of clear sense of identity.
9780399536212_IHateYou_TX_p1-272.indd 11 20/09/10 11:06 AM
THE WORLD OF THE BORDERLINE 11
4.
Impulsiveness in potentially self-damaging behaviors, such as
substance abuse, sex, shoplifting, reckless driving, binge eating.
5. Recurrent suicidal threats or gestures, or self-mutilating
behaviors.
6. Severe mood shifts and extreme reactivity to situational
stresses.
7. Chronic feelings of emptiness.
8. Frequent and inappropriate displays of anger.
9. Transient, stress-related feelings of unreality or paranoia.
This constellation of nine symptoms can be grouped into four
primary areas toward which treatment is frequently directed:
1. Mood instability (criteria 1, 6, 7, and 8).
2. Impulsivity and dangerous uncontrolled behavior (criteria 4
and 5).
3. Interpersonal psychopathology (criteria 2 and 3).
4. Distortions of thought and perception (criterion 9).
Emotional Hemophilia
Beneath the clinical nomenclature lies the anguish experienced
by borderlines and their families and friends. For the borderline,
much of life is a relentless emotional roller coaster with no appar-
ent destination. For those living with, loving, or treating the bor-
derline, the trip can seem just as wild, hopeless, and frustrating.
Jennifer and millions of other borderlines are provoked to rage
uncontrollably against the people they love most. They feel help-
less and empty, with an identity splintered by severe emotional
contradictions.
Mood changes come swiftly, explosively, carrying the borderline
9780399536212_IHateYou_TX_p1-272.indd 12 20/09/10 11:06 AM
12 I HATE YOUDON’T LEAVE ME
from the heights of joy to the depths of depression. Filled with anger
one hour, calm the next, he often has little inkling about why he
was driven to such wrath. Afterward, the inability to understand
the origins of the episode brings on more self-hate and depression.
A borderline suffers a kind of “emotional hemophilia”; she lacks
the clotting mechanism needed to moderate her spurts of feeling.
Prick the delicate “skin” of a borderline and she will emotionally
bleed to death. Sustained periods of contentment are foreign to
the borderline. Chronic emptiness depletes him until he is forced
to do anything to escape. In the grip of these lows, the borderline
is prone to a myriad of impulsive, self-destructive acts—drug and
alcohol binges, eating marathons, anorexic fasts, bulimic purges,
gambling forays, shopping sprees, sexual promiscuity, and self-
mutilation. He may attempt suicide, often not with the intent to
die but to feel something, to conrm he is alive.
“I hate the way I feel,” confesses one borderline. “When I think
about suicide, it seems so tempting, so inviting. Sometimes it’s the
only thing I relate to. It is difcult not to want to hurt myself. It’s
like, if I hurt myself, the fear and pain will go away.”
Central to the borderline syndrome is the lack of a core sense
of identity. When describing themselves, borderlines typically
paint a confused or contradictory self-portrait, in contrast to other
patients who generally have a much clearer sense of who they are.
To overcome their indistinct and mostly negative self-image, bor-
derlines, like actors, are constantly searching for “good roles,”
complete “characters” they can use to ll their identity void. So
they often adapt like chameleons to the environment, situation, or
companions of the moment, much like the title character in Woody
Allen’s lm Zelig, who literally assumes the personality, identity,
and appearance of people around him.
The lure of ecstatic experiences, whether attained through sex,
drugs, or other means, is sometimes overwhelming for the borderline.
9780399536212_IHateYou_TX_p1-272.indd 13 20/09/10 11:06 AM
THE WORLD OF THE BORDERLINE 13
In ecstasy, he can return to a primal world where the self and the
external world merge—a form of second infancy. During periods
of intense loneliness and emptiness, the borderline will go on drug
binges, bouts with alcohol, or sexual escapades (with one or sev-
eral partners), sometimes lasting days at a time. It is as if when the
struggle to nd identity becomes intolerable, the solution is either to
lose identity altogether or to achieve a semblance of self through pain
or numbness.
The family background of a borderline is often marked by
alcoholism, depression, and emotional disturbances. A border-
line childhood is frequently a desolate battleeld, scarred with the
debris of indifferent, rejecting, or absent parents, emotional depri-
vation, and chronic abuse. Most studies have found a history of
severe psychological, physical, or sexual abuse in many borderline
patients. Indeed, a history of mistreatment, witness to violence, or
invalidation of experience by parents or primary caregivers distin-
guishes borderline patients from other psychiatric patients.
16,17
These unstable relationships carry over into adolescence and
adulthood, where romantic attachments are highly charged and
usually short-lived. The borderline will frantically pursue a man (or
woman) one day and send him packing the next. Longer romances—
usually measured in weeks or months rather than years—are usu-
ally lled with turbulence and rage, wonder, and excitement.
Splitting: The Black-and-White
World of the Borderline
The world of a borderline, like that of a child, is split into heroes
and villains. A child emotionally, the borderline cannot tolerate
human inconsistencies and ambiguities; he cannot reconcile anoth-
er’s good and bad qualities into a constant, coherent understanding
9780399536212_IHateYou_TX_p1-272.indd 14 20/09/10 11:06 AM
14 I HATE YOUDON’T LEAVE ME
of that person. At any particular moment, one is either “good” or
“evil”; there is no in-between, no gray area. Nuances and shad-
ings are grasped with great difculty, if at all. Lovers and mates,
mothers and fathers, siblings, friends, and psychotherapists may be
idolized one day, totally devalued and dismissed the next.
When the idealized person nally disappoints (as we all do,
sooner or later), the borderline must drastically restructure his
strict, inexible conceptualization. Either the idol is banished to
the dungeon or the borderline banishes himself in order to preserve
the “all-good” image of the other person.
This type of behavior, called “splitting,” is the primary defense
mechanism employed by the borderline. Technically de ned, split-
ting is the rigid separation of positive and negative thoughts and
feelings about oneself and others; that is, the inability to synthesize
these feelings. Most individuals can experience ambivalence and
perceive two contradictory feeling states at one time; borderlines
characteristically shift back and forth, entirely unaware of one
emotional state while immersed in another.
Splitting creates an escape hatch from anxiety: the borderline
typically experiences a close friend or relation (call him “Joe”) as
two separate people at different times. One day, she can admire
“Good Joe” without reservation, perceiving him as completely
good; his negative qualities do not exist; they have been purged and
attributed to “Bad Joe.” Other days, she can guiltlessly and totally
despise “Bad Joe” and rage at his evil without self-reproach—for
now his positive traits do not exist; he fully deserves the rage.
Intended to shield the borderline from a barrage of contradic-
tory feelings and images—and from the anxiety of trying to rec-
oncile those images—the splitting mechanism often and ironically
achieves the opposite effect: the frays in the personality fabric
become full-edged rips; the sense of her own identity and the
identities of others shift even more dramatically and frequently.
9780399536212_IHateYou_TX_p1-272.indd 15 20/09/10 11:06 AM
THE WORLD OF THE BORDERLINE 15
Stormy Relationships
Despite feeling continually victimized by others, a borderline des-
perately seeks out new relationships; for solitude, even temporary
aloneness, is more intolerable than mistreatment. To escape the
loneliness, the borderline will ee to singles bars, the arms of recent
pickups, somewhere—anywhere—to meet someone who might save
her from the torment of her own thoughts. The borderline is con-
stantly searching for Mr. Goodbar.
In the relentless search for a structured role in life, the bor-
derline is typically attracted to—and attracts to her—others with
complementary personality traits. The domineering, narcissistic
personality of Jennifer’s husband, for example, cast her in a well-
dened role with little effort. He was able to give her an identity
even if the identity involved submissiveness and mistreatment.
Yet, for a borderline, relationships often disintegrate quickly.
Maintaining closeness with a borderline requires an understanding
of the syndrome and a willingness to walk a long, perilous tight-
rope. Too much closeness threatens the borderline with suffoca-
tion. Keeping one’s distance or leaving a borderline alone—even for
brief periods—recalls the sense of abandonment he felt as a child.
In either case, the borderline reacts intensely.
In a sense, the borderline is like an emotional explorer who
carries only a sketchy map of interpersonal relations; he nds it
extremely difcult to gauge the optimal psychic distance from oth-
ers, particularly signicant others. To compensate, he caroms back
and forth from clinging dependency to angry manipulation, from
gushes of gratitude to ts of irrational anger. He fears abandon-
ment, so he clings; he fears engulfment, so he pushes away. He
craves intimacy and is terried of it at the same time. He winds up
repelling those with whom he most wants to connect.
9780399536212_IHateYou_TX_p1-272.indd 16 20/09/10 11:06 AM
16 I HATE YOUDON’T LEAVE ME
Job and Workplace Problems
Though borderlines have extreme difculties managing their personal
lives, many are able to function productively in a work situation—
particularly if the job is well structured, clearly dened, and support-
ive. Some perform well for long periods, but then suddenly—because
of a change in the job structure, or a drastic shift in personal life, or
just plain boredom and a craving for change—they abruptly leave
or sabotage their position and go on to the next opportunity. Many
borderlines complain of frequent or chronic minor medical illnesses,
leading to recurrent doctor visits and sick days.
18
The work world can provide sanctuary from the anarchy of their
social relationships. For this reason, borderlines frequently function
best in highly structured work environments. The helping professions—
medicine, nursing, clergy, counseling—also attract many borderlines
who strive to achieve the power or control that elude them in social
relationships. Perhaps more important, in these roles borderlines can
provide the care for others—and receive the recognition from others—
that they yearn for in their own lives. Borderlines are often very intel-
ligent and display striking artistic abilities; fueled by easy access to
powerful emotions, they can be creative and successful professionally.
But a highly competitive or unstructured job, or a highly criti-
cal supervisor, can trigger the intense, uncontrolled anger and the
hypersensitivity to rejection to which the borderline is susceptible.
The rage can permeate the workplace and literally destroy a career.
A “Woman’s Illness”?
Until recently, studies suggested that women borderlines outnum-
bered men by as much as three or four to one. However, more
9780399536212_IHateYou_TX_p1-272.indd 17 20/09/10 11:06 AM
THE WORLD OF THE BORDERLINE 17
recent epidemiological research conrms that prevalence is similar
in both genders, although women enter treatment more frequently.
Moreover, severity of symptoms and disability are greater among
women. These factors may help explain why females have been
overrepresented in clinical trials. But there may be other factors
that contribute to the impression that BPD is a “woman’s disease.”
Some critics feel that a kind of clinician bias operates with bor-
derline diagnoses: Psychotherapists may perceive problems with
identity and impulsivity as more “normal” in men; as a result, they
may underdiagnose BPD among males. Where destructive behav-
ior in women may be seen as a result of mood dysfunction, similar
behavior in men may be perceived as antisocial. Where women in
such predicaments may be directed toward treatment, men may
instead be channeled through the criminal justice system where
they may elude correct diagnosis forever.
BPD in Dierent Age Groups
Many of the features of the borderline syndrome—impulsivity,
tumultuous relationships, identity confusion, mood instability—are
major developmental hurdles for any adolescent. Indeed, establish-
ing a core identity is the primary quest for both the teenager and the
borderline. It follows, then, that BPD is diagnosed more commonly
among adolescents and young adults than other age groups.
19
BPD appears to be rare in the elderly. Recent studies demonstrate
that the greatest decline in diagnosis of BPD occurs after the mid-
forties. From this data, some researchers hypothesize that many older
borderline adults “mature out” and are able to achieve stabilization
over time. However, elderly adults must contend with a progressive
decline in physical and mental functioning, which can be a perilous
adaptive process for some aging borderlines. For a fragile identity, the
9780399536212_IHateYou_TX_p1-272.indd 18 20/09/10 11:06 AM
18 I HATE YOUDON’T LEAVE ME
task of altering expectations and adjusting self-image can exacerbate
symptoms. The aging borderline with persistent psychopathology
may deny deteriorating functions, project the blame for de ciencies
onto others, and become increasingly paranoid; at other times, he
may exaggerate handicaps and become more dependent.
Socioeconomic Factors
Borderline pathology has been identied in all cultures and economic
classes in the United States. However, rates of BPD were signi cantly
higher among those separated, divorced, widowed, or living alone,
and among those with lower income and education. The conse-
quences of poverty on infants and children—higher stress levels, less
education, and lack of good child care, psychiatric care, and preg-
nancy care (perhaps resulting in brain insults or malnutrition)—
might lead to higher incidence of BPD among the poor.
Geographic Borders
Although most of the theoretical formulations and empirical stud-
ies of the borderline syndrome have been conducted in the United
States, other countries—Canada, Mexico, Israel, Sweden, Denmark,
other Western European nations, and the former USSR—have rec-
ognized borderline pathologies within their populations.
Comparative studies are scant and contradictory at this point.
For example, some studies indicate higher rates of BPD among His-
panics, while others do not conrm this nding. Some studies have
found greater rates of BPD among Native American men. Consis-
tent studies are meager but could provide great insight into the child-
rearing, cultural, and social threads that compose the causal fabric
of the syndrome.
9780399536212_IHateYou_TX_p1-272.indd 19 20/09/10 11:06 AM
THE WORLD OF THE BORDERLINE 19
Borderline Behavior in Celebrities
and Fictional Characters
Whether the borderline personality is a new phenomenon or sim-
ply a new label for a long-standing, interrelated cluster of internal
feelings and external behaviors is a topic of some interest in the
mental health community. Most psychiatrists believe that the bor-
derline syndrome has been around for quite some time; that its
increasing prominence results not so much from its spreading (like
an infectious disease or a chronic debilitating condition) in the
minds of patients but from the awareness of clinicians. Indeed,
many psychiatrists believe that some of Sigmund Freud’s most
interesting cases of “neurosis” at the turn of the century would
today be clearly diagnosed as borderline.
20
Perceived in this way, the borderline syndrome becomes an inter-
esting new perspective from which to understand some of our most
complex personalities—both past and present, real and ctional.
Conversely, well-known gures and characters can be understood
to illustrate different aspects of the syndrome. Along these lines,
biographers and others have speculated that the term might apply
to such wide-ranging gures as Princess Diana, Marilyn Monroe,
Zelda Fitzgerald, Thomas Wolfe, T. E. Lawrence, Adolf Hitler, and
Muammar al-Gadha. Cultural critics can observe borderline fea-
tures in Blanche Dubois in A Streetcar Named Desire, Martha in
Who’s Afraid of Virginia Woolf?, Sally Bowles in Cabaret, Travis
Bickle in Taxi Driver, Howard Beale in Network, and Carmen in
Bizet’s opera. Although borderline symptoms or behaviors may be
spotted in these characters, BPD should not be assumed to neces-
sarily cause or propel the radical actions or destinies of these real
people or the ctional characters or the works in which they appear.
Hitler, for example, was probably driven by mental malfunctions
9780399536212_IHateYou_TX_p1-272.indd 20 20/09/10 11:06 AM
20 I HATE YOUDON’T LEAVE ME
and societal forces much more prominent in his psyche than BPD;
the root causes of Marilyn Monroe’s (alleged) suicide were prob-
ably more complex than to say simply it was caused by BPD. There
is little evidence that the authors of Taxi Driver or Network were
consciously trying to create a borderline protagonist. What the bor-
derline syndrome does furnish is another perspective from which to
interpret and analyze these fascinating personalities.
Advances in Research and Treatment
Since publication of the rst edition of this book, signi cant
strides have been made in research into the root causes of BPD and
its treatment. Advances in our understanding of the biological,
physiological, and genetic underpinnings of psychiatric diseases
are exploding. Interactions between different parts of the brain
and how emotions and executive reasoning intersect are being illu-
minated. The roles of neurotransmitters, hormones, and chemical
reactions in the brain are better understood. Genetic vulnerabil-
ity, how genes can be switched on and off, and the collision with
life events to determine personality functioning are being studied.
New psychotherapeutic techniques have evolved.
Long-term studies conrm that many patients recover over time
and even more improve signicantly. Over a decade 86 percent of
borderline patients achieve sustained relief of symptoms, almost half
of those within the rst two years. However, despite diminution of
dening symptoms, many of these patients continue to struggle in
social and work or school environments. Although recurrence rates
are as high as 34 percent, after ten years, full and complete recovery
with good social and vocational functioning is achieved in 50 percent
of patients.
21,22
Many borderline patients improve without consistent
treatment, although continued therapy hastens improvement.
23
9780399536212_IHateYou_TX_p1-272.indd 21 20/09/10 11:06 AM
THE WORLD OF THE BORDERLINE 21
The Question of Borderline “Pathology”
To one degree or another, we all struggle with the same issues as
the borderline—the threat of separation, fear of rejection, confu-
sion about identity, feelings of emptiness and boredom. How many
of us have not had a few intense, unstable relationships? Or ew
into a rage now and then? Or felt the allure of ecstatic states? Or
dreaded being alone, or gone through mood swings, or acted in a
self-destructive manner in some way?
If nothing else, BPD serves to remind us that the line between
“normal” and “pathological” may sometimes be a very thin one.
Do we all display, to one degree or another, some symptoms of bor-
derline personality? The answer is probably yes. Indeed, many of
you reading this rst chapter might be thinking that this sounds
like you or someone you know. The discriminating factor, however,
is that not all of us are controlled by the syndrome to the degree
that it disrupts—or rules—our lives. With its extremes of emotion,
thought, and behavior, BPD represents some of the best and worst
of human character—and of our society in the nascent years of the
twenty-rst century. By exploring its depths and boundaries, we may
be facing up to our ugliest instincts and our highest potentials—and
the hard road we must travel to get from one point to the other.
9780399536212_IHateYou_TX_p1-272.indd 22 20/09/10 11:06 AM
Chapter Two
Chaos and Emptiness
All is caprice. They love without measure those whom they will
soon hate without reason.
—Thomas Sydenham, seventeenth-century English physician, on
“hystericks,” the equivalent of today’s borderline personality
“I sometimes wonder if I’m possessed by the devil,” says Carrie,
a social worker in the psychiatric unit of a large hospital. “I don’t
understand myself. All I know is, this borderline personality of
mine has forced me into a life where I’ve cut everyone out. So it’s
very, very lonely.”
Carrie was diagnosed with the borderline syndrome after twenty-
two years of therapy, medication, and hospitalizations for a variety
of mental and physical illnesses. By then, her medical le resembled
a well-worn passport, the pages stamped with the numerous psychi-
atric “territories” through which she had traveled.
“For years I was in and out of hospitals, but I never found a
therapist who understood me and knew what I was going through.”
Carrie’s parents were divorced when she was an infant, and she
was raised by her alcoholic mother until she was nine. A boarding
school took care of her for four years after that.
When she was twenty-one, overwhelming depression forced
9780399536212_IHateYou_TX_p1-272.indd 23 20/09/10 11:06 AM
CHAOS AND EMPTINESS 23
her to seek therapy; she was diagnosed and treated for depres-
sion at that time. A few years later, her moods began to uctuate
wildly and she was treated for bipolar disorder (manic depression).
Throughout this period she repeatedly overdosed on medications
and cut her wrists many times.
“I was cutting myself and overdosing on tranquilizers, antide-
pressants, or whatever drug I happened to be on,” she recalls. “It
had become almost a way of life.”
In her mid-twenties, she began to have auditory hallucinations
and became severely paranoid. At this time she was hospitalized
for the rst time and diagnosed schizophrenic.
And still later in life, Carrie was hospitalized in a cardiac-care
unit numerous times for severe chest pains, subsequently recog-
nized to be anxiety related. She went through periods of binge
eating and starvation fasting; over a period of several weeks, her
weight would vary by as much as seventy pounds.
When she was thirty-two, she was brutally raped by a physi-
cian on the staff of the hospital in which she worked. Soon after,
she returned to school and was drawn into a sexual relationship
with one of her female professors. By the age of forty-two, her
collection of medical les was lled with almost every diagnosis
imaginable, including schizophrenia, depression, bipolar disorder,
hypochondriasis, anxiety, anorexia nervosa, sexual dysfunction,
and post-traumatic stress disorder.
Despite her mental and physical problems, Carrie was able to
perform her work fairly well. Though she changed jobs frequently,
she managed to complete a doctorate in social work. She was even
able to teach for a while at a small women’s college.
Her personal relationships, however, were severely limited. “The
only relationships I’ve had with men were ones in which I was sexually
abused. A few men have wanted to marry me, but I have a big prob-
lem with getting close or being touched. I can’t tolerate it. It makes me
9780399536212_IHateYou_TX_p1-272.indd 24 20/09/10 11:06 AM
24 I HATE YOUDON’T LEAVE ME
want to run. I was engaged a couple of times, but had to break them
off. It’s unrealistic of me to think I could be anybody’s wife.”
As for friends, she says, “I’m very self-absorbed. I say every-
thing I think, feel, know, or don’t know. It’s so hard for me to get
interested in other people.”
After more than twenty years of treatment, Carrie’s symptoms
were nally recognized and diagnosed as BPD. Her dysfunction
evolved from ingrained, enduring personality traits, more indica-
tive of a personality or “trait” disorder than her previously diag-
nosed, transient “state” illnesses.
“The most difcult part of being a borderline personality has
been the emptiness, the loneliness, and the intensity of feelings,”
she says today. “The extreme behaviors keep me so confused. At
times I don’t know what I’m feeling or who I am.”
A better understanding of Carrie’s illness has led to more con-
sistent treatment. Medications have been useful for treating acute
symptoms and providing the glue for maintaining a more coherent
sense of self; at the same time, she has acknowledged the limita-
tions of the medications.
Her psychiatrist, working with her other physicians, has helped
her to understand the connection between her physical complaints
and her anxiety and to avoid unnecessary medical tests, drugs,
and surgeries. Psychotherapy has been geared for the “long haul,”
focusing on her dependency and stabilization of her identity
and relationships, rather than on an endless succession of acute
emergencies.
Carrie, at forty-six, has had to learn that an entire set of previ-
ous behaviors are no longer acceptable. “I don’t have the option
of cutting myself, or overdosing, or being hospitalized anymore.
I vowed I would live in and deal with the real world, but I’ll tell
you, it’s a frightening place. I’m not sure yet whether I can do it or
whether I want to do it.”
9780399536212_IHateYou_TX_p1-272.indd 25 20/09/10 11:06 AM
CHAOS AND EMPTINESS 25
Borderline: A Personality Disorder
Carrie’s journey through this maze of psychiatric and medical
symptoms and diagnoses exemplies the confusion and despera-
tion experienced by individuals aficted with mental illness and by
those who minister to them. Though the specics of Carrie’s case
might be considered extreme by some, millions of women—and
men—suffer similar problems with relationships, intimacy, depres-
sion, and drug abuse. Perhaps if she had been diagnosed earlier and
more accurately, she would have been spared some of the pain and
loneliness.
Though borderline personalities suffer a tangle of painful symp-
toms that severely disrupt their lives, only recently have psychia-
trists begun to understand the disorder and treat it effectively. What
is a “personality disorder”? What exactly does borderline border?
How is borderline personality similar to and different from other
disorders? How does the borderline syndrome t into the overall
schema of psychiatric medicine? These are difcult questions even
for the professional, particularly in light of the elusive, paradoxical
nature of the illness and its curious evolution in psychiatry.
One widely accepted model suggests that individual personal-
ity is actually a combination of temperament (inherited personal
characteristics, such as impatience, vulnerability to addiction,
etc.) and character (developmental values emerging from environ-
ment and life experiences)—in other words a “nature-nurture”
mix. Temperament characteristics may be correlated with genetic
and biological markers, develop early in life, and are perceived as
instincts or habits. Character emerges more slowly into adulthood,
shaped by encounters in the world. Through the lens of this model,
BPD may be viewed as the collage resulting from the collision of
genes and environment.
1,2
9780399536212_IHateYou_TX_p1-272.indd 26 20/09/10 11:06 AM
26 I HATE YOUDON’T LEAVE ME
BPD is one of ten personality disorders noted in DSM-IV-TR:
in DSM terminology personality disorders are categorized on Axis
II. (See Appendix A for a more detailed discussion of categoriza-
tion in DSM-IV-TR.) These disorders are distinguished by a clus-
ter of developing traits that become prominent in an individual’s
behavior. These traits are relatively inexible and result in mal-
adaptive patterns of perceiving, behaving, and relating to others.
In contrast, state disorders (Axis I in DSM-IV-TR) are usually
not as enduring as trait disorders. State disorders, such as depres-
sion, schizophrenia, anorexia nervosa, chemical dependency, are
more often time- or episode-limited. Symptoms may emerge sud-
denly and then be resolved, as the patient returns to “normal.”
Many times these illnesses are directly correlated with imbalances
in the body’s biochemistry and can often be treated with medica-
tions, which virtually eliminate the symptoms.
Symptoms of a personality disorder, on the other hand, tend
to be more durable traits and change only gradually; medications
are, in general, less effective. Psychotherapy is primarily indicated,
though other treatments, including medication, may alleviate many
symptoms, especially severe agitation or depression (see chapter
9). In most cases, borderline and other personality disorders are a
secondary diagnosis, describing the underlying characterological
functioning of a patient who exhibits more acute and prominent
symptoms of a state disorder.
Comparisons to Other Disorders
Because the borderline syndrome often masquerades as a differ-
ent illness and is often associated with other illnesses, clinicians
often fail to recognize that BPD may be an important component
in evaluating a patient. As a result, the borderline often becomes,
like Carrie, a well-traveled patient, evaluated by multiple hospitals
9780399536212_IHateYou_TX_p1-272.indd 27 20/09/10 11:06 AM
D epersonaliz ation
Antisocial
I nter mittent Ex plosiv e
Hypochondriasis
Somatiz ation
CHAOS AND EMPTINESS 27
and doctors and accompanied throughout life by an assortment of
diagnostic labels.
BPD can interact with other disorders in several ways (see Fig-
ure 2-1). First, BPD can coexist with state (Axis I) disorders in such
a way that borderline pathology is camouaged. For example, BPD
may be submerged in the wake of a more prominent and severe
depression. After resolution of the depression with antidepressant
medications, borderline characteristics may surface and only then
be recognized as the underlying character structure requiring fur-
ther treatment.
Second, BPD may be closely linked and perhaps even contribute
to the development of another disorder. For example, the impul-
sivity, self-destructiveness, interpersonal dif culties, de ated self-
image, and moodiness often exhibited by patients with substance
AFFECTIVE DISORDERS
Schiz oa ec tiv e
SCHIZOPHRENIFORM
DISORDERS
SOMATOFORM
DISORDERS
Major Depression
Dysthymia
Bipolar
Cyclothymia
Conversion
Brief Reactive
Psychosis
Borderline
Personality
Phobias
DISSOCIATIVE
ANXIETY
Multiple
Panic
Personality
DISORDERS
Post-Traumatic
DISORDERS
Stress
Dependent
Histrionic
Anorexia, Bulimia,
Psychosexual
Ob sessiv e-Compulsiv e
Chemical abuse
Narcissistic
Obesity
Kleptomania
Gambling
DEVELOPMENTAL
IMPULSE/ADDICTION
Schizotypal
Attention
Decit
PERSONALITY
DISORDERS
DISORDERS
DISORDERS
FIGURE 21. Schematic of position of BPD in relation to other mental disorders.
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28 I HATE YOUDON’T LEAVE ME
abuse or eating disorders may be more reective of BPD than the
primary Axis I disorder. Although it could be argued that chronic
abuse of alcohol could eventually alter personality characteristics
in such a way that a borderline pattern could evolve secondarily,
it seems more likely that underlying character pathology would
develop rst and lead to alcoholism.
The question of which is the chicken and which is the egg may
be difcult to resolve, but the development of illnesses associated
with BPD may represent a kind of psychological vulnerability to
stress. Just as certain individuals have genetic and biological dis-
positions to physical diseases—heart attacks, cancers, gastroin-
testinal disorders, etc.—many also have biologically determined
propensities to psychiatric illnesses, particularly when stress is
added to an underlying vulnerability to BPD. Thus, under stress,
one borderline turns to drugs, another develops an eating disorder,
still another becomes severely depressed.
Third, BPD may so completely mimic another disorder that the
patient may be erroneously diagnosed with schizophrenia, anxiety,
bipolar disease, attention decit/hyperactivity disorder (ADHD),
or other illnesses.
Comparison to Schizophrenia
Schizophrenic patients are usually much more severely impaired
than borderlines and less capable of manipulating and relating to
others. Both kinds of patients may experience agitated, psychotic
episodes, but these are usually less consistent and less pervasive
over time for borderlines. Schizophrenics are much more likely
to grow accustomed to their hallucinations and delusions and are
often less disturbed by them. Additionally, both may be destruc-
tive and self-mutilating, but whereas the borderline usually can
function appropriately, the schizophrenic is much more severely
impaired socially.
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CHAOS AND EMPTINESS 29
Comparison to Aective Disorders (Bipolar and Depressive Disorders)
“Mood swings” and “racing thoughts” are common patient com-
plaints, to which the knee-jerk diagnostic response from the clini-
cian is to diagnose depression or bipolar disorder (manic depression).
However, such symptoms are consistent with BPD, and even ADHD,
both of which are signi cantly more prevalent than bipolar disorder.
The differences between these syndromes are dramatic. For those
aficted with bipolar disorder or depression, episodes of depression
or mania represent radical departures in functioning. Mood changes
last from days to weeks. Between mood swings, these individuals
maintain relatively normal lives and can usually be treated effectively
with medications. Borderlines, in contrast, typically have dif culties
in functioning (at least internally) even when not displaying promi-
nent mood swings. When self-destructive, threatening suicide, hyper-
active, or experiencing wide and rapid mood swings, the borderline
may appear bipolar, but the borderline’s mood variations are more
transient (lasting hours, rather than days or weeks), and more often
reactive to environmental stimuli.
3
BPD and ADHD
Individuals with ADHD are subjected to a constant scramble of
ashing cognitions. Like borderlines, they often experience wild
mood changes, racing thoughts, impulsivity, anger outbursts,
impatience, and low frustration tolerance; have a history of drug
or alcohol abuse (self-medicating) and torturous relationships; and
are bored easily. Indeed, many borderline personality characteris-
tics correspond to the “typical ADHD temperament,” such as fre-
quent novelty-seeking (searching for excitement) coupled with low
reward dependence (lack of concern for immediate consequences).
4
Not surprisingly, several studies have noted correlations between
these diagnoses. Some prospective studies have noted that children
diagnosed with ADHD frequently develop a personality disorder,
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30 I HATE YOUDON’T LEAVE ME
especially BPD, as they get older. Retrospective researchers have
determined that adults with the diagnosis of BPD often t a child-
hood diagnosis of ADHD.
5,6,7
Whether one illness causes the
other, whether they frequently travel together, or, possibly, if they
are merely related manifestations of the same disorder remains for
intriguing further investigation. Interestingly, one study demon-
strated that treatment of ADHD symptoms also ameliorated BPD
symptoms in patients diagnosed with both disorders.
8
BPD and Pain
Borderlines have been demonstrated to reect paradoxical reac-
tions to pain. Many studies have shown a signi cantly decreased
sensitivity to acute pain, particularly when self-inicted (see “Self-
Destruction” on page 45). However, borderlines exhibit greater
sensitivity to chronic pain. This “pain paradox” appears unique to
borderlines and has not been satisfactorily explained. Some posit
that acute pain, especially when self-in icted, satises certain psy-
chological needs for the patient and is associated with changes in
electrical brain activity and perhaps quick release of endogenous
opioids, the body’s own narcotics. However, ongoing pain, expe-
rienced outside the borderline’s control, may result in less internal
analgesic protection and cause more anxiety.
9,10
BPD and Somatization Disorder
The borderline may focus on his physical ills, complaining loudly
and dramatically to medical personnel and acquaintances, in order
to maintain dependency relationships with them. He may be consid-
ered merely a hypochondriac, while the underlying understanding of
his problems is completely ignored. Somatization disorder is a con-
dition dened by the patient’s multiple physical complaints (includ-
ing pain, gastric, neurological, and sexual symptoms), unexplained
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CHAOS AND EMPTINESS 31
by any known medical condition. In hypochondriasis the patient
is convinced he has a terrible disease despite a negative medical
evaluation.
BPD and Dissociative Disorders
Dissociative disorders include such phenomena as amnesia, feel-
ings of unreality about oneself (depersonalization) or about the
environment (derealization). The most extreme form of dissocia-
tion is dissociative identity disorder (DID), previously referred to
as “multiple personality.” Almost 75 percent of individuals with
BPD experience some dissociative phenomena.
11
The prevalence of
BPD in those suffering from the most severe form of dissociation,
DID, as a primary diagnosis is even greater.
12
Both disorders share
common symptoms—impulsivity, anger outbursts, disturbed rela-
tionships, severe mood changes, and a propensity for self-muti-
lation. There is frequently a childhood history of mistreatment,
abuse, or neglect.
BPD and Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is a complex of symptoms
that follows an extraordinarily severe traumatic event, such as
a natural disaster or combat. It is characterized by intense fear,
emotional re-experiencing of the event, nightmares, irritability,
exaggerated startle response, avoidance of associated places or
activities, and a sense of helplessness. Since both BPD and PTSD
have frequently been associated with a history of extreme abuse in
childhood and reect similar symptoms—such as extreme emo-
tional reactions and impulsivity—some have posited that they are
the same illness. Although some studies indicate that they may
occur together as much as 50 percent or more of the time, they are
distinctly different disorders with different de ning criteria.
13
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32 I HATE YOUDON’T LEAVE ME
BPD and Associated Personality Disorders
Many characteristics of BPD overlap with those of other person-
ality disorders. For example, the dependent personality shares
with the borderline the features of dependency, avoidance of being
alone, and strained relationships. But the dependent personality
lacks the self-destructiveness, anger, and mood swings of a border-
line. Similarly, the schizotypal personality exhibits poor relations
with others and difculty in trusting, but is more eccentric and less
self-destructive. Often a patient exhibits enough characteristics of
two or more personality disorders to warrant diagnoses for each.
For example, a patient may demonstrate characteristics that lead
to diagnoses of both borderline personality disorder and obses-
sive-compulsive personality disorder.
In DSM-IV-TR, BPD is grouped in a cluster of personality dis-
orders that generally reect dramatic, emotional, or erratic fea-
tures (see Appendix A). The others in this group are narcissistic,
antisocial, and histrionic personality disorders, to which BPD is
often compared.
Both borderlines and narcissists display hypersensitivity to crit-
icism; failures or rejections can precipitate severe depression. Both
exploit others; both demand almost constant attention. The nar-
cissistic personality, however, usually functions at a higher level.
He exhibits an inated sense of self-importance (sometimes cam-
ouaging desperate insecurity), displays disdain for others, and
lacks even a semblance of empathy. In contrast, the borderline has
a lower self-esteem and is highly dependent on others’ reassurance.
The borderline desperately clings to others and is usually more
sensitive to their reaction.
Like the borderline, the antisocial personality exhibits impulsiv-
ity, poor tolerance of frustration, and manipulative relationships.
The antisocial personality, however, lacks a sense of guilt or con-
science; he is more detached and is not purposefully self-destructive.
9780399536212_IHateYou_TX_p1-272.indd 33 20/09/10 11:06 AM
CHAOS AND EMPTINESS 33
The histrionic personality shares with the borderline tendencies
of attention-seeking, manipulativeness, and shifting emotions. The
histrionic, however, usually develops more stable roles and relation-
ships. He is usually more amboyant in speech and manner, and
emotional reactions are exaggerated. Physical attractiveness is the
histrionic’s primary concern. One study compared psychological
and social functioning in patients with BPD, schizotypal, obsessive-
compulsive, or avoidant personality disorders and patients with
major depression. Patients with borderline and schizotypal person-
ality disorders were signicantly more functionally impaired than
those with the other personality disorders and those with major
depression.
14
BPD and Substance Abuse
BPD and chemical abuse are frequently associated. Nearly one-third
of those with a lifetime diagnosis of substance abuse also ful ll crite-
ria for BPD. And over 50 percent of BPD inpatients also abuse drugs
or alcohol.
15,16
Alcohol or drugs might reect self-punishing, angry, or
impulsive behaviors, a craving for excitement, or a mechanism of
coping with loneliness. Drug dependency may be a substitute for
nurturing social relationships, a familiar, comforting way to stabi-
lize or self-medicate uctuating moods, or a way to establish some
sense of belonging or self-identication. These possible explanations
for the appeal of chemical abuse are also some of the de ning crite-
ria for BPD.
The Anorexic/Bulimic Borderline or
the Borderline Anorexic/Bulimic?
Anorexia nervosa and bulimia have become major health prob-
lems in this country, especially among young women. Eating disor-
ders are fueled by a fundamental distaste for one’s own body and
a general disapproval of one’s identity. The anorexic sees herself
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34 I HATE YOUDON’T LEAVE ME
in absolute black or white extremes—as either obese (which she
always feels) or thin (which she feels she never completely achieves).
Since she constantly feels out of control, she impulsively utilizes
starvation or binging and purging to maintain an illusion of self-
control. The similarity of this pattern to the borderline pattern has
led many mental health professionals to infer a strong connection
between the two. Indeed, many studies conrm the high preva-
lence of personality disorders in those with eating disorders and,
conversely, the frequent co-occurrence of personality disorders in
those with any eating disorder.
17
BPD and Compulsive Behaviors
Certain compulsive or destructive behaviors may re ect border-
line patterns. For example, a compulsive gambler will continue to
gamble despite a shortage of funds. He may be seeking a thrill
from a world that habitually leaves him bored, restless, and numb.
Or the gambling may be an expression of impulsive self-punish-
ment. Shoplifters often steal items they do not need. Fifty percent
of bulimics exhibit kleptomania, drug use, or promiscuity.
18
When
these behaviors are governed by compulsion, they may represent a
need to feel or a need to self-in ict pain.
Promiscuity often reects a need for constant love and attention
from others, in order to hold on to positive feelings about oneself.
The borderline typically lacks consistent, positive self-regard and
requires continuous reassurance. A borderline woman, lacking in
self-esteem, may perceive her physical attractiveness as her only
asset and may require conrmation of her worth by engaging in fre-
quent sexual encounters. Such involvements avoid the pain of being
alone and create articial relationships she can totally control. Feel-
ing desired can instill a sense of identity. When self-punishment
becomes a prominent part of the psychodynamics, humiliation and
9780399536212_IHateYou_TX_p1-272.indd 35 20/09/10 11:06 AM
CHAOS AND EMPTINESS 35
masochistic perversions may enter the relationships. From this per-
spective, it is logical to speculate that many prostitutes and porno-
graphic actors and models may be borderline.
Difculties with relationships may result in private, ritualistic
thinking and behaviors, often expressed as obsessions or compul-
sion. A borderline may develop specic phobias as he employs
magical thinking to deal with fears; sexual perversions may evolve
as a mechanism to approach intimacy.
Appeal of Cults
Because borderlines yearn for direction and acceptance, they may
be attracted to strong leaders of disciplined groups. The cult can
be very enticing since it provides instant and unconditional accep-
tance, automatic intimacy, and a paternalistic leader who will be
readily idealized. The borderline can be very vulnerable to such a
black-and-white worldview in which “evil” is personied by the
outside world and “good” is encompassed within the cult group.
BPD and Suicide
As many as 70 percent of BPD patients attempt suicide, and the
rate of completed suicide approaches 10 percent, almost a thou-
sand times the rate seen in the general population. In the high-risk
group of adolescents and young adults (ages fteen to twenty-
nine), BPD was diagnosed in a third of suicide cases. Hopelessness,
impulsive aggressiveness, major depression, concurrent drug use,
and a history of childhood abuse increase the risk. Although anxi-
ety symptoms are often associated with suicide in other illnesses,
borderlines who exhibit signicant anxiousness are actually less
likely to commit suicide.
19,20,21
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36 I HATE YOUDON’T LEAVE ME
Clinical Denition of Borderline
Personality Disorder
The current of cial denition of borderline pathology is contained
in the DSM-IV-TR diagnostic criteria of Borderline Personality
Disorder.
22
This designation emphasizes descriptive, observable
behavior.
The diagnosis of BPD is conrmed when at least ve of the fol-
lowing nine criteria are present.
“Others Act Upon Me, Therefore I Am”
Criterion 1. Frantic eorts to avoid real or imagined abandonment.
Just as an infant cannot distinguish between the temporary absence
of her mother and her “extinction,” the borderline often experiences
temporary aloneness as perpetual isolation. As a result, the border-
line becomes severely depressed over the real or perceived aban-
donment by signicant others and then enraged at the world (or
whoever is handy) for depriving her of this basic ful llment.
Fears of abandonment in the borderline can even be measured
in the brain. One study utilized PET scanning to demonstrate that
women with BPD experienced alterations of blood ow in certain
areas of the brain when exposed to memories of abandonment.
23
Particularly when they are alone, borderlines may lose the sensa-
tion of existing, of feeling real. Rather than embracing Descartes’
“I think, therefore I am” principle of existence, they live by a phi-
losophy closer to “Others act upon me, therefore I am.”
The theologian Paul Tillich wrote that “loneliness can be con-
quered only by those who can bear solitude.” Because the borderline
nds solitude so difcult to tolerate, she is trapped in a relentless
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CHAOS AND EMPTINESS 37
metaphysical loneliness from which the only relief comes in the form
of the physical presence of others. So she will often rush to singles
bars or other crowded haunts, often with disappointing—or even
violent—results.
In Marilyn: An Untold Story, Norman Rosten recalled Mari-
lyn Monroe’s hatred of being alone. Without people constantly
around her, she would fall into a void, “endless and terrifying.”
24
For most of us, solitude is longed for, cherished, a rare opportunity
to reect on memories and matters important to our well-being—a
chance to get back in touch with ourselves, to rediscover who we are:
“The walls of an empty room are mirrors that double and redouble
our sense of ourselves,” the late John Updike wrote in The Centaur.
But the borderline, with only the weakest sense of self, looks
back at only vacant reections. Solitude recapitulates the panic
that the borderline experienced as a child when faced with the
prospect of abandonment by parents: Who will take care of me?
The pain of loneliness can only be relieved by the rescue of a fanta-
sized lover, as expressed in the lyrics of countless love songs.
The Relentless Search for Mr./Ms. Right
Criterion 2. Unstable and intense interpersonal relationships, with
marked shifts in attitudes toward others (from idealization to
devaluation or from clinging dependency to isolation and avoidance),
and prominent patterns of manipulation of others.
The borderline’s unstable relationships are directly related to his
intolerance of separation and fear of intimacy. The borderline is
typically dependent, clinging, and idealizing until the lover, spouse,
or friend repels or frustrates these needs with some sort of rejection
or indifference, then the borderline caroms to the other extreme—
devaluation, resistance to intimacy, and outright avoidance. A
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38 I HATE YOUDON’T LEAVE ME
continual tug-of-war develops between the wish to merge and be
taken care of, on the one hand, and the fear of engulfment, on the
other. For the borderline, engulfment means the obliteration of sep-
arate identity, the loss of autonomy, and a feeling of nonexistence.
The borderline vacillates between a desire for closeness to relieve
the emptiness and boredom, and fear of intimacy, which is per-
ceived as the thief of self-con dence and independence.
In relationships, these internal feelings are dramatically trans-
lated into intense, shifting, manipulative couplings. The borderline
often makes unrealistic demands of others, appearing to observers
as spoiled. Manipulativeness is manifested through physical com-
plaints and hypochondriasis, expressions of weakness and help-
lessness, provocative actions, and masochistic behaviors. Suicidal
threats or gestures are often used to obtain attention and rescue.
The borderline may use seduction as a manipulative strategy, even
with someone known to be inappropriate and inaccessible, such as
a therapist or minister.
Though very sensitive to others, the borderline lacks true empathy.
He may be dismayed to encounter an acquaintance, such as teacher,
coworker, or therapist, outside of his usual place of business because it
is difcult to conceive of that person as having a separate life. Further-
more, he may not understand or be extremely jealous of his therapist’s
separate life, or even of other patients he may encounter.
The borderline lacks “object constancy,” the ability to under-
stand others as complex human beings who nonetheless can relate
in consistent ways. The borderline experiences another on the
basis of his most recent encounter, rather than on a broader-based,
consistent series of interactions. Therefore, a constant, predictable
perception of another person never emerges—the borderline, as if
aficted with a kind of targeted amnesia, continues to respond to
that person as someone new on each occasion.
Because of the borderline’s inability to see the big picture, to learn
9780399536212_IHateYou_TX_p1-272.indd 39 20/09/10 11:06 AM
CHAOS AND EMPTINESS 39
from previous mistakes, and to observe patterns in his own behav-
ior, he often repeats destructive relationships. A female borderline,
for example, will typically return to her abusive ex-husband, who
proceeds to abuse her again; a male borderline frequently couples
with similar, inappropriate women with whom he repeats sadomas-
ochistic afliations. Since the borderline’s dependency is often dis-
guised as passion, the spouse persists in the destructive relationship
“because I love him.” Later, when the relationship disintegrates,
one partner can blame the other’s pathology. Thus, as is often heard
in the therapist’s ofce, “My rst wife was a borderline!”
The borderline’s endless quest is to nd a perfect caregiver who
will be all-giving and omnipresent. The search often leads to partners
with complementary pathology: both lack insight into their mutual
destructiveness. For example, Michelle desperately craves protection
and comfort from a man. Mark displays bravura self-assurance; even
though the self-assurance covers his deep insecurity, it ts the bill
for Michelle. Just as Michelle needs Mark to be her protective white
knight, so Mark needs Michelle to remain helpless and dependent on
his benecence. After a while, both fail to live up to their assigned
stereotypes. Mark cannot bear the narcissistic wounds of challenge
or failure and begins to cover his frustrations with alcohol and by
physically abusing Michelle. Michelle bristles under his controlling
yoke, yet becomes frightened when she sees his weaknesses. The dis-
satisfactions lead to more provocation and more con ict.
Aficted with self-loathing, the borderline distrusts others’
expressions of caring. Like Groucho Marx, he would never belong
to a club that would have him as a member. Sam, for example, was a
twenty-one-year-old college student whose chief complaint in ther-
apy was “I need a date.” An attractive man with serious interpersonal
problems, Sam characteristically approached women he deemed
inaccessible. However, whenever his overtures were accepted, he
immediately devalued the woman as no longer desirable.
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40 I HATE YOUDON’T LEAVE ME
All of these characteristics make it difcult for borderlines to
achieve real intimacy. As Carrie relates, “A few men have wanted
to marry me, but I have a big problem with getting close or being
touched. I can’t tolerate it.” The borderline cannot seem to gain
enough independence to be dependent in healthy, rather than des-
perate, ways. True sharing is sacriced to a demanding depen-
dency and a desperate need to join with another person in order to
complete one’s own identity, as kind of Siamese twins of the soul.
“You complete me,” the famous line from the lm Jerry Maguire,
turns into an elusive goal that is always just out of reach.
Who Am I?
Criterion 3. Marked and persistent identity disturbance manifested by an
unstable self-image or sense of self.
Borderlines lack a constant, core sense of identity, just as they lack
a constant, core conceptualization of others. The borderline does
not accept her own intelligence, attractiveness, or sensitivity as
constant traits, but rather as comparative qualities to be continu-
ally re-earned and judged against others’. The borderline may view
herself as intelligent, for example, based solely on the results of a
just-administered IQ test. Later that day when she makes a “dumb
mistake” she will revert to seeing herself as “stupid.” The border-
line considers herself attractive until she spies a woman whom she
feels is prettier, then she feels ugly. Surely, the borderline envies the
self-acceptance of Popeye—“I yam what I yam.” As in her close
relationships, the borderline becomes mired in a kind of amnesia—
about herself. The past becomes obfuscated; she is much like the
demanding boss who continually asks herself and others, “Yeah,
so? What have you done for me lately?”
9780399536212_IHateYou_TX_p1-272.indd 41 20/09/10 11:06 AM
CHAOS AND EMPTINESS 41
For the borderline, identity is graded on a curve. Who she is
(and what she does) today determines her worth, with little regard
to what has come before. The borderline allows herself no laurels
on which to rest. Like Sisyphus, she is doomed to roll the boul-
der repeatedly up the hill, needing to prove herself over and over
again. Self-esteem is only attained through impressing others, so
pleasing others becomes critical to loving herself.
In his book Marilyn, Norman Mailer describes how Mari-
lyn Monroe’s search for identity became Marilyn’s driving force,
absorbing all aspects of her life:
What an obsession is identity! We search for it, because the pri-
vate sensation when we are in our own identity is that we feel
sincere as we speak, we feel real, and this little phenomenon
of good feeling conceals an existential mystery as important
to psychology as the cogito ergo sum—it is nothing less than
that the emotional condition of feeling real is, for whatever
reason, so far superior to the feeling of a void in oneself that it
can become for protagonists like Marilyn a motivation more
powerful than the instinct of sex, or the hunger for position or
money. Some will give up love or security before they dare to
lose the comfort of identity.
25
Later, Marilyn found sustenance in acting, particularly in “the
Method”:
Actors in the Method will act out; their technique is designed
like psychoanalysis itself, to release emotional lava, and thereby
enable the actor to become acquainted with his depths, then
possess them enough to become possessed by his role. A magi-
cal transaction. We can think of Marlon Brando in A Streetcar
9780399536212_IHateYou_TX_p1-272.indd 42 20/09/10 11:06 AM
42 I HATE YOUDON’T LEAVE ME
Named Desire. To be possessed by a role is satori (or intuitive
illumination) for an actor because one’s identity can feel whole
so long as one is living in the role.
26
The borderline’s struggle in establishing a consistent identity is
related to a prevailing sense of inauthenticity—a constant sense of
“faking it.” Most of us experience this sensation at various times
in our lives. When one starts a new job, for example, one tries to
exude an air of knowledge and condence. After gaining experi-
ence, the condence becomes increasingly genuine because one has
learned the system and no longer needs to fake it. As Kurt Von-
negut wrote, “We are what we pretend to be.” Or, as some phrase
it, “Fake it ’til you make it.”
The borderline never reaches that point of condence. He con-
tinues to feel like he is faking it and is terried that he will, sooner
or later, be “found out.” This is particularly true when the border-
line achieves some kind of success—it feels misplaced, undeserved.
This chronic sense of being a fake or sham probably originates in
childhood. As explored in chapter 3, the pre-borderline often grows up
feeling inauthentic due to various environmental circumstances—
suffering physical or sexual abuse or being forced to adopt an adult’s
role while still a child or to parent his own sick parent. At the other
extreme, he may be discouraged from maturing and separating,
and may be trapped in a dependent child’s role, well past an appro-
priate time for separation. In all of these situations, the borderline
never develops a separate sense of self but continues to “fake” a
role that is prescribed by someone else. (“He never chooses an opin-
ion,” was how Leo Tolstoy described one of his characters, “he just
wears whatever happens to be in style.”) If he fails in the role, he
fears he will be punished; if he succeeds, he is sure he will soon be
uncovered as a fraud and be humiliated.
9780399536212_IHateYou_TX_p1-272.indd 43 20/09/10 11:06 AM
CHAOS AND EMPTINESS 43
Unrealistic attempts at achieving a state of perfection are often
part of the borderline pattern. For example, a borderline anorexic
might try to maintain a constant low weight and become horri-
ed if it varies as little as one pound, unaware that this expecta-
tion is unrealistic. Perceiving themselves as static, rather than in a
dynamic state of change, borderlines may view any variation from
this in exible self-image as shattering.
Conversely, the borderline may search for satisfaction in the
opposite direction—by frequently changing jobs, careers, goals,
friends, sometimes even gender. By altering external situations and
making drastic changes in lifestyle, he hopes to achieve inner con-
tentment. Some instances of so-called midlife crisis or male meno-
pause represent an extreme attempt to ward off fears of mortality
or deal with disappointments in life choices. An adolescent border-
line may constantly change his clique of friends—from “jocks” to
“burnouts” to “brains” to “geeks”—hoping to achieve a sense of
belonging and acceptance. Even sexual identity can be a source of
confusion for the borderline. Some writers have noted an increased
incidence of homosexuality, bisexuality, and sexual perversions
among borderline personalities.
27
Cult groups that promise unconditional acceptance, a structured
social framework, and a circumscribed identity are powerful attrac-
tions for the borderline personality. When the individual’s identity and
value system merge with the accepting group’s, the faction’s leader
assumes extraordinary power—to the point where he can induce fol-
lowers to emulate his actions, even if fatal, as witnessed by the Jones-
town Massacre in 1978, the fatal conict with Branch Davidians in
1993, and the mass suicides of the Heaven’s Gate cult in 1997.
Aaron, after dropping out of college, attempted to assuage his
feelings of aimlessness by joining the “Moonies.” He left the cult
after two years, only to return after two more years of directionless
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44 I HATE YOUDON’T LEAVE ME
wandering among different cities and jobs. Ten months later he left
the group again, but this time, lacking a stable set of goals or a com-
fortable sense of who he was or what he wanted, he attempted suicide.
The phenomenon of “cluster suicides,” especially among teen-
agers, may reect weaknesses in identity formation. The national
suicide rate dramatically leaps upward after the suicide of a famous
person, such as Marilyn Monroe or Kurt Cobain. The same dynam-
ics may operate among adolescents with fragile identity structures:
they are susceptible to the suicidal tendencies of the peer group
leader or of another suicidal teenage group in the same region.
The Impulsive Character
Criterion 4. Impulsiveness in at least two areas that are potentially
self-destructive, e.g., substance abuse, sexual promiscuity, gambling,
reckless driving, shoplifting, excessive spending, or overeating.
The borderline’s behaviors may be sudden and contradictory, since
they result from strong, momentary feelings—perceptions that rep-
resent isolated, unconnected snapshots of experience. The imme-
diacy of the present exists in isolation, without the benet of the
experience of the past, or the hopefulness of the future. Because
historical patterns, consistency, and predictability are unavailable
to the borderline, similar mistakes are repeated again and again.
The 2001 lm Memento presents metaphorically what the bor-
derline faces on a regular basis. Aficted with short-term memory
loss, insurance investigator Leonard Selby must hang Polaroids and
Post-it notes all over his room—and even tattoo messages on his
own body—to remind himself what has happened only hours or
minutes before. (In one car-chase scene, trying to avenge his wife’s
murder, he cannot remember if he is chasing someone—or being
chased!) The lm dramatically illustrates the loneliness of a man
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CHAOS AND EMPTINESS 45
who constantly feels “like I just woke up.” The borderline’s limited
patience and need for immediate gratication may be connected to
behaviors that dene other BPD criteria: Impulsive conict and rage
may emerge from the frustrations of a stormy relationship (criterion
2); precipitous mood changes (criterion 6) may result in impulsive
outbursts; inappropriate outbursts of anger (criterion 8) may develop
from a failure to control impulses; self-destructive or self-mutilating
behaviors (criterion 5) may result from the borderline’s frustrations.
Often, impulsive actions such as drug and alcohol abuse serve as
defenses against feelings of loneliness and abandonment.
Joyce was a thirty-one-year-old divorced woman who increas-
ingly turned to alcohol after her divorce and her husband’s subse-
quent remarriage. Though attractive and talented, she let her work
deteriorate and spent more time at bars. “I made a career out of
avoiding,” she later said. When the pain of being alone and feeling
abandoned became too great, she would use alcohol as anesthe-
sia. She would sometimes pick up men and take them home with
her. Characteristically, after such alcohol or sexual binges, she
would berate herself with guilt and feel deserving of her husband’s
abandonment. Then the cycle would start again, as she required
more punishment for her worthlessness. Thus, self-destructive-
ness became both a means of avoiding pain and a mechanism for
inicting it as expiation for her sins.
Self-Destruction
Criterion 5. Recurrent suicidal threats, gestures, or behavior, or self-
mutilating behaviors.
Suicidal threats and gestures—reecting both the borderline’s
propensity for overwhelming depression and hopelessness and his
knack for manipulating others—are prominent features of BPD.
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46 I HATE YOUDON’T LEAVE ME
As many as 75 percent of borderlines have a history of self-
mutilation, and the vast majority of those have made at least one
suicide attempt.
28
Often, the frequent threats or halfhearted sui-
cide attempts are not a wish to die but rather a way to communi-
cate pain and a plea for others to intervene. Unfortunately, when
habitually repeated, these suicidal gestures often lead to just the
opposite scenario—others get fed up and stop responding, which
may result in progressively more serious attempts. Suicidal behav-
ior is one of the most difcult BPD symptoms for family and thera-
pists to cope with: addressing it can result in endless unproductive
confrontations; ignoring it can result in death (see chapters 6–8).
Although many of the dening criteria for BPD diminish over time,
the risk of suicide persists throughout the life cycle.
29
Borderlines
with a childhood history of sexual abuse are ten times more likely
to attempt suicide.
30
Self-mutilation—except when clearly associated with psychosis—
is the hallmark of BPD. This behavior, more closely connected to
BPD than any other psychiatric malady, may take the form of self-
inicted wounds to the genitals, limbs, or torso. For these border-
lines, the body becomes a road map highlighted with a lifetime tour
of self-inicted scars. Razors, scissors, ngernails, and lit cigarettes
are some of the more common instruments used; excessive use of
drugs, alcohol, or food can also inict the damage.
Often, self-mutilation begins as an impulsive, self-punishing
action, but over time it may become a studied, ritualistic procedure.
In such instances the borderline may carefully scar body areas that
are covered by clothing—which illustrates the borderline’s intense
ambivalence: he feels compelled to amboyantly self-punish, yet
he carefully conceals the evidence of his tribulation. Though many
people get tattoos for decorative reasons, on a societal level the
increasing fascination with tattoos and piercings over the past two
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CHAOS AND EMPTINESS 47
decades may be less a fashion trend than a reection of borderline
tendencies in society (see chapter 4).
Jennifer (see chapter 1) would fulll her need to self-in ict pain
by scratching her wrists, abdomen, and waist, leaving deep nger-
nail marks that could easily be covered.
Sometimes the self-punishment is more indirect. The borderline
may often be the victim of recurrent “quasi accidents.” He may
provoke frequent ghts. In these incidents, the borderline feels less
directly responsible; circumstances or others provide the violence
for him.
When Harry, for example, broke up with his girlfriend, he blamed
his parents. They had not been supportive enough or friendly enough,
he thought, and when she ended the affair after six years, he was
forlorn. At twenty-eight he continued to live in an apartment paid
for by his parents and worked sporadically in his father’s of ce. Ear-
lier in his life he had attempted suicide but decided he wouldn’t give
his parents “the satisfaction” of killing himself. Instead, he engaged
in increasingly dangerous behaviors. He had numerous automobile
accidents, some while intoxicated, and continued to drive despite
the revocation of his driver’s license. He frequented bars where he
sometimes picked ghts with much bigger men. Harry recognized
the destructiveness of his behavior and sometimes wished that “one
of these times I would just die.”
These dramatic self-destructive behaviors and threats may be
explained in several ways. The self-inicted pain may re ect the
borderline’s need to feel, to escape an encapsulating numbness.
Borderlines form a kind of insulating bubble that not only protects
them from emotional hurt but also serves as a barrier from the
sensations of reality. The experience of pain, then, becomes an
important link to existence. Often, however, the inicted pain is
not strong enough to transcend this barrier (though the blood and
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48 I HATE YOUDON’T LEAVE ME
scars may be fascinating for the borderline to observe), in which
case the frustration may compel him to accelerate attempts to
induce pain.
Self-induced pain can also function as a distraction from other
forms of suffering. One patient, when feeling lonely or afraid,
would cut different parts of her body as a way “to take my mind
off” the loneliness. Another would bang her head in the throes of
stress-related migraine headaches. Relief of inner tension may be
the most common reason for self-harming.
31
Self-damaging behavior can also serve as an expiation for sin.
One man, guilt-ridden after the breakup of his marriage for which
he totally blamed himself, would repeatedly drink gin—a taste he
abhorred—until reaching the point of retching. Only after endur-
ing this discomfort and humiliation would he feel redeemed and
able to return to his usual routine.
Painful, self-destructive behavior may be employed in an
attempt to constrict actions that are felt to be dangerously out of
control. One adolescent boy cut his hands and penis to dissuade
himself from masturbation, an act he considered loathsome. He
hoped that the memory of the pain would prevent him from fur-
ther indulging in this repugnant behavior.
Impulsive, self-destructive acts (or threats) may result from a
wish to punish another person, often a close relation. One woman
consistently described her promiscuous behavior (often involv-
ing masochistic, degrading rituals) to her boyfriend. These affairs
invariably occurred when she was angry and wanted to punish him.
Finally, self-destructive behavior can evolve from a manipula-
tive need for sympathy or rescue. One woman, after arguments
with her boyfriend, repeatedly slashed her wrists in his presence,
forcing him to secure medical assistance for her.
Many borderlines deny feeling pain during self-mutilation and
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CHAOS AND EMPTINESS 49
even report a calm euphoria after it. Before hurting themselves,
they may experience great tension, anger, or overwhelming sadness;
afterward there is a sensation of release and relief from anxiety.
This relief may result from psychological or physiological fac-
tors, or a combination of both. Physicians have long recognized
that following severe physical trauma, such as battle wounds, the
patient may experience an unexpected calm and a kind of nat-
ural anesthesia despite the lack of medical attention. Some have
hypothesized that during such times, the body releases biological
substances, called endorphins, the body’s internal opiate drugs
(like morphine or heroin), which serve as the organism’s self-treat-
ment of pain.
Radical Mood Shifts
Criterion 6. Aective instability due to marked reactivity of mood with
severe episodic shifts to depression, irritability, or anxiety, usually
lasting a few hours and only rarely more than a few days.
The borderline undergoes abrupt mood shifts, lasting for short
periods—usually hours. His base mood is not usually calm and
controlled, but more often either hyperactive and irrepressible or
pessimistic, cynical, and depressed.
Audrey was giddy with excitement as she ooded Owen with
kisses after he surprised her with owers he bought on the way
home from work. As he washed up for dinner, Audrey took a call
from her mother, who again berated her for not calling to ask about
her constant body aches. By the time Owen returned from the bath-
room, Audrey had mutated into a raging harridan, screaming at
him for not helping with dinner. He could only sit there, stunned
and perplexed at the transformation.
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50 I HATE YOUDON’T LEAVE ME
Always Half Empty
Criterion 7. Chronic feelings of emptiness.
Lacking a core sense of identity, borderlines commonly experience
a painful loneliness that motivates them to search for ways to ll
up the “holes.”
The painful, almost physical sensation is lamented by Shake-
speare’s Hamlet: “I have of late—but wherefore I know not—lost
all my mirth, forgone all custom of exercises; and indeed it goes
so heavily with my disposition, that this goodly frame the earth
seems to me a sterile promontory.”
Tolstoy dened boredom as “the desire for desires”; in this con-
text it can be seen that the borderline’s search for a way to relieve
the boredom often results in impulsive ventures into destructive
acts and disappointing relationships. In many ways the border-
line seeks out a new relationship or experience not for its posi-
tive aspects but to escape the feeling of emptiness, acting out the
existential destinies of characters described by Sartre, Camus, and
other philosophers.
The borderline frequently experiences a kind of existential
angst, which can be a major obstacle in treatment for it saps the
motivational energy to get well. From this feeling state radiate
many of the other features of BPD. Suicide may appear to be the
only rational response to a perpetual state of emptiness. The need
to ll the void or relieve the boredom can lead to outbursts of anger
and self-damaging impulsiveness—especially drug abuse. Aban-
donment may be more acutely felt. Relationships may be impaired.
A stable sense of self cannot be established in an empty shell. And
mood instability may result from the feelings of loneliness. Indeed,
depression and feelings of emptiness often reinforce each other.
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CHAOS AND EMPTINESS 51
Raging Bull
Criterion 8. Inappropriate, intense anger, or lack of control of anger, e.g.,
frequent displays of temper, constant anger, recurrent physical ghts.
Along with affective instability, anger is the most persistent symp-
tom of BPD over time.
32
The borderline’s outbursts of rage are as unpredictable as they
are frightening. Violent scenes are disproportionate to the frustra-
tions that trigger them. Domestic fracases that may involve chases
with butcher knives and thrown dishes are typical of borderline
rage. The anger may be sparked by a particular (and often triv-
ial) offense, but underneath the spark lies an arsenal of fear from
the threat of disappointment and abandonment. After a disagree-
ment over a trivial remark about their contrasting painting styles,
Vincent van Gogh picked up a butcher knife and chased his good
friend, Paul Gauguin, around his house and out the door. He then
turned his rage on himself, using the same knife to slice off a sec-
tion of his ear.
The rage, so intense and so near the surface, is often directed
at the borderline’s closest relationships—spouse, children, parents.
Borderline anger may represent a cry for help, a testing of devotion,
or a fear of intimacy—whatever the underlying factors, it pushes
away those whom the borderline needs most. The spouse, friend,
lover, or family member who sticks around despite these assaults
may be very patient and understanding, or, sometimes, very dis-
turbed himself. In the face of these eruptions, empathy is dif cult
and the relation must draw on every resource at hand in order to
cope (see chapter 5).
The rage often carries over to the therapeutic setting, where
psychiatrists and other mental health professionals become the
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52 I HATE YOUDON’T LEAVE ME
target. Carrie, for example, often raged against her therapist, con-
stantly looking for ways to test his commitment to staying with
her in therapy. Treatment becomes precarious in this situation (see
chapter 7), and many therapists have been forced to drop border-
line patients for this reason. Most therapists will, whenever pos-
sible, try to limit the number of borderline patients they treat.
Sometimes I Act Crazy
Criterion 9. Transient, stress-related paranoid thoughts or symptoms of
severe dissociation.
The most common psychotic experiences for the borderline involve
feelings of unreality and paranoid delusions. Unreality feelings
involve dissociation from usual perceptions. The individual or
those around her feel unreal. Some borderlines experience a kind
of internal splitting, in which they feel different aspects of their
personality emerge in different situations. Distorted perceptions
can involve any of the ve senses.
The borderline may become transiently psychotic when con-
fronted with stressful situations (such as feeling abandoned) or
placed in very unstructured surroundings. For example, therapists
have observed episodes of psychosis during classical psychoanaly-
sis, which relies heavily on free association and uncovering past
trauma in an unstructured setting. Psychosis may also be stimu-
lated by illicit drug use. Unlike patients with psychotic illnesses,
such as schizophrenia mania, psychotic depression, or organic/
drug illnesses, borderline psychosis is usually of shorter dura-
tion and perceived as more acutely frightening to the patient and
extremely different from his ordinary experience. And yet, to the
outside world, the presentation of psychosis in BPD may be indis-
tinguishable, in the acute form, from the psychotic experiences of
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CHAOS AND EMPTINESS 53
these other illnesses. The main difference is duration: within hours
or days the breaks with reality may disappear, as the borderline
recalibrates to usual functioning, unlike other forms of psychosis.
The Borderline Mosaic
BPD is clearly becoming acknowledged by mental health profes-
sionals as one of the more common psychiatric maladies in this
country. The professional must be able to recognize the features of
BPD to effectively treat large numbers of patients. The layperson
must be able to recognize them to better understand those with
whom he shares his life.
While digesting this chapter, the astute reader will observe that
these symptoms typically interact; they are less like isolated lakes
than streams that feed into each other and eventually merge into
rivers and then into bays or oceans. They are also interdependent.
The deep furrows etched by these oods of emotions inform not
only the borderline but also parts of the culture in which he lives.
How these markings are formed in the individual and re ected in
our society is explored in the next chapters.
9780399536212_IHateYou_TX_p1-272.indd 54 20/09/10 11:06 AM
Chapter Three
Roots of the
Borderline Syndrome
All happy families resemble one another; every unhappy family
is unhappy in its own fashion.
—From Anna Karenina, by Leo Tolstoy
Growing up was not easy for Dixie Anderson. Her father was
rarely at home and when he was, he didn’t say much. For years,
she didn’t even know what he did for a living, just that he was gone
all the time. Margaret, Dixie’s mother, called him a “workaholic.”
Throughout her childhood, Dixie sensed that her mother was hid-
ing something, though Dixie was never quite sure what it was.
But when Dixie turned eleven, things changed. She was an
“early developer,” her mother said, though Dixie really wasn’t sure
what that meant. All she knew was that her father was suddenly
home more than he had ever been, and he was also more attentive.
Dixie enjoyed the new attention and the new feeling of power she
had over him when he was nished touching her. After he was
done, he would do whatever she asked him.
About this same time, Dixie suddenly became more popular
in the family’s af uent suburban Chicago neighborhood. The kids
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ROOTS OF THE BORDERLINE SYNDROME 55
began to offer her their secret stashes of pot and, a few years later,
mushrooms and ecstasy.
Middle school was a drag. Halfway through a school day, she’d
wind up ghting with some of the other kids, which did not rattle
her at all: she was tough; she had friends and drugs; she was cool.
Once, she even punched her science teacher, whom she felt was a
real jerk. He didn’t take it well at all and went to the principal,
who expelled her.
At age thirteen she saw her rst psychiatrist, who diagnosed
her as hyperactive and treated her with several medications that
didn’t make her feel anywhere near as good as weed. She decided
to run away. She packed an overnight bag, took a bus to the inter-
state, stuck out her thumb, and in a few minutes was on her way
to Las Vegas.
The way Margaret saw it, no matter what she did, it always
seemed to turn out the same with Dixie: her older daughter could
not be pleased. Dixie had obviously inherited her dad’s genes,
always criticizing the way Margaret looked and the way she kept
the house. She had tried everything to lose weight—amphetamines,
booze, even the stomach operation—yet nothing seemed to work.
She’d always been fat, always would be.
She often wondered why Roger had married her. He was a
handsome man; from the beginning she could not understand why
he wanted her. After a while it was obvious he didn’t want her: he
simply stopped coming home at night.
Dixie was the one bright spot in Margaret’s life. Her other
daughter, Julie, was already obese at age ve and seemed a lost
cause. But Margaret would do anything for Dixie. She clung to
her daughter like a lifeline. But the more Margaret clung, the more
Dixie resented it. She became more demanding, throwing tantrums
and screaming about her mother’s weight. The doctors could do
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56 I HATE YOUDON’T LEAVE ME
nothing to help Margaret; they said she was manic-depressive and
addicted to alcohol and amphetamines. The last time Margaret
was in the hospital they gave her electroshock treatment. And now
with Roger gone and Dixie always running away, the world was
closing in.
After a few frantic months in Vegas, Dixie took off for Los
Angeles, which was the same story as Vegas: she was promised
cars and money and good times. Well, she had ridden in a lot of
cars, but the good times were few and far between. Her friends
were losers and sometimes she had to sleep with a guy to “borrow”
a few bucks. Finally, with nothing but a few dollars in her jeans,
she went back home.
Dixie arrived to nd Roger gone and her mother in a thick fog
of depression and drug-induced numbness. In all this bleakness at
home, it wasn’t long before Dixie fell back into her alcohol and
drug habits. At fteen she had been hospitalized twice for chemical
abuse and was treated by a number of therapists. At sixteen, she
became pregnant by a man she had met only a few weeks before.
She married him soon after the pregnancy tests.
Seven months later, when Kim was born, the marriage began to
fall apart. Dixie’s husband was a weak and passive oaf who could
not get his own life together, much less provide a solid home envi-
ronment for their child.
By the time the baby was six months old, the marriage was
over, and Dixie and Kim moved in with Margaret. It was then that
Dixie became obsessed with her weight. She would go entire days
without eating, and then eat frantically and voluminously only to
vomit it all up in the toilet. What she couldn’t get rid of by vomit-
ing she eliminated in other ways: she ate squares of Ex-Lax as if
they were candy. She exercised until sweat drenched her clothes
and she was too exhausted to move. The pounds dropped off—but
so did her health and her mood. Her periods stopped; her energy
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ROOTS OF THE BORDERLINE SYNDROME 57
waned; her capacity to concentrate weakened. She became very
depressed about her life, and for the rst time suicide seemed like
a real alternative.
Initially she felt safe and comfortable when she was readmitted
to the hospital, but soon her old self returned. By the fourth day,
she was trying to seduce her doctor; when he didn’t respond, she
threatened him with all sorts of retaliation. She demanded extra
privileges and special attention from the nurses and refused to par-
ticipate in unit activities.
As abruptly as she had gone into the hospital, she pronounced
herself cured and demanded discharge, days after admission. Over
the next year, she would be readmitted to the hospital several
times. She would also see several psychotherapists, none of whom
seemed to understand or know how to treat her dramatic mood
shifts, her depression, her loneliness, her impulsiveness with men
and drugs. She began to doubt that she could ever be happy.
It wasn’t long before Margaret and Dixie were again ghting
and screaming at each other. For Margaret it was like seeing her-
self growing up all over again and making the same mistakes. She
couldn’t bear to watch it any longer.
Margaret’s father had been just like Roger, a lonely, unhappy
man who had little to do with his family. Her mother ran the family
much like Margaret ran hers. And just as Margaret clung to Dixie,
so had her mother clung to Margaret, trying desperately to mold
her every step of the way. Margaret was fed her mother’s ideas and
feelings—and enough food for a battalion. By the age of sixteen,
she was grossly obese and taking large amounts of amphetamines
prescribed by the family doctor to suppress her appetite. By the age
of twenty, she was drinking alcohol and taking Fiorinal to bring
her down from the amphetamines.
Margaret was never able to please her mother even as the con-
stant struggle for control between them raged on. Neither could
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58 I HATE YOUDON’T LEAVE ME
Margaret please her own daughter or husband. She had never been
able to make anyone happy, she realized, not even herself. Yet she
persisted in trying to please people who would not be pleased.
Now, with Roger gone and Dixie so sick, Margaret’s life seemed
to be falling apart. Dixie nally told her mother how Roger had
sexually abused her. And before Roger left, he had bragged all
about his women. Despite everything, Margaret still missed him.
He was alone, she knew, just like she was.
It was time, Dixie recognized, to do something about the plight
of this self-destructive family. Or at least herself anyway. A job
would be the rst priority, something to combat the relentless
boredom. But she was nineteen years old with a two-year-old child
and no husband, and she still hadn’t graduated high school.
With characteristic compulsiveness, she ung herself into a high
school equivalency program and received her diploma in a matter
of months. Within days of obtaining her diploma, she was applying
for loans and grants to attend college.
Margaret had begun to take care of Kim, and in many ways
the arrangement looked like it might work: raising Kim gave Mar-
garet some meaning in her life, Kim had built-in child care, and
Dixie had time for her new mission in life. But soon, the system
showed cracks: Margaret sometimes got too drunk or depressed
to be of any help. When this happened, Dixie had a simple solu-
tion: she would threaten to take Kim away from Margaret. Both
the grandmother and granddaughter obviously needed each other
desperately, so Dixie was able to totally control the household.
Through it all, Dixie still managed to nd time for men, though
her frequent liaisons were usually of short duration. She seemed
to follow a pattern: whenever a man started to care for her, she
became bored. Distant, older men—unavailable doctors, married
acquaintances, professors—were her usual type, but she would
drop them the instant they responded to her irtations. The young
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ROOTS OF THE BORDERLINE SYNDROME 59
men she did date were all members of a church that was strictly
opposed to premarital sex.
Dixie avoided women and had no female friends. She thought
women were weak and uninteresting. Men, at least, had some sub-
stance. They were fools if they responded to her irtations and
hypocrites if they did not.
As time went on, the more Dixie succeeded in her studies, the
more frightened she became. She could pursue a particular interest—
school, a certain man—relentlessly, almost obsessively, but each suc-
cess spurred ever higher, and more unrealistic, demands. Despite
good grades, she would explode in rage and threaten to kill herself
when she performed below her expectations on an exam.
At times like these, her mother would try to console her, but
Margaret was also becoming preoccupied with suicide, and the
roles often reversed. Mother and daughter were again shuf ing in
and out of the hospital trying to overcome depression and chemi-
cal abuse.
Like her mother and grandmother, Kim didn’t know her father
very well either. Sometimes he came to visit; sometimes she went
to the house that he shared with his mother. He always seemed
awkward around her.
With her mother detached and her grandmother ineffectual or
preoccupied with her own problems, Kim took control of the house-
hold by the time she was four. She ignored Dixie, who responded
by ignoring her. If Kim threw a tantrum, Margaret would cave in
to her wishes.
The household was in an almost constant state of chaos. Some-
times both Margaret and Dixie would be in the hospital at the
same time, Margaret for her drinking, Dixie for her bulimia. Kim
would then go to her father’s house, although he was unable to
care for her and would have his own mother tend to her.
On the surface, Kim seemed oddly mature for a six-year-old,
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60 I HATE YOUDON’T LEAVE ME
despite the chaos around her. To her, other kids were “just kids,”
without her experience. She didn’t think her particular type of
maturity was unusual at all: she had seen old photographs of her
mother and grandmother when they were her age, and in the snap-
shots they all had the same look.
Across Generations
In many respects, the Andersons’ saga is typical of borderline cases:
the factors contributing to the borderline syndrome often transcend
generations. The genealogy of BPD is often rife with deep and long-
lasting problems, including suicide, incest, drug abuse, violence,
losses, and loneliness.
It has been observed that borderlines often have borderline moth-
ers, who, in turn, have borderline mothers. This hereditary predis-
position to BPD prompts a number of questions, such as: How do
borderline traits develop? How are they passed down through fami-
lies? Are they, indeed, passed down at all?
In examining the roots of this illness, these questions resur-
rect the traditional “nature versus nurture” (or, temperament ver-
sus character) question. The two major theories on the causes of
BPD—one emphasizing developmental (psychological) roots, the
other constitutional (biological and genetic) origins—re ect the
dilemma.
A third theoretical category, which focuses on environmen-
tal and sociocultural factors, such as our fast-paced, fragmented
societal structure, destruction of the nuclear family, increased
divorce rates, increased reliance on nonparental day care, greater
geographical mobility, and changing patterns of gender roles, is
also important (see chapter 4). Though empirical research on these
environmental elements is limited, some professionals speculate
that these factors would tend to increase the prevalence of BPD.
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ROOTS OF THE BORDERLINE SYNDROME 61
The available evidence points to no one de nitive cause—or
even type of cause—of BPD. Rather, a combination of genetic,
developmental, neurobiological, and social factors contribute to
the development of the illness.
Genetic and Neurobiological Roots
Family studies suggest that rst-degree relatives of borderlines are
several times more likely to show signs of a personality disorder,
especially BPD, than the general public. These close family mem-
bers are also signicantly more likely to exhibit mood, impulse, and
substance abuse disorders.
1
It is unlikely that one gene contributes
to BPD; instead, like most medical disorders, many chromosomal
loci are activated or subdued—probably inuenced by environmen-
tal factors—in the development of what we label BPD.
Biological and anatomical correlations with BPD have been
demonstrated. In our book Sometimes I Act Crazy, we discuss in
more detail how specic genes affect neurotransmitters (brain hor-
mones, which relay messages between brain cells).
2
Dysfunction in
some of these neurotransmitters, such as serotonin, norepineph-
rine, dopamine, and others, are associated with impulsivity, mood
disorders, and other characteristics of BPD. These neurotransmit-
ters also affect the balance of adrenaline and steroid production in
the body. Some of the genes affecting these neurotransmitters have
been associated with several psychiatric illnesses. However, stud-
ies with variable results demonstrate that multiple genes (intersect-
ing with environmental stressors) contribute to the expression of
most medical and psychiatric disorders.
The borderline’s frequent abuse of food, alcohol, and other
drugs—typically interpreted as self-destructive behavior—may
also be seen as an attempt to self-medicate inner emotional turmoil.
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62 I HATE YOUDON’T LEAVE ME
Borderlines frequently report the calming effects of self-mutila-
tion; rather than feeling pain, they experience soothing relief or
distraction from internal psychological pain. Self-mutilation, like
any other physical trauma or stress, may result in the release of
endorphins—the body’s natural narcotic-like substances that pro-
vide relief during childbirth, physical traumas, long-distance run-
ning, and other physically stressful activities.
Changes in brain metabolism and morphology (or structure)
are also associated with BPD. Borderline patients express hyper-
activity in the part of the brain associated with emotionality and
impulsivity (limbic areas), and decreased activity in the section
that controls rational thought and regulation of emotions (the pre-
frontal cortex). (Similar imbalances are observed in patients suf-
fering from depression and anxiety.) Additionally, volume changes
in these parts of the brain are also associated with BPD and are
correlated with these physiological changes.
3
These alterations in the brain may be related to brain injury or
disease. A signicant percentage of borderline patients have a his-
tory of brain trauma, encephalitis, epilepsy, learning disabilities,
ADHD, and pregnancy complications.
4
These abnormalities are
reected in brain wave (EEG, or electroencephalogram) irregu-
larities, metabolic dysfunction, and white and gray matter volume
reductions.
Since failure to achieve healthy parent-child attachment may
result in later character pathology, cognitive impairment on the
part of the child and/or the parent may hinder the relationship.
As the latest research strongly suggests that BPD may be at least
partly inherited, parent and child may both experience dysfunc-
tion in cognitive and/or emotional connection. A poor communi-
cation t may perpetuate the insecurities and impulse and affective
defects that result in BPD.
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ROOTS OF THE BORDERLINE SYNDROME 63
Developmental Roots
Developmental theories on the causes of BPD focus on the deli-
cate interactions between child and caregivers, especially during
the rst few years of life. The ages between eighteen and thirty
months, when the child begins the struggle to gain autonomy,
are particularly crucial. Some parents actively resist the child’s
progression toward separation and insist instead on a controlled,
exclusive, often suffocating symbiosis. At the other extreme, other
parents offer only erratic parenting (or are absent) during much
of the child-raising period and so fail to provide suf cient atten-
tion to, and validation for, the child’s feelings and experiences.
Either extreme of parental behavior—behavioral over-control and/or
emotional under-involvement—can result in the child’s failure to
develop a positive, stable sense of self and may lead to a constant,
intense need for attachment and chronic fears of abandonment.
In many cases the broken parent-child relationship takes the
more severe form of early parental loss or prolonged, traumatic sep-
aration, or both. As with Dixie, many borderlines have an absent
or psychologically disturbed father. Primary mother gures (who
may sometimes be the father) tend to be erratic and depressed and
have signicant psychopathology themselves, often BPD. The bor-
derline’s family background is frequently marked by incest, vio-
lence, and/or alcoholism. Many cases show an ongoing hostile or
combative relationship between mother and pre-borderline child.
Object Relations Theory and Separation-Individuation
in Infancy
Object relations theory, a model of infant development, emphasizes
the signicance of the child’s interactions with his environment, as
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64 I HATE YOUDON’T LEAVE ME
opposed to internal psychic instincts and biological drives uncon-
nected to sensations outside himself. According to this theory, the
child’s relationships with “objects” (people and things) in his envi-
ronment determines his later functioning.
The primary object relations model for the early phases of
infant development was created by Margaret Mahler and col-
leagues.
5
They postulated that the infant’s rst one to two months
of life were characterized by an obliviousness to everything except
himself (the autistic phase). During the next four or ve months,
designated the symbiotic phase, he begins to recognize others in
his universe, not as separate beings, but as extensions of himself.
In the following separation-individuation period, extending
through ages two to three years, the child begins to separate and
disengage from the primary caregiver and begins to establish a
separate sense of self. Mahler and others consider the child’s abil-
ity to navigate through this phase of development successfully to
be crucial for later mental health.
During the entire separation-individuation period, the develop-
ing child begins to sketch out boundaries between self and others,
a task complicated by two central conicts—the desire for auton-
omy versus closeness and dependency needs, and fear of engulf-
ment versus fear of abandonment.
A further complicating factor during this time is that the devel-
oping infant tends to perceive each individual in the environment
as two separate personae. For example, when mother is comfort-
ing and sensitive, she is seen as “all-good.” When she is unavailable
or unable to comfort and soothe, she is perceived as a separate,
“ all-bad” mother. When she leaves his sight, the infant perceives her
as annihilated, gone forever, and cries for her return to relieve the
despair and panic. As the child develops, this normal “splitting” is
replaced by a healthier integration of mother’s good and bad traits,
and separation anxiety is replaced by the knowledge that mother
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ROOTS OF THE BORDERLINE SYNDROME 65
exists even when she is not physically present and will, in time,
return—a phenomenon commonly known as object constancy (see
page 67). Prevailing over these developmental milestones is the
child’s developing brain, which can sabotage normal adaptation.
Mahler divides separation-individuation into four overlapping
subphases.
DIFFERENTIATION PHASE 58 MONTHS. In this phase of development,
the infant becomes aware of a world separate from mother. “Social
smiling” begins—a reaction to the environment, but directed mostly
at mother. Near the end of this phase, the infant displays the oppo-
site side of this same response—“stranger anxiety”—the recogni-
tion of unfamiliar people in the environment.
If the relationship with mother is supportive and comforting,
reactions to strangers are mainly characterized by curious won-
der. If the relationship is unsupportive, anxiety is more prominent;
the child begins to divide positive and negative emotions toward
other individuals, relying on splitting to cope with these con ict-
ing emotions.
PRACTICING PHASE 816 MONTHS. The practicing phase is marked
by the infant’s increasing ability to move away from mother, rst
by crawling, then by walking. These short separations are punctu-
ated by frequent reunions to “check in” and “refuel,” behavior that
demonstrates the child’s rst ambivalence toward his developing
autonomy.
RAPPROCHEMENT PHASE 1625 MONTHS. In the rapprochement
phase, the child’s expanding world sparks the recognition that he
possesses an identity separate from those around him. Reunions
with mother and the need for her approval shape the deepening
realization that she and others are separate, real people. It is in
the rapprochement phase, however, that both child and mother
confront conicts that will determine future vulnerability to the
borderline syndrome.
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66 I HATE YOUDON’T LEAVE ME
The mother’s role during this time is to encourage the child’s
experiments with individuation, yet simultaneously provide a con-
stant, supportive, refueling reservoir. The normal two-year-old not
only develops a strong bond with parents but also learns to sepa-
rate temporarily from them with sadness rather than with rage or
tantrum. When reunited with the parent, the child is likely to feel
happy as well as angry over the separation. The nurturing mother
empathizes with the child and accepts the anger without retalia-
tion. After many separations and reunions, the child develops an
enduring sense of self, love and trust for parents, and a healthy
ambivalence toward others.
The mother of a pre-borderline, however, tends to respond to
her child in a different way—either by pushing her child away pre-
maturely and discouraging reunion (perhaps due to her own fear
of closeness) or by insisting on a clinging symbiosis (perhaps due
to her own fear of abandonment and need for intimacy). In either
case, the child becomes burdened by intense fears of abandonment
and/or engulfment that are mirrored back to him by mother’s own
fears.
As a result, the child never grows into an emotionally separate
human being. Later in life, the borderline’s inability to achieve inti-
macy in personal relationships reects this infant stage. When an
adult borderline confronts closeness, she may resurrect from child-
hood either the devastating feelings of abandonment that always
followed her futile attempts at intimacy or the feeling of suffo-
cation from mother’s constant smothering. Defying such controls
risks losing mother’s love; satisfying her risks losing oneself.
This fear of engulfment is well illustrated by T. E. Lawrence
(Lawrence of Arabia), who at age thirty-eight writes about his
fear of closeness to his overbearing mother: “I have a terror of her
knowing anything about my feelings, or convictions, or way of life.
If she knew, they would be damaged; violated; no longer mine.”
6
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ROOTS OF THE BORDERLINE SYNDROME 67
OBJECT CONSTANCY PHASE 2536 MONTHS.
By the end of the sec-
ond year of life, assuming the previous levels of development have
progressed satisfactorily, the child enters the object constancy
phase, wherein the child recognizes that the absence of mother
(and other primary caregivers) does not automatically mean her
annihilation. The child learns to tolerate ambivalence and frustra-
tion. The temporary nature of mother’s anger is recognized. The
child also begins to understand that his own rage will not destroy
mother. He begins to appreciate the concept of unconditional love
and acceptance and develops the capacity to share and to empa-
thize. The child becomes more responsive to father and others in
the environment. Self-image becomes more positive, despite the
self-critical aspects of an emerging conscience.
Aiding the child in all these tasks are transitional objects—
the familiar comforts (teddy bears, dolls, blankets) that represent
mother and are carried everywhere by the child to help ease sepa-
rations. The object’s form, smell, and texture are physical repre-
sentations of the comforting mother. Transitional objects are one
of the rst compromises made by the developing child in negotiat-
ing the conict between the need to establish autonomy and the
need for dependency. Eventually, in normal development, the tran-
sitional object is abandoned when the child is able to internalize a
permanent image of a soothing, protective mother gure.
Developmental theories propose that the borderline is never
able to progress to this object constancy stage. Instead, the border-
line is xated at an earlier developmental phase, in which splitting
and other defense mechanisms remain prominent.
Because they are locked into a continual struggle to achieve
object constancy, trust, and a separate identity, adult borderlines
continue to rely on transitional objects for soothing. One woman,
for example, always carried in her purse a newspaper article that
contained quotes from her psychiatrist. When she was under stress,
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68 I HATE YOUDON’T LEAVE ME
she would take it out, calling it her “security blanket.” Seeing her
doctor’s name in print reinforced his existence and his continued
interest and concern for her.
Princess Diana also took comfort in transitional objects, keep-
ing a menagerie of twenty stuffed animals—“my family,” she
called them—at the foot of her bed . . . As her lover James Hewitt
observed, they “lay in a line, about thirty cuddly animals—animals
that had been with her in her childhood, which she had tucked up
in her bed at Park House and which had comforted her and repre-
sented a certain security.” When she went on trips, Diana took a
favorite teddy bear with her.
7
Ritualized, superstitious acts, when
done in extremes, may represent borderline utilization of transi-
tional objects. The ballplayer who wears the same socks or refuses
to shave while in the midst of a hitting streak, for example, may
simply be prone to the superstitions that prevail in sports; only when
such behaviors are repeated compulsively and inexibly and inter-
fere with routine functioning does the person cross the border into
the borderline syndrome.
Childhood Con icts
The child’s evolving sense of object constancy is consistently chal-
lenged as he progresses through developmental milestones. The
toddler, entranced by fairy tales lled with all-good and all-bad
characters, encounters numerous situations in which he uses split-
ting as a primary coping strategy. (Snow White, for example, can
only be conceptualized as all-good and the evil queen as all-bad;
the fairy tale does not elicit sympathy for a queen who may be a
product of a chaotic upbringing or criticism of the heroine’s cohab-
itation with the seven short guys!) Though now trusting mother’s
permanent presence, the growing child must still contend with
the fear of losing her love. The four-year-old who is scolded for
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ROOTS OF THE BORDERLINE SYNDROME 69
being “bad” may feel threatened with the withdrawal of mother’s
love; he cannot yet conceive of the possibility that mother may be
expressing her own frustrations quite apart from his own behav-
ior, nor has he learned that mother can be angry and yet love him
just as much at the same time.
Eventually, children are confronted with the separation anxiety
of starting school. “School phobia” is neither a real phobia nor
related exclusively to school itself, but instead represents the subtle
interplay between the child’s anxiety and the reactions of parents
who may reinforce the child’s clinging with their own ambivalence
about the separation.
Adolescent Con icts
Separation-individuation issues are repeated during adolescence,
when questions of identity and closeness to others once again become
vital concerns. During both the rapprochement phase of infancy
and adolescence, the child’s primary mode of relating is less acting
than reacting to others, especially parents. While the two-year-old
tries to elicit approval and admiration from parents by molding
his identity to emulate caregivers, the adolescent tries to emulate
peers or adopts behaviors that are consciously different—even
opposite—from those of parents. In both stages, the child’s behav-
ior is based less on independently determined internal needs than
on reacting to the signicant people in the immediate environ-
ment. Behavior then becomes a quest to discover identity rather
than to reinforce an established one.
An insecure teenager may ruminate endlessly about her boy-
friend in a “he loves me, he loves me not” fashion. Failure to inte-
grate these positive and negative emotions and to establish a rm,
consistent perception of others leads to continued splitting as a
defense mechanism. The adolescent’s failure to maintain object
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70 I HATE YOUDON’T LEAVE ME
constancy results in later problems with sustaining consistent,
trusting relationships, establishing a core sense of identity, and tol-
erating anxiety and frustration.
Often, entire families adopt a borderline system of interaction,
with the family members’ undifferentiated identities alternately
merging with and separating from each other. Melanie, the adoles-
cent daughter in one such family, closely identied with her chroni-
cally depressed mother, who felt abandoned by her philandering
husband. With her husband often away from home and her other
children of much younger age, the mother fastened onto her teen-
age daughter, relating intimate details of the unhappy marriage
and invading the teenager’s privacy with intrusive questions about
her friends and activities. Melanie’s feelings of responsibility for
her mother’s happiness interfered to the point where she could not
attend to her own needs. She even selected a college nearby so
she could continue to live at home. Eventually, Melanie developed
anorexia nervosa, which became her primary mechanism for feel-
ing in control, independent, and comforted.
Similarly, Melanie’s mother felt responsible and guilty for her
daughter’s illness. The mother sought relief in extravagant spend-
ing sprees (which she concealed from her husband) and then cov-
ered the bills by stealing money from her daughter’s bank account.
Mother, father, and daughter were trapped in a dysfunctional fam-
ily swamp, which they were unwilling to confront and from which
they were unable to escape. In such cases, treatment of the bor-
derline may require treatment of the entire family (see chapter 7).
Traumas
Major traumas—parental loss, neglect, rejection, physical or sexual
abuse—during the early years of development can increase the prob-
ability of BPD in adolescence and adulthood. Indeed, case histories
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ROOTS OF THE BORDERLINE SYNDROME 71
of borderline patients are typically desolate battleelds, scarred by
broken homes, chronic abuse, and emotional deprivation.
Norman Mailer described the effect of an absent parent on
Marilyn Monroe, who never knew her father. Though his absence
would contribute to her emotional instability in later life, it would
also ironically be one of the motivating forces in her career:
Great actors usually discover they have a talent by rst search-
ing in desperation for an identity. It is no ordinary identity that
will suit them, and no ordinary desperation can drive them.
The force that propels a great actor in his youth is insane ambi-
tion. Illegitimacy and insanity are the godparents of the great
actor. A child who is missing either parent is a study in the
search for identity and quickly becomes a candidate for actor
(since the most creative way to discover a new and possible
identity is through the close t of a role).
8
Similarly, Princess Diana, rejected by her mother and reared
by a cold, withdrawn father, exhibited similar characteristics. “I
always used to think that Diana would make a very good actress
because she would play out any role she chose,” said her former
nanny, Mary Clarke.
9
Raised in an orphanage during many years of her early child-
hood, Marilyn had to learn to survive with a minimum of love
and attention. It was her self-image that suffered the most and led
to her manipulative behavior with lovers later in life. For Diana,
her “deep feelings of unworthiness” (in the eulogizing words of
her brother, Charles) hindered her relationships with men. “I’d
always kept [boyfriends] away, thought they were all trouble—and
I couldn’t handle it emotionally. I was very screwed up, I thought.”
10
Not all children who are traumatized or abused become bor-
derline adults, of course; nor do all borderline adults have a history
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72 I HATE YOUDON’T LEAVE ME
of trauma or abuse. Further, most studies on the effects of child-
hood trauma are based on inferences from adult reports and not on
longitudinal studies that follow young children through to adult-
hood. Finally, other studies have demonstrated less extreme forms
of abuse in the histories of borderlines, particularly neglect (some-
times from the father) and a rigid, tight marital bond that excludes
adequate protection and support for the child.
11,12,13
Nevertheless,
the large amount of anecdotal and statistical evidence demonstrates
a link between various forms of abuse, neglect, and BPD.
Nature Versus Nurture
The “nature-nurture” question is, of course, a long-standing and
controversial one that applies to many aspects of human behavior.
Is one aficted with BPD because of a biological destiny inher-
ited from parents—or because of the way parents handled—or
mishandled—upbringing? Do the biochemical and neurological
signs of the disorder cause the illness—or are they caused by the
illness? Why do some people develop BPD in spite of an apparently
healthy upbringing? Why do others, burdened with a background
lled with trauma and abuse, not develop it?
These “chicken-or-egg” dilemmas can lead to false assumptions.
For example, one might conclude, based on developmental theo-
ries, that the causal direction is strictly downward; that is, an aloof,
detached mother would produce an insecure borderline child. But
the relationship might be more complex, more interactive than
that: a colicky, unresponsive, unattractive infant may generate dis-
appointment and detachment in the mother. Regardless of which
comes rst, both continue to interact and perpetuate interpersonal
patterns, which may endure over many years and extend to other
relationships The mitigating effects of other factors—a supportive
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ROOTS OF THE BORDERLINE SYNDROME 73
father, accepting family and friends, superior education, physical
and mental abilities—will help determine the ultimate emotional
health of the individual.
Though no evidence supports a specic BPD gene, humans may
inherit chromosomal vulnerabilities that are later expressed as a
particular illness, depending on a variety of contributing factors—
childhood frustrations and traumas, specic stress events in life,
healthy nutrition, access to health care, and so on. Just as some have
postulated that heritable biological defects in the body’s metabo-
lism of alcohol may be associated with an individual’s propensity
to develop alcoholism, so there may exist a genetic predisposition
for BPD, involving a biological weakness in stabilizing mood and
impulses.
As many borderlines learn that they must reject the either-or,
black-or-white ways of thinking, researchers are beginning to appre-
ciate that the most likely model for BPD (and for most medical and
psychiatric illnesses) recognizes multiple contributing factors—nature
and nurture—working and interacting simultaneously. Borderline
personality is a complex tapestry, richly embroidered with innumer-
able, intersecting threads.
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Chapter Four
The Borderline Society
Where there is no vision, the people perish.
—Proverbs 29:18
States are as the men are; they grow out of human characters.
—From Plato’s Republic
From the beginning Lisa Barlow couldn’t do anything right. Her
older brother was the golden boy: good grades, polite, athletic, per-
fect. Her younger sister, who had asthma, was also lavished with
constant attention. Lisa was never good enough, especially in the
eyes of her father. She remembered how he constantly reminded all
three children that he had started with nothing, that his parents
had no money, didn’t care about him, and drank too much. But
he had prevailed. He had worked his way through high school,
college, and through several promotions at a national investment
bank. In 1999, he made a fortune in the dot-com stock boom, only
to lose it all a year later after some professional missteps.
Lisa’s earliest memories of her mother were of her lying on
the couch either sick or in pain, ordering Lisa to do one chore or
another around the house. Lisa tried hard to care for her mother
and to persuade her to stop taking the pain pills and tranquilizers
that seemed to make her so foggy and distant.
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THE BORDERLINE SOCIETY 75
Lisa felt that if she was just good enough, she could not only
make her mother better but also please her father. Though her
grades were always excellent (even better than her brother’s), her
father always maligned her achievements: the course was too easy
or she could have done even better than a B+ or an A−. At one
point, she thought she might want to become a doctor, but her
father convinced her she would never make it.
In her childhood and adolescence the Barlows moved constantly,
following whatever job or promotion her father chased after. From
Omaha to St. Louis to Chicago and nally to New York. Lisa hated
these moves and realized later that she resented her mother for never
objecting to them. Every couple of years Lisa would be packed up
and shipped like baggage to a strange new city where she would
attend a new school lled with strange new students. (Years later
she would recount these experiences to her therapist as “feeling like
a kidnap victim or a slave.”) By the time the family arrived in New
York, Lisa was in high school. She vowed never to make another
friend so she would never have to say good-bye again.
The family moved into a posh home in a posh New York sub-
urb. Sure, the house was bigger and the lawn more manicured, but
that didn’t come close to compensating for the friendships she left
behind. Her father rarely came home in the evenings, and when he
did, it was late and he would start drinking and railing against Lisa
and her mother for doing nothing all day. When her father drank
too much, he became violent, sometimes hitting the kids harder
than he intended. The most frightening time of all was when he was
drunk and their mother was spaced out on pain pills; then there was
no one to take care of the family—except Lisa, and she hated it.
In 2000, everything started coming apart. Somehow her father’s
rm (or her father himself, she was never sure which) lost every-
thing when the stock market crashed. Her father was suddenly in
danger of losing his job, and if he did, the Barlows would have to
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76 I HATE YOUDON’T LEAVE ME
move again, to a smaller house in a less desirable neighborhood. He
seemed to blame his family and especially Lisa. And then, on a clear,
bright morning in September 2001, Lisa came downstairs to nd
her father lying on the sofa, tears streaming down his cheeks. Had
it not been for a hangover from a drinking bout the night before, he
would have been killed in his ofce in the World Trade Center.
For months afterward her father was helpless and so was her
mother. They eventually divorced six months later. During this
period, Lisa felt lost and isolated. It was similar to the way she felt
in biology class when she’d look around the room and observe the
other kids squinting into their microscopes, taking notes, appar-
ently knowing exactly what to do, while she became queasy, not
quite understanding what was expected of her and feeling too
scared to ask for help.
After a while she just stopped trying. In high school she began
to hang out with the “wrong kids.” She made sure her parents saw
them and how freaky they dressed. The bodies of many of her friends
were covered—almost literally—with tattoos and body piercings,
and the local tattoo parlor became a second home for Lisa as well.
Because her father insisted she couldn’t make it as a doctor Lisa
went into nursing. At her rst hospital job, she met a “free spirit”
who wanted to bring his nursing expertise to underprivileged
areas. Lisa was enthralled by him and they married soon after
meeting. His habitual “social” drinking became more prominent
as the months went by, and he began hitting her. Bruised and bat-
tered, Lisa still felt it was her fault—she just wasn’t good enough,
couldn’t make him happy. She had no friends, she said, because he
wouldn’t let her have any, but deep down she knew it was due more
to her own fears of closeness.
She was relieved when he nally left her. She had wanted the
split but couldn’t cut the cord herself. But after the relief came fear:
“Now what do I do?”
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THE BORDERLINE SOCIETY 77
Between the divorce settlement and her salary Lisa had enough
money to return to school. This time she was determined to be a
doctor and, much to her father’s shock, was accepted into medical
school. She was starting to feel good again, valued and respected.
But then in medical school the self-doubts returned. Her supervi-
sors said she was too slow, clumsy with simple procedures, dis-
organized. They criticized her for not ordering the right tests or
getting lab results back in time. Only with the patients did she feel
comfortable—with them she could be whomever she needed to be:
kind and compassionate when that was needed, confrontational
and demanding when that was called for.
Lisa also experienced a great deal of prejudice in medical school.
She was older than most of the other students; she had a much dif-
ferent background; and she was a woman. Many of the patients
called her “nurse,” and some of the male patients didn’t want “no
lady doctor.” She was hurt and angry because, like her parents,
society and its institutions had also robbed her of her dignity.
The Disintegrating Culture
Psychological theories take on a different dimension when looked
upon in light of the culture and time period from which they emanate.
At the turn of the century, for instance, when Freud was formulating
the system that would become the foundation of modern psychiat-
ric thought, the cultural context was a formally structured, Victo-
rian society. His theory that the primary origins of neuroses were
the repression of unacceptable thoughts and feelings—aggressive and
especially sexual—was entirely logical in this strict social context.
Now, over a century later, aggressive and sexual instincts
are expressed more openly, and the social milieu is much more
confused. What it means to be a man or a woman is much more
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78 I HATE YOUDON’T LEAVE ME
ambiguous in modern Western civilization than in turn-of-the-
century Europe. Social, economic, and political structures are less
xed. The family unit and cultural roles are less dened, and the
very concept of “traditional” is unclear.
Though social factors may not be direct causes of BPD (or other
forms of mental illness), they are, at the least, important indirect
inuences. Social factors interact with BPD in several ways and can-
not be overlooked. First, if borderline pathology originates early in
life—and much of the evidence points in this direction—an increase
in the pathology is likely tied to the changing social patterns of fam-
ily structure and parent-child interaction. In this regard, it is worth-
while to examine social changes in the area of child-raising patterns,
stability of home life, and child abuse and neglect.
Second, social changes of a more general nature have an exac-
erbative effect on people already suffering from the borderline syn-
drome. The lack of structure in American society, for example, is
especially difcult for borderlines to handle, since they typically
have immense problems creating structure for themselves. Women’s
shifting role patterns (career versus homemaker, for example) tend
to aggravate identity problems. Indeed, some researchers attribute
the prominence of BPD among women to this social role con ict,
now so widespread in our society. The increased severity of BPD
in these cases may, in turn, be transmitted to future generations
through parent-child interactions, multiplying the effects over time.
Third, the growing recognition of personality disorders in gen-
eral, and borderline personality more specically, may be seen as
a natural and inevitable response to—or an expression of—our
contemporary culture. As Christopher Lasch noted in The Culture
of Narcissism,
Every society reproduces its culture—its norms, its underly-
ing assumptions, its modes of organizing experience—in the
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THE BORDERLINE SOCIETY 79
individual, in the form of personality. As Durkheim said, per-
sonality is the individual socialized.
1
For many, American culture has lost contact with the past
and remains unconnected to the future. The ooding of technical
advancement and information that swept over the late twentieth and
early twenty-rst centuries, much of it involving computers, PDAs,
cell phones, and so on, often requires greater individual commit-
ment to solitary study and practice, thus sacri cing opportunities
for real social interaction. Indeed, the preoccupation—some would
say obsession—with computers and other digital gadgetry, especially
among the young in what is commonly called “social media” (Face-
book, MySpace, Twitter, YouTube, etc.), may be resulting ironically
in more self-absorption and less physical interaction; texting, blog-
ging, posting, and tweeting all avoid eye contact. Increasing divorce
rates, expanding use of day care, and greater geographical mobility
have all contributed to a society that lacks constancy and reliabil-
ity. Personal, intimate, lasting relationships become difcult or even
impossible to achieve, and deep-seated loneliness, self-absorption,
emptiness, anxiety, depression, and loss of self-esteem ensue.
The borderline syndrome represents a pathological response to
these stresses. Without outside sources of stability and validation of
worthiness, borderline symptoms of black-and-white thinking, self-
destructiveness, extreme mood changes, impulsivity, poor relation-
ships, impaired sense of identity, and anger become understandable
reactions to our culture’s tensions. Borderline traits, which may be
present to some extent in most people, are being elicited—perhaps
even bred—on a wide scale by the prevailing social conditions.
New York Times writer Louis Sass put it this way:
Each culture probably needs its own scapegoats as expressions
of society’s ills. Just as the hysterics of Freud’s day exempli ed
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80 I HATE YOUDON’T LEAVE ME
the sexual repression of that era, the borderline, whose identity
is split into many pieces, represents the fracturing of stable
units in our society.
2
Though conventional wisdom presumes that borderline pathol-
ogy has increased over the last few decades, some psychiatrists
believe that the symptoms were just as common early in the twen-
tieth century. They claim that the change is not in the prevalence
of the disorder, but in the fact that it is now of cially identi ed
and dened, and so merely diagnosed more frequently. Even some
of Freud’s early cases, scrutinized in the light of current criteria,
might be diagnosed today as borderline personalities.
This possibility, however, by no means diminishes the impor-
tance of the growing number of borderline patients who are end-
ing up in psychiatrists’ ofces and of the growing recognition of
borderline characteristics in the general population. In fact, the
major reason why it has been identied and covered so widely in
the clinical literature is its prevalence in both therapeutic settings
and the general culture.
The Breakdown of Structure:
A Fragmented Society
Few would dispute the notion that society has become more frag-
mented since the end of World War II. Family structures in place for
decades—the nuclear family, extended family, one-wage-earner
households, geographical stability—have been replaced by a wide
assortment of patterns, movements, and trends. Divorce rates have
soared. Drug and alcohol abuse and child neglect and abuse
have skyrocketed. Crime, terrorism, and political assassination have
become widespread, at times almost commonplace. Periods of
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THE BORDERLINE SOCIETY 81
economic uncertainty, exemplied in roller-coaster boom-and-
bust scenarios, have become the rule, not the exception.
Some of these changes may be related to society’s failure to
achieve a kind of “social rapprochement.” As noted in chapter 3,
during the separation-individuation phase, the infant ventures cau-
tiously away from mother but returns to her reassuring warmth,
familiarity, and acceptance. Disruption of this rapprochement cycle
often results in a lack of trust, disturbed relationships, emptiness,
anxiety, and an uncertain self-image—characteristics that make
up the borderline syndrome. Similarly, it may be seen that contem-
porary culture interferes with a healthy “social rapprochement”
by obstructing access to comforting anchors. At no time has this
disruption been more evident than in the rst decade of the twenty-
rst century, racked as it has been by economic collapse, recession,
loss of jobs, foreclosures, and so on. In most areas of the country,
the need for two incomes to maintain a decent standard of living
forces many parents to relinquish parenting duties to others; paid
parental leave or on-site day care for new parents is still relatively
rare and almost always limited. Jobs, as well as economic and
social pressures, encourage frequent moves, and this geographical
mobility, in turn, removes us from our stabilizing roots, as it did in
Lisa’s family. We are losing (or have already lost) the comforts of
neighborly nearby family and consistent social roles.
When the accoutrements of custom disappear, they may be
replaced by a sense of abandonment, of being adrift in unchartered
waters. Our children lack a sense of history and belonging—of an
anchored presence in the world. To establish a sense of control and
comforting familiarity in an alienating society, the individual may
resort to a wide range of pathological behavior—substance addic-
tion, eating disorders, criminal behaviors, and so on.
Society’s failure to provide rapprochement with reassuring, sta-
bilizing bonds is reected in the relentless series of sweeping societal
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82 I HATE YOUDON’T LEAVE ME
movements over the past fty years. We roller-coastered from the
explosive other-directed, ght-for-social justice “We Decade” of the
1960s, to the narcissistic “Me Decade” of the 1970s, to the mate-
rialistic, look-out-for-number-one “Whee Decade” of the 1980s.
The relatively prosperous and stable 1990s was followed by the
turbulent 2000s: nancial boom-and-busts, natural catastrophes
(Katrina and other hurricanes, major tsunamis, earthquakes, and
res), a prolonged war, and sociopolitical movements (antiwar, gay
rights)—bringing us almost full circle back to the 1960s.
One of the big losers in these tectonic shifts has been group
loyalties—devotion to family, neighborhood, church, occupation,
and country. As society continues to foster detachment from people
and institutions that provide reassuring rapprochement, individ-
uals are responding in ways that virtually dene the borderline
syndrome: decreased sense of validated identity, worsening inter-
personal relationships, isolation and loneliness, boredom, and
(without the stabilizing force of group pressures) impulsivity.
Like the world of the borderline, ours in many ways is a world
of massive contradictions. We presume to believe in peace, yet our
streets, movies, television, and sports are lled with aggression and
violence. We are a nation virtually founded on the principle of “Help
thy neighbor,” yet we have become one of the most politically con-
servative, self-absorbed, and materialistic societies in the history
of humankind. Assertiveness and action are encouraged; re ection
and introspection are equated with weakness and incompetency.
Contemporary social forces implore us to embrace a mythical
polarity—black or white, right or wrong, good or bad—relying
on our nostalgia for simpler times, for our own childhoods. The
political system presents candidates who adopt polar stances: “I’m
right, the other guy is wrong”; America is good; the Soviet Union
is “the Evil Empire”; Iran, Iraq, and North Korea are the “Axis of
Evil.” Religious factions exhort us to believe that theirs is the only
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THE BORDERLINE SOCIETY 83
route to salvation. The legal system, built on the premise that one
is either guilty or not guilty with little or no room for gray areas,
perpetuates the myth that life is intrinsically fair and justice can be
attained—that is, when something bad does happen, it necessarily
follows that it is someone else’s fault and that person should pay.
The ood of information and leisure alternatives makes it dif -
cult to establish priorities in living. Ideally, we—as individuals and
as a society—attempt to achieve a balance between nurturing the
body and the mind, between work and leisure, between altruism
and self-interest. But in an increasingly materialistic society it is a
small step from assertiveness to aggressiveness, from individualism
to alienation, from self-preservation to self-absorption.
The ever-growing reverence for technology has led to an obses-
sive pursuit of precision. Calculators replaced memorized multipli-
cation tables and slide rules, and then were replaced by computers,
which have become omnipresent in almost every aspect of our
lives—our cars, our appliances, our cell phones—running what-
ever machine or device they are a part of. The microwave relieves
adults from the chore of cooking. Velcro absolves children of learn-
ing how to tie shoelaces. Creativity and intellectual diligence are
sacriced to convenience and precision.
All these attempts to impose order and fairness on a naturally
random and unfair universe endorse the borderline’s futile struggle
to choose only black or white, right or wrong, good or bad. But the
world is neither intrinsically fair nor exact; it is composed of sub-
tleties that require less simplistic approaches. A healthy civilization
can accept the uncomfortable ambiguities. Attempts to eradicate
or ignore uncertainty tend only to encourage a borderline society.
We would be naive to believe that the cumulative effect of all this
change—the excruciating pull of opposing forces—has had no effect
on our psyches. In a sense, we all live in a kind of “borderland”—
between the prosperous, healthy, high-technology America, on the
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84 I HATE YOUDON’T LEAVE ME
one hand, and the underbelly of poverty, homelessness, drug abuse,
and mental illness, on the other; between the dream of a sane, safe,
secure world and the insane nightmare of nuclear holocaust.
The price tag of social change has come in the form of stress
and stress-related physical disorders, such as heart attacks, strokes,
and hypertension. We must now confront the possibility that men-
tal illness has become part of the psychological price.
Dread of the Future
Over the past four decades, therapeutic settings have seen a basic change
in dening psychopathology—from symptom neuroses to character
disorders. As far back as 1975, psychiatrist Peter L. Giovachinni
wrote, “Clinicians are constantly faced with the seemingly increas-
ing number of patients who do not t current diagnostic categories.
[They suffer not from] denitive symptoms but from vague ill-de ned
complaints. . . . When I refer to this type of patient, practically every-
one knows to whom I am referring.”
3
Beginning in the 1980s, such
reports have become commonplace, as personality disorders have
replaced classical neurosis as the prominent pathology. Which social
and cultural factors have inuenced this change in pathology? Many
believe that one factor is our devaluation of the past:
To live for the moment is the prevailing passion—to live for
yourself, not for your predecessors or posterity. . . .We are fast
losing the sense of historical continuity, the sense of belong-
ing to a succession of generations originating in the past and
stretching into the future.
4
This loss of historical continuity reaches both backward and
forward: devaluation of the past breaks the perceptual link to
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THE BORDERLINE SOCIETY 85
the future, which becomes a vast unknown, a source of dread as
much as hope, a vast quicksand, from which it becomes incredibly
difcult to extricate oneself. Time is perceived as isolated points
instead of as a logical, continuous string of events in uenced by
past achievement, present action, and anticipation of the future.
The looming possibility of a catastrophic event—the threat of
nuclear annihilation, another massive terrorist attack like 9/11,
environmental destruction due to global warming, and so on—
contributes to our lack of faith in the past and our dread of the
future. Empirical studies with adolescents and children consistently
show “awareness of the danger, hopelessness about surviving, a
shortened time perspective, and pessimism about being able to reach
life goals. Suicide is mentioned again and again as a strategy for
dealing with the threat.”
5
Other studies have found that the threat
of nuclear war rushes children to a kind of “early adulthood,” simi-
lar to the type witnessed in pre-borderline children (like Lisa) who
are forced to take control of families that are out of control due to
BPD, alcoholism, and other mental disorders.
6
Many U.S. youth
ages fourteen to twenty-two expect to die before age thirty, accord-
ing to a 2008 study published in the Journal of Adolescent Health.
About one out of fteen young people (6.7 percent) expressed such
“unrealistic fatalism,” the study concludes. The ndings are based
on four years of survey data totaling 4,201 adolescents conducted
between 2002 and 2005 by the Adolescent Risk Communication
Institute of the Annenberg Public Policy Center. Despite a decline
in the suicide rate for ten- to twenty-four-year-olds, suicide remains
the third leading cause of death in this age group.
7
The borderline, as we have seen, personies this orientation to
the “now.” With little interest in the past, the borderline is almost a
cultural amnesiac; his cupboard of warm memories (which sustain
most of us in troubled times) is bare. As a result, he is doomed to
suffer torment with no breathers, no cache of memories of happier
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86 I HATE YOUDON’T LEAVE ME
times to get him through the tough periods. Unable to learn from
his mistakes, he is doomed to repeat them.
Parents who fear the future are not likely to be engrossed by the
needs of the next generation. A modern parent, emotionally detached
and alienated—yet at the same time pampering and overindulgent—
becomes a likely candidate to mold future borderline personalities.
The Jungle of Interpersonal Relationships
Perhaps the hallmark social changes over the last fty years have
come in the area of sexual mores, roles, and practices—from the
suppressed sexuality of the 1950s, to the “free-love” and “open
marriage” trends of the 1960s sexual revolution, to the massive
sexual reevaluation in the 1980s (resulting in large part from the
fear of AIDS and other sexually transmitted diseases), to the gay
and lesbian movements over the last decade. The massive spread
of dating and “matching” websites and social media has made it
so easy to establish personal contact that the old brick-and-mortar
“pickup bar” is becoming increasingly irrelevant. Innocent—or
illicit—romantic or sexual relationships can now be initiated with a
few keyboard strokes or a text message. The jury is out on whether
cyberspace has “civilized” the world of interpersonal relationships
or turned it into more of a dangerous jungle than it ever was.
As a result of these and other societal forces, deep and lasting
friendships, love affairs, and marriages have become increasingly
difcult to achieve and maintain. Sixty percent of marriages for
couples between the ages of twenty and twenty-ve end in divorce;
the number is 50 percent for those over twenty- ve.
8
Even back
in 1982, Lasch noted that “as social life becomes more and more
warlike and barbaric, personal relations, which ostensibly provide
relief from those conditions, take on the character of combat.”
9
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THE BORDERLINE SOCIETY 87
Ironically, borderlines may be well suited for this kind of com-
bat. The narcissistic man’s need to dominate and be idolized ts
well with the borderline woman’s ambivalent need to be controlled
and punished. Borderline women, as we saw with Lisa at the start
of this chapter, often marry at a young age to escape the chaos of
family life. They cling to dominating husbands with whom they re-
create the miasma of home life. Both may enter a kind of “Slap! . . .
Thanks, I needed that!” sadomasochistic dyad. Less typical, but
still common, is a reversal of these roles, with a borderline male
linked with a narcissistic female partner.
Masochism is a prominent characteristic of borderline relation-
ships. Dependency coupled with pain elicits the familiar refrain
“Love hurts.” As a child, the borderline experiences pain and con-
fusion in trying to establish a maturing relationship with his mother
or primary caregiver. Later in life, other partners—spouse, friends,
teacher, employer, minister, doctor—renew this early confusion.
Criticism or abuse particularly reinforces the borderline’s self-image
of worthlessness. Lisa’s later relationships with her husband and
supervisors, for example, recapitulated the profound feelings of
worthlessness that were ingrained by her father’s constant criticisms.
Sometimes the borderline’s masochistic suffering transforms
into sadism. For example, Ann would sometimes encourage her hus-
band Larry to drink, knowing about his drinking problem. Then
she would instigate a ght, fully aware of Larry’s violent propensi-
ties when drunk. Following a beating, Ann would wear her bruises
like battle ribbons, reminding Larry of his violence, and insisting
they go out in public, where Ann would explain away her marks as
“accidents,” such as “running into doors.” After each episode, Larry
would feel profoundly regretful and humiliated, while Ann would
present herself as a long-suffering martyr. In this way Ann used her
beatings to exact punishment from Larry. The identication of the
real victim in this relationship becomes increasingly vague.
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88 I HATE YOUDON’T LEAVE ME
Even when a relationship is apparently ruptured, the borderline
comes crawling back for more punishment, feeling he deserves the
denigration. The punishment is comfortably familiar, easier to cope
with than the frightening prospect of solitude or a different partner.
A typical scenario for modern social relationships is the “over-
lapping lover” pattern, commonly called “shingling”—establishing
a new romance before severing a current one. The borderline exem-
plies this constant need for partnership: As the borderline climbs
the jungle gym of relationships, he cannot let go of the lower bar
until he has rmly grasped the higher one. Typically, the border-
line will not leave his current, abusive spouse until a new “white
knight” is at least visible on the horizon.
Periods of relaxed social-sexual mores and less structured
romantic relationships (such as in the late 1960s and 1970s) are
more difcult for borderlines to handle; increased freedom and
lack of structure paradoxically imprison the borderline, who is
severely handicapped in devising his own individual system of val-
ues. Conversely, the sexual withdrawal period of the late 1980s
(due in part to the AIDS epidemic) can be ironically therapeutic for
borderline personalities. Social fears enforce strict boundaries that
can be crossed only at the risk of great physical harm; impulsivity
and promiscuity now have severe penalties in the form of STDs,
violent sexual deviants, and so on. This external structure can help
protect the borderline from his own self-destructiveness.
Shifting Gender Role Patterns
Earlier in the last century, social roles were fewer, well de ned, and
much more easily combined. Mother was domestic, working in the
home, in charge of the children. Outside interests, such as school
involvement, hobbies, and charity work, owed naturally from
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THE BORDERLINE SOCIETY 89
these duties. Father’s work and community visibility also com-
bined smoothly. And, together, their roles worked synchronously.
The complexities of modern society, however, dictate that the
individual develop a plethora of social roles—many of which do
not combine so easily. The working mother, for example, has two
distinct roles and must struggle to perform both well. The policies
of most employers demand that the working mom keep the home
and workplace separate; as a result, many mothers feel guilty or
embarrassed when problems from one impact the other.
A working father also nds work and home roles compartmen-
talized. He is no longer the owner of the local grocery who lives
above the store. More likely, he works miles from home and has
much less time to be with his family. What’s more, the modern dad
plays an increasingly participatory role with familial responsibility.
Shifting role patterns over the last twenty-ve years are central
to theories on why BPD is identied more commonly in women.
In the past, a woman had essentially one life course—getting mar-
ried (usually in her late teens or early twenties), having children,
staying in the home to raise those children, and repressing any
career ambitions. Today, in contrast, a young woman is faced with
a bewildering array of role models and expectations—from the
single career woman, to the married career woman, to the tradi-
tional nurturing mother, to the “supermom,” who strives to com-
bine marriage, career, and children successfully.
Men have also experienced new roles and expectations, of
course, but not nearly so wide-ranging—nor con icting—as women.
Today, men are expected to be more sensitive and open and to
take a larger part in child raising than in previous eras, yet these
qualities and responsibilities usually t within the overall role of
“provider” or “co-provider.” It is the rare man who, for example,
abandons career ambitions for the role of “househusband,” nor is
this expected of him.
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90 I HATE YOUDON’T LEAVE ME
Men have fewer adjustments to make during the evolution of
relationships and marriages. For example, relocations are usually
dictated by the man’s career needs, since he is most often the pri-
mary wage earner. Throughout pregnancy, birth, and child rearing,
few changes occur in the man’s day-to-day reality. The woman not
only endures the physical demands of pregnancy and childbirth and
must leave her job to give birth, but it is also she who must make
the transition back to work or give up her career. And yet in many
dual-earner households, although it may not be openly stated, the
woman simply assumes the primary responsibility for the mainte-
nance of the home. She is the one who usually adjusts her plans to
stay home with a sick child or waits for the repairman to come.
Though women have struggled successfully to achieve increased
social and career options, they may have had to pay an exacting
price in the process: excruciating life decisions about career, fami-
lies, and children; strains on their relationships with their children
and husband; the stress resulting from making and living with
these decisions; and confusion about who they are and who they
want to be. From this perspective, it is understandable that women
should be more closely associated with BPD, a disorder in which
identity and role confusion are such central components.
Sexual Orientation and Borderlines
Sexual orientation may also play a part in the borderline’s role
confusion. In line with this theory, some researchers estimate a
signicantly increased rate of sexual perversions among border-
lines.
10,11
Environmental factors that may theoretically contribute
to the development of sexual identity include lack of role models,
sexual assaults, an insatiable need for affection and attention, dis-
comfort with one’s own body, and inconsistent sexual information.
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THE BORDERLINE SOCIETY 91
Family and Child-Rearing Patterns
Since the end of World War II, our society has experienced striking
changes in family and child-rearing patterns:
• The institution of the nuclear family has been in steady
decline. Largely due to divorce, half of all American children
born in the 1990s will spend some part of their childhood in
a single-parent home.
12
• Alternative family structures (such as “blended families,” in
which a single parent with children combines with another
one-parent household to form a new family unit) have led
to situations in which many children are raised by persons
other than their birth parents. According to one study, only
63 percent of American children grow up with both biologi-
cal parents—the lowest percentage in the Western world.
13
Due to increased geographical mobility, among other factors,
the traditional extended family, with grandparents, siblings,
cousins, and other family relations living in close proxim-
ity, is almost extinct, leaving the nuclear family virtually
unsupported.
• The number of women working outside the home has increased
dramatically. Forty percent of working women are mothers of
children under age eighteen; 71 percent of all single mothers
are employed.
14
• As a result of women working outside the home, more chil-
dren than ever before are being placed in various forms of
day care—and at a much earlier age. The number of infants
in day care increased 45 percent during the 1980s.
15
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92 I HATE YOUDON’T LEAVE ME
• The evidence clearly suggests that the incidence of child phys-
ical and sexual abuse has increased signicantly over the past
twenty- ve years.
16
What are the psychological effects of these child-rearing changes—
on both children and parents? Though many of these changes (such
as blended families,) are too new to be the subject of intensive long-
term studies, psychiatrists and developmental experts generally agree
that children growing up in settings marked by turmoil, instability,
or abuse are at much greater risk for emotional and mental problems
in adolescence and adulthood. Moreover, parents in such environ-
ments are much more likely to develop stress, guilt, depression, lower
self-esteem—all characteristics associated with BPD.
Child Abuse and Neglect: Destroyer of Trust
Child abuse and neglect have become signicant health problems.
In 2007, about 5.8 million children were involved in an estimated
3.2 million child abuse reports and allegations in the United
States.
17
Some studies estimate that 25 percent of girls experience
some form of sexual abuse (from parents or others) by the time
they reach adulthood.
18
Characteristics of physically abused preschool-age children
include inhibition, depression, attachment dif culties, behavior
problems (such as hyperactivity and severe tantrums), poor impulse
control, aggressiveness, and peer-relation problems.
“Violence begets violence,” said John Lennon, and this is par-
ticularly true in the case of battered children. Because those who
are abused often become abusers themselves, this problem can self-
perpetuate over many decades and generations. In fact, about 30
percent of abused and neglected children will later abuse their own
children, continuing the vicious cycle.
19
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THE BORDERLINE SOCIETY 93
The incidence of abuse or neglect among borderlines is high
enough to be a factor that separates BPD from other personal-
ity disorders. Verbal or psychological abuse is the most common
form, followed by physical and then sexual abuse. Physical and
sexual abuse may be more dramatic in nature, but the emotionally
abused child can suffer total loss of self-esteem.
Emotional child abuse can take several forms:
• Degradation—constantly devaluing the child’s achievements
and magnifying misbehavior. After a while, the child becomes
convinced that he really is bad or worthless.
• Unavailability—psychologically absent parents show little
interest in the child’s development and provide no affection
in times of need.
• Domination—use of extreme threats to control the child’s
behavior. Some child development experts have compared
this form of abuse to the techniques used by terrorists to
brainwash captives.
20
Recall from Lisa’s story that she probably suffered all of these
forms of emotional abuse: her father hammered her constantly
that she was “not good enough”; her mother rarely stood up for
Lisa, almost always deferring to her husband in all important deci-
sions; and Lisa perceived the family’s numerous relocations as
“kidnappings.”
The pattern of the neglected child, as described by psychologist
Hugh Missildine, mirrors the dilemmas of borderlines in later life:
If you suffered from neglect in childhood, it may cause you to
go from one person to another, hoping that someone will supply
whatever is missing. You may not be able to care much about
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94 I HATE YOUDON’T LEAVE ME
yourself, and think marriage will end this, and then nd yourself
in the alarming situation of being married but emotionally unat-
tached. . . . Moreover, the person who [has] neglect in his back-
ground is always restless and anxious because he cannot obtain
emotional satisfaction. . . . These restless, impulsive moves help
to create the illusion of living emotionally. . . . Such a person
may, for example, be engaged to be married to one person and
simultaneously be maintaining sexual relationships with two
or three others. Anyone who offers admiration and respect has
appeal to them—and because their need for affection is so great,
their ability to discriminate is severely impaired.
21
From what we understand of the roots of BPD (see chapter 3),
abuse, neglect, or prolonged separations early in childhood can
greatly disrupt the developing infant’s establishment of trust.
Self-esteem and autonomy are crippled. The abilities to cope with
separation and to form identity do not proceed normally. As they
become adults, abused children may recapitulate frustrating rela-
tionships with others. Pain and punishment may become associ-
ated with closeness—they come to believe that “love hurts.” As
the borderline matures, self-mutilation may become the proxy for
the abusive parent.
Children of Divorce: The Disappearing Father
Due primarily to divorce, more children than ever before are being
raised without the physical and/or emotional presence of their
father. Because most courts award children to the mother in cus-
tody cases, the large majority of single-parent homes are headed by
mothers. Even in cases of joint custody or liberal visitation rights,
the father, who is more likely to remarry sooner after divorce and
start a new family, often fades from the child’s upbringing.
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THE BORDERLINE SOCIETY 95
The recent trend in child raising, toward a more equal shar-
ing of parental responsibilities between mother and father, makes
divorce even more upsetting for the child. Children clearly bene t
from dual parenting, but they also lose more when the marriage
dissolves, especially if the breakup occurs during the formative
years when the child still has many crucial developmental stages
to hurdle.
Studies on the effects of divorce typically report profound upset,
neediness, regression, and acute separation anxiety related to fears
of abandonment in children of preschool age.
22
A signi cant num-
ber are found to be depressed
23
or antisocial in later stages of child-
hood.
24
Indeed, teens living in single-parent families are not only
more likely to commit suicide but also more likely to suffer from
psychological disorders, when compared to teens living in intact
families.
25
During separation and divorce, the child’s need for physical
intimacy increases. For example, it is typical for a child at the time
of separation to ask a parent to sleep with him. If the practice con-
tinues and sleeping in the same bed becomes the parent’s need as
well, the child’s own sense of autonomy and bodily integrity may
be threatened. This, combined with the loneliness and severe nar-
cissistic injury caused by the divorce, places some children at high
risk for developmental arrest or, if the need for affection and reas-
surance becomes desperate, for sexual abuse. A father separated
from the home may demand more time with the child in order to
relieve his own feelings of loneliness and deprivation. If the child
becomes a lightning rod for his father’s resentment and bitterness,
he may again be at higher risk for abuse.
In many situations of parental separation, the child becomes
the pawn in a destructive battle between his parents. David, a
divorced father who usually ignored his visitation privileges, sud-
denly demanded that his daughter stay with him whenever he was
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96 I HATE YOUDON’T LEAVE ME
angry at her mother. These visits were usually unpleasant for the
child as well as for her father and his new family, yet were used as
punishment for his ex-wife, who would feel guilty and powerless
at his demands. Bobby became embroiled in con icts between his
divorced parents when his mother periodically took his father back
to court to extract more child support monies. Bribes of material
gifts or threats to cut off support for school or home maintenance
are common weapons used between continuously skirmishing par-
ents; the bribes and threats are usually more harmful to the chil-
dren than they are to the parents.
Children may even be drawn into court battles and forced to
testify about their parents. In these situations neither the parents,
nor the courts, nor social welfare organizations can protect the
child, who is often left with a sense of overwhelming helplessness
(conicts continue despite his input), or of intoxicating power (his
testimony controls the battle between his parents). He may feel
enraged at his predicament and yet fearful that he could be aban-
doned by everyone. All of this becomes fertile ground for the devel-
opment of borderline pathology.
In addition to divorce, other powerful societal forces have con-
tributed to the “absent father syndrome.” The past half century has
witnessed the maturing of children of thousands of war veterans—
World War II, Korean War, Vietnam, Persian Gulf, Iraq—not to
mention many prison-camp and concentration-camp survivors.
Not only were many of these fathers absent during signi cant
portions of their children’s development, but many were found
to develop post-traumatic stress disorders and delayed mourning
(“impacted grief”) related to combat that also in uenced child
development.
26
By 1970, 40 percent of World War II and Korean
War POWs had met violent death by suicide, homicide, or auto
accident (mostly one-car single-occupant accidents).
27
The same
trend has continued with Iraq War vets. According to U.S. Army
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THE BORDERLINE SOCIETY 97
gures, ve soldiers per day tried to commit suicide in 2007, com-
pared to less than one per day before the war.
28
Children of holo-
caust survivors often have severe emotional difculties, rooted in
their parents’ massive psychic trauma.
29
The absent father syndrome can lead to pathological conse-
quences. Often in families torn by divorce or death, the mother
tries to compensate by becoming the ideal parent, arranging every
aspect of her child’s life; naturally, the child has limited opportu-
nity to develop his own identity. Without the buffering of another
parent, the mother-child link can be too close to allow for healthy
separating.
Though the mother often seeks to replace the missing father, in
many cases it is actually the child who tries to replace the absent
father. In the absence of father, the symbiotic intensity of the bond
with mother is greatly magnied. The child grows up with an ide-
alized view of the mother and fantasies of forever trying to please
her. And a parent’s dependence on the child may persist, interfer-
ing with growth and individuation, planting the seeds of BPD.
Permissive Child-Rearing Practices
Modern permissive child-rearing practices, involving the transfer
of traditional parental functions to outside agencies—the school,
mass media, industry—have signicantly altered the quality of
parent-child relationships. Parental “instinct” has been supplanted
by a reliance on books and child-rearing experts. Child rearing, in
many households, takes a backseat to the demands of dual careers.
“Quality time” becomes a guilt-induced euphemism for “not enough
time.”
Many parents overcompensate by lavishing attention on the
child’s practical and recreational needs, yet providing little real
warmth. Narcissistic parents perceive their children as extensions
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98 I HATE YOUDON’T LEAVE ME
of themselves or as objects/possessions, rather than as separate
human beings. As a result, the child suffocates in emotionally dis-
tant attention, leading to an exaggerated sense of his own impor-
tance, regressive defenses, and loss of a sense of self.
Geographical Mobility: Where Is Home?
We are moving more than ever before. Greater geographical mobil-
ity can bring rich educational bene ts and cultural exchange for a
child, but numerous relocations are often also accompanied by a
feeling of rootlessness. Some investigators have found that children
who move frequently and stay in one place for only short periods
of time often have confused responses, or no response at all, to the
simple question, “Where is your home?”
Because hypermobility is typically correlated with career-oriented
lifestyles and job demands, one or both parents in mobile families
tend to work long hours and so are less available to their children.
Having few enough constants in their environment to provide bal-
last for development, mobility adds another disruptive force—the
world turns into a menagerie of changing places and faces. Such
children may grow up bored and lonely, looking for constant stimu-
lation. Continually forced to adapt to new situations and people,
they may lose the stable sense of self encouraged by secure commu-
nity anchors. Though socially graceful, like Lisa they typically feel
they are gracefully faking it.
With increasing geographical mobility, the stability of the
neighborhood, community school systems, church and civic insti-
tutions, and friendships are weakened. Traditional af liations are
lost. About 44 percent of Americans profess af nity to a different
church from the one in which they were raised.
30
Generations are
becoming separated by long distances, and the extended family
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THE BORDERLINE SOCIETY 99
is lost for emotional support and child care. Children are raised
without knowing their grandparents, aunts, uncles, and cousins,
losing a strong connection to the past and a source of love and
warmth to nurture healthy emotional growth.
The Rise of the Faux Family
With society fragmenting, marriages dissolving, and families break-
ing up, it is no coincidence that the decade has given rise to the “faux
family,” or virtual community, to replace the real communities of the
past. This yearning for “tribe” afliation manifests in a variety of
ways: football fans identify themselves as “Raider Nation”; 30 mil-
lion people wait for hours each week to vote for their favorite Amer-
ican Idol, simply to be a part of a larger group with a “common”
purpose; and millions of young people join Facebook and MySpace
to be a member of a vast electronic social network. Fifty years ago in
his novel Cat’s Cradle, Kurt Vonnegut playfully (but prophetically)
called these “connections” a “granfalloon”—a group of people who
choose, or claim to have, a shared identity or purpose, but whose
mutual association is actually meaningless. The author offered two
examples, Daughters of the American Revolution and the General
Electric Company; if Vonnegut wrote the novel today, the examples
could just as easily be Facebook or Twitter.
Since 2003, social networking sites have rocketed from a niche
activity into a phenomenon that engages tens of millions of Internet
users. More than half (55 percent) of all online American youths
ages twelve to seventeen use online social networking sites, such as
Facebook and MySpace.
31
The initial evidence suggests that teens
use these sites primarily to communicate, to stay in touch and
make plans with friends, and to make new friends. However, the
motivation might not be this “pure.” For example, a 2007 study by
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100 I HATE YOUDON’T LEAVE ME
Microsoft (which should know something about this topic) found
that “ego” is the largest driver of participation: people contribute
to “increase their social, intellectual, and cultural capital.”
32
Twitter, the most recent electronic “rage” to sweep the (faux)
nation, is unabashed in its narcissistic bent. A kind of instant text-
messaging service, “tweeting” is intended to announce (in 140 char-
acters or less) “what I’m doing” to a group of “followers.” There is
little pretense that the communication is intended to be a two-way
street.
Few would dispute the growing narcissism in American culture.
Initially documented by Tom Wolfe’s landmark article “The Me
Decade” in 1976 and Christopher Lasch’s Culture of Narcissism
in 1978, the narcissistic impulse has been evidenced since then by
a wide assortment of cultural trends: reality TV turning its fod-
der participants into instant famous-for-being-famous celebrities;
plastic surgery exploding into a growth industry; indulgent par-
enting, celebrity worship, lust for material wealth, and now social
networking creating one’s own group of faux friends. As Jean M.
Twenge and W. Keith Campbell note in The Narcissism Epidemic
(2009): “The Internet brought useful technology but also the pos-
sibility of instant fame and a ‘Look at me!’ mentality. . . . People
strive to create a ‘personal brand’ (also called ‘self-branding’),
packaging themselves like a product to be sold.”
33
As a relatively recent phenomenon, it is too soon to know
whether social media is a passing fad or a transformative tech-
nological innovation, though it can be safely said that researchers
and clinicians should keep a watchful eye on its overall psychologi-
cal effect, not to mention the inherent potential physical danger,
especially for young people.
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Chapter Five
Communicating with
the Borderline
Alright . . . what do you want me to say? Do you want me to say it’s
funny, so you can contradict me and say it’s sad? Or do you want
me to say it’s sad so you can turn around and say no, it’s funny. You
can play that damn little game any way you want to, you know!
—From Who’s Afraid of Virginia Woolf?, by Edward Albee
The borderline shifts her personality like a rotating kaleido-
scope, rearranging the fragmented glass of her being into different
formations—each collage different, yet each, her. Like a chame-
leon, the borderline transforms herself into any shape that she
imagines will please the viewer.
Dealing with borderline behavior can be frustrating for everyone
in regular contact with the borderline personality because, as we have
seen, their explosions of anger, rapid mood swings, suspiciousness,
impulsive actions, unpredictable outbursts, self-destructive actions,
and inconsistent communications are understandably upsetting to all
around them.
In this chapter we will describe a consistent, structured method
of communicating with borderlines—the SET-UP system—that
can be easily understood and adopted by family, friends, and ther-
apists for use on a daily basis, and which may help in convincing a
borderline to consider treatment (see chapter 7).
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102 I HATE YOUDON’T LEAVE ME
The SET-UP system evolved as a structured framework of com-
munication with the borderline in crisis. During such times,
communication with the borderline is hindered by his impen-
etrable, chaotic internal force eld, characterized by three major
feeling states: terrifying aloneness, feeling misunderstood, and
overwhelming helplessness.
As a result, concerned individuals are often unable to reason
calmly with the borderline and instead are forced to confront out-
bursts of rage, impulsive destructiveness, self-harming threats or ges-
tures, and unreasonable demands for caretaking. SET-UP responses
can serve to address the underlying fears, dilute the borderline con-
agration, and prevent a “meltdown” into greater con ict.
Although SET-UP was developed for the borderline in crisis, it
can also be useful for others who require concise, consistent com-
munication, even when not in crisis.
SET Communication
“SET”—Support, Empathy, Truth—is a three-part system of com-
munication (see Figure 5-1). During confrontations of destructive
behavior, important decision-making sessions, or other crises,
interactions with the borderline should invoke all three elements.
UP stands for Understanding and Perseverance—the goals that all
parties try to achieve.
The S stage of this system, Support, invokes a personal, “I”
statement of concern. “I am sincerely worried about how you are
feeling” is an example of a Support statement. The emphasis is on
the speaker’s own feelings and is essentially a personal pledge to
try to be of help.
With the Empathy segment, one attempts to acknowledge the
borderline’s chaotic feelings with a “You” statement: “How awful
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COMMUNICATING WITH THE BORDERLINE 103
S
E
S = Self-Statement of Support
E = Empathy
T
T = Truth
FIGURE 51
you must be feeling.” It is important not to confuse empathy with
sympathy (“I feel so sorry for you . . .”), which may elicit rage over
perceived condescension. Also, Empathy should be expressed in a
neutral way with minimal personal reference to the speaker’s own
feelings. The emphasis here is on the borderline’s painful experi-
ence, not the speaker’s. A statement like “I know just how bad you
are feeling” invites a mocking rejoinder that, indeed, you do not
know, and only aggravates con ict.
The T statement, representing Truth or reality, emphasizes that
the borderline is ultimately accountable for his life and that others’
attempts to help cannot preempt this primary responsibility. While
Support and Empathy are subjective statements conrming how the
principals feel, Truth statements acknowledge that a problem exists
and address the practical, objective issue of what can be done to solve
it. “Well, what are you going to do about it?” is one essential Truth
response. Other characteristic Truth expressions refer to actions that
the speaker feels compelled to take in response to the borderline’s
behaviors, which should be expressed in a matter-of-fact, neutral
fashion (“Here’s what happened . . .These are the consequences . . .
This is what I can do . . . What are you going to do?”). But they
should be stated in a way that avoids blaming and sadistic punishing
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104 I HATE YOUDON’T LEAVE ME
(“This is a ne mess you’ve gotten us into!” “You made your bed;
now lie in it!”). The Truth part of the SET system is the most impor-
tant and the most difcult for the borderline to accept since so much
of his world excludes or rejects realistic consequences.
Communication with the borderline should attempt to include
all three messages. However, even if all three parts are stated, the
borderline may not integrate all of them. Predictable responses result
when one of these levels is either not clearly stated or is not “heard.”
For example, when the Support stage of this system is bypassed
(see Figure 5-2), the borderline characteristically accuses the other
of not caring or not wanting to be involved with him. The border-
line then tends to tune out further exchanges on the basis that the
other person does not care, or may even wish him harm. The bor-
derline’s accusation that “You don’t care!” usually suggests that
the Support statement is not being integrated.
X
“You don’t care . . . ”
E T
FIGURE 52
The inability to communicate the Empathy part of the mes-
sage (see Figure 5-3) leads to feelings that the other person does
not understand what the borderline is going through. (“You don’t
know how I feel!”) Here, the borderline will justify his rejection of
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COMMUNICATING WITH THE BORDERLINE 105
the communication by saying he is misunderstood. Since the other
person cannot appreciate the pain, his responses can be deval-
ued. When either the Support or the Empathy overtures are not
accepted by the borderline, further communications are not heard.
S
“You don’t know
how I feel . . . ”
X T
FIGURE 53
When the Truth element is not clearly expressed (see Figure 5-4),
a more dangerous situation emerges. The borderline interprets oth-
ers’ acquiescence in ways he nds most comfortable for his needs,
usually as conrmation that others really can be responsible for him,
or that his own perceptions are universally shared and supported.
The borderline’s fragile merger with these other people eventually
disintegrates when the relationship is unable to sustain the weight
of his unrealistic expectations. Without clearly stated Truth and
confrontation, the borderline continues to be overly entangled with
others. His needs grati ed, the borderline will insist that all is well
or, at least, that things will get better. Indeed, the evidence for this
enmeshment is often a striking, temporary absence of con ict: The
borderline will exhibit less hostility and anger. However, when his
unrealistic expectations are eventually frustrated, the relationship
collapses in a ery maelstrom of anger and disappointment.
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106 I HATE YOUDON’T LEAVE ME
S
E
X
Enmeshment
FIGURE 54
Borderline Dilemmas
The SET-UP principles can be used in a variety of settings in
attempts to defuse unstable situations. Following are some typical
borderline predicaments in which the SET strategy may be used.
Damned If You Do, and Damned If You Don’t
Borderline confusion often results in contradictory messages to oth-
ers. Frequently, the borderline will communicate one position with
words, but express a contradictory message with behavior. Although
the borderline may not be consciously aware of this dilemma, he fre-
quently places a friend or relation in a no-win situation in which the
other person is condemned no matter which way he goes.
CASE 1: GLORIA AND ALEX. Gloria tells her husband Alex that she is
forlorn and depressed. She says she plans to kill herself but forbids
him from seeking help for her.
In this situation, Alex is confronted with two contradictory
messages: (1) Gloria’s overt message, which essentially states, “If
you care about me, you will respect my wishes and not challenge
my autonomy to control my own destiny and even die, if I choose”;
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COMMUNICATING WITH THE BORDERLINE 107
and (2) the opposite message, conveyed in the very act of announc-
ing her intentions, which says, “For God’s sake, if you care about
me, help me, and don’t let me die.”
If Alex ignores Gloria’s statements, she will accuse him of being
cold and uncaring. If he attempts to list reasons why she should not
kill herself, she will frustrate him with relentless counter-arguments
and will ultimately condemn him for not truly understanding her
pain. If he calls the police or her doctor, he will be rejecting her
requests and proving that she cannot trust him.
Because Gloria doesn’t feel strong enough to take responsibil-
ity for her own life, she looks to Alex to take on this burden. She
feels overwhelmed and helpless in the wake of her depression. By
drawing Alex into this drama, she is making him a character in
her own scripted play, with an uncertain ending to be resolved not
by herself, but by Alex. She faces her ambivalence about suicide by
turning over to him the responsibility for her fate.
Further, Gloria splits off the negative portions of her available
choices and projects them onto Alex, preserving for herself the
positive side of the ambivalence. No matter how Alex responds, he
will be criticized. If he does not actively intercede, he is uncaring
and heartless and she is “tragically misunderstood.” If he tries to
stop her suicide attempts, he is controlling and insensitive, while
she is bereft of her self-respect.
Either way, Gloria envisions herself a helpless and self-righteous
martyr—a victim who has been deprived by Alex of achieving her
full potential. As for Alex, he is damned if he does and damned if
he doesn’t!
SET-UP principles may be helpful in confronting a dif cult sit-
uation like this. Ideally, Alex’s responses should embrace all three
sides of the SET triangle. Alex’s S statement should be a declara-
tion of his commitment to Gloria and his wish to help her: “I am
very concerned about how bad you are feeling and want to help
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108 I HATE YOUDON’T LEAVE ME
because I love you.” If the couple can identify the speci c areas
of concern that are adding to her anguish, he could suggest solu-
tions and proclaim his willingness to help: “I think some of this
might be related to the problems you’ve been having with your
boss. Let’s discuss some of the alternatives. Maybe you could ask
for a transfer. Or if the job is causing you this much dif culty, I
want you to know that’s okay with me if you want to quit and look
for another job.”
The E statement should attempt to convey Alex’s awareness of
Gloria’s current pain and his understanding of how such extreme
circumstances might lead her to contemplate ending her life: “The
pressure you’ve been under these past several months must be get-
ting unbearable. All of this agony must be bringing you to the
edge, to a point where you feel like you just can’t go on anymore.”
The most important part of Alex’s T statement should iden-
tify his untenable “damned-if-he-does and damned-if-he-doesn’t”
dilemma. He should also attempt to clarify Gloria’s ambivalence
about dying by acknowledging that in addition to that part of her
that wants to end her life, another part of her wishes to be saved and
helped. Alex’s T responses might be something like: “I recognize
how bad you are feeling and your wish to die. I know you said that
if I cared at all for you, I should just leave you alone. But if I cared,
how could I possibly sit back and watch you destroy yourself? Your
alerting me to your suicidal plans tells me that, as much as you may
wish to die, there is at least some part of you that doesn’t want to
die. And it is to that part that I feel I must respond. I want you to
come with me to see a doctor to help us with these problems.”
Depending on the immediacy of the circumstances, Alex should
insist that Gloria be psychiatrically evaluated soon or, if she is in
imminent danger, he should take her to an emergency room or
seek help from police or paramedics.
At this juncture Gloria’s fury may be exacerbated as she blames
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COMMUNICATING WITH THE BORDERLINE 109
Alex for forcing her into the hospital. But Truth statements should
remind Gloria that she is there not so much because of what Alex
did, but because of what Gloria did—threatening suicide. The bor-
derline may frequently need to be reminded that others’ reactions
to him are based primarily on what he does, and that he must take
responsibility for the consequences, rather than blaming others for
realistic responses to his behavior.
When the immediate danger has passed, subsequent T statements
should refer to Gloria’s unproductive patterns of handling stress and
the need to develop more effective ways of dealing with her life.
Truth considerations should also include how Gloria’s and Alex’s
behaviors affect each other and their marriage. Over time they may
be able to work out a system of responding to each other, either on
their own or within therapy, that will fulll the needs of both.
This kind of problem is especially common within families
of borderlines who display prominent self-destructive behaviors.
Delinquent or suicidal adolescents, alcoholics, and anorexics may
present similar no-win dilemmas to their families. They actively
resist help, while behaving in obviously self-destructive ways. Usu-
ally, direct confrontation that precipitates a crisis is the only way
to help. Some groups, such as Alcoholics Anonymous, recommend
standardized confrontational situations in which family, friends,
or coworkers, often together with a counselor, confront the patient
with his addictive behavior and demand treatment.
“Tough Love” groups believe that true caring forces the indi-
vidual to face the consequences of his behaviors rather than protect
him from them. “Tough Love” groups for parents of teenagers, for
example, may insist that an adolescent drug abuser either be hospi-
talized or barred from the home. This type of approach emphasizes
the Truth element of the SET-UP triangle but may ignore the Support
and Empathy segments. Therefore, these systems may be only par-
tially successful for the borderline, who may go through the motions
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110 I HATE YOUDON’T LEAVE ME
of change that Truth confrontations force on him; underneath, how-
ever, the lack of nurturing and trust provided by Support and Empa-
thy hinder his motivation for dedicated and lasting change.
Feeling Bad About Feeling Bad
Borderlines typically respond to depression, anxiety, frustration,
or anger with more layers of these same feelings. Because of the
borderline’s perfectionism and tendency to perceive things in black-
and-white extremes, he attempts to obliterate unpleasant feelings
rather than understand or cope with them. When he nds that
he cannot simply erase these bad feelings, he becomes even more
frustrated or guilty. Since feeling bad is unacceptable, he feels bad
about feeling bad. When this makes him feel worse, he becomes
caught in a seemingly bottomless downward spiral.
One of the goals for the borderline’s therapists and other close
relations is to crack through these successive layers to locate the
original feeling and help the borderline accept it as part of himself.
The borderline must learn to allow himself the luxury of “bad”
feelings without rebuke, guilt, or denial.
CASE 2: NEIL AND FRIENDS. Neil, a fty-three-year-old bank of cer,
has had episodes of depression for more than half his life. Neil’s
parents died when he was young, and he was reared mostly by his
much older, unmarried sister, who was cold and hypercritical. She
was a religious zealot who insisted he attend church services daily,
and frequently accused him of sinful transgressions.
Neil grew up to become a passive man, dominated by his wife.
He was reared to believe that anger was unacceptable and denied
ever feeling angry at others. He was hardworking and respected at
his job, but received little affection from his wife. She rejected his
sexual advances, which frustrated and depressed him. Neil would
initially get angry at his wife for her rejections, then feel guilty and
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COMMUNICATING WITH THE BORDERLINE 111
get angry at himself for being angry, and then lapse into depression.
This process permeated other areas of Neil’s life. Whenever he expe-
rienced negative feelings, he would pressure himself to end them.
Since he could not control his inner feelings, he became increasingly
disappointed and frustrated with himself. His depression worsened.
Neil’s friends tried to comfort him. They told him they were
behind him and were available whenever he wanted to talk. They
empathized with his discomfort at work and his problems in deal-
ing with his wife. They pointed out that “he was feeling bad over
feeling bad,” and that he should straighten up. This advice, how-
ever, didn’t help; in fact, Neil felt worse because he now felt he was
letting his friends down on top of everything else. The harder he
tried to stop his negative feelings, the more he felt like a failure,
and the more depressed he became.
SET-UP statements could help Neil confront this dilemma.
Neil received much Support and Empathy from his friends, but
their Truth messages were not helpful. Rather than trying to erase
his unpleasant emotions (an all-or-none proposition), Neil must
understand the necessity of accepting them as real and appropri-
ate, within a nonjudgmental context. Instead of adding layers of
more self-condemnation, which allows him to continue to wallow
in the muck of “woe is me,” he must instead confront the criticism
and work to change.
Further Truth statements would acknowledge the reasons for
Neil’s passive behavior and the behaviors of his wife and others in
his life. He must recognize that, to some degree, he places himself
in a position of being abused by others. Although he can work
to change this situation in the future, he must now deal with the
way things are currently. This means recognizing his anger, that
he has reasons to be angry, and that he has no choice but to accept
his anger, for he cannot make it disappear, at least not right away.
Though he may regret the presence of unacceptable feelings, he
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112 I HATE YOUDON’T LEAVE ME
is powerless to change them (a dictum similar to those used in
Alcoholics Anonymous). Accepting these uncomfortable feelings
means accepting himself as an imperfect human being and relin-
quishing the illusion that he can control uncontrollable factors. If
Neil can accept his anger, or his sadness, or any unpleasant feeling,
the “feeling bad about feeling bad” phenomenon will be short-
circuited. He can move on to change other aspects of his life.
Much of the success in Neil’s life has resulted from trying
harder: Studying harder usually results in better grades. Practic-
ing harder usually results in a better performance. But some situa-
tions in life require the opposite. The more you grit your teeth and
clench your sts and try to go to sleep, the more likely you will be
awake all night. The harder you try to make yourself relax, the
more tense you may become.
The borderline trapped in this dilemma will often break free
when he least expects it—when he relaxes, becomes less obsessive
and self-demanding, and learns to accept himself. It is no coinci-
dence that the borderline who seeks a healthy love relationship
more often nds it when he is least desperate for one and more
engaged in self-fullling activities. For it is at this point that he is
more attractive to others and less pressured to grasp at immediate
and unrealistic solutions to loneliness.
The Perennial Victim
The borderline frequently involves himself in predicaments in which
he becomes a victim. Neil, for example, perceives himself as a help-
less character upon whom others act. The borderline frequently is
unaware that his behavior is provocative or dangerous, or that it
may in some way invite persecution. The woman who continually
chooses men who abuse her is typically unaware of the patterns
she is repeating. The borderline’s split view of himself includes a
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COMMUNICATING WITH THE BORDERLINE 113
special, entitled part and an angry, unworthy part that masochis-
tically deserves punishment, although he may not be consciously
aware of one side or the other. In fact, a pattern of this type of
“invited” victimization is often a solid indication of BPD pathology.
Although being a victim is most unpleasant, it can also be a very
appealing role. A helpless waif, buffeted by the turbulent seas of an
unfair world, is very attractive to some people. A match between
the helpless waif and one who feels a strong need to rescue and take
care of others satises needs for both parties. The borderline nds a
“kind stranger” who promises complete and total protection. And
the partner ful lls his own desire to feel strong, protective, impor-
tant, and needed—to be the one to “take her away from all this.”
CASE 3: ANNETTE. Born to a poor black family, Annette lost her
father at a very young age when he abandoned the household.
A succession of other men briey occupied the “father” chair in
the home. Eventually her mother remarried, but her second hus-
band was also a drinker and carouser. When Annette was about
eight, her stepfather began sexually abusing her and her sister.
Annette was afraid to tell her mother, who gloried in the family’s
nally achieving some nancial security. So Annette allowed it to
continue—“for her mother’s sake.”
At seventeen, Annette became pregnant and married the baby’s
father. She managed to graduate from high school, where her
grades were generally good, but other aspects of her life were in
turmoil: her husband drank and ran with other women. After a
while, he began beating her. She continued to bear more of his
children, complaining and enduring—“for the children’s sake.”
After six years and three children, Annette’s husband left her.
His departure prompted a kind of anxious relief—the wild ride was
nally over, but concerns over what to do next loomed ominously.
Annette and the kids tried to make things work, but she felt con-
stantly overwhelmed. Then she met John, who was about twenty- ve
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114 I HATE YOUDON’T LEAVE ME
years older (he refused to tell her his exact age) and seemed to have
a genuine desire to take care of her. He became the good father
Annette never had. He encouraged and protected her. He advised
her on how to dress and how to talk. After a while, Annette became
more self-condent, got a good job, and began enjoying her life.
A few months later, John moved in—sort of. He lived with her on
weekends but slept away during the week because of work assign-
ments that made it “more convenient to sleep at the of ce.”
Deep inside, Annette knew John was married, but she never
asked. When John became less dependable, stayed away more, and
generally became more detached, she held in her anger. On the job,
however, this anger surfaced, and she was passed over for many
promotions. Her supervisors said that she lacked the academic
qualications of others and that she was abrasive, but Annette
wouldn’t accept those explanations.
Incensed, she attributed the rejections to racial discrimination.
She became more and more depressed and eventually entered the
hospital.
In the hospital, Annette’s racial sensitivities exploded. Most of
the doctors were white, as were most of the nurses and most of the
other patients. The hospital decor was “white” and the meals were
“white.” All of the anger built up over the years was now focused on
society’s discrimination against blacks. By concentrating exclusively
on this global issue, Annette avoided her own personal demons.
Her most challenging target was Harry, a music therapist on
staff at the hospital. Annette felt that Harry (who was white)
insisted on playing only “white” music, and that his looks and
whole demeanor embodied “whiteness.” Annette vented her fury
on this therapist, and she would stalk away angrily from the music
therapy sessions.
Although Harry was frightened by the outbursts, he sought out
Annette. His Support statement reected his personal concern about
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COMMUNICATING WITH THE BORDERLINE 115
Annette’s progress in the hospital program. Harry expressed his
Empathy for Annette by voicing his recognition of how frustrating it
feels to be discriminated against, and cited his own experiences as one
of the only Jews in his educational program. Then Harry attempted
to confront the Truth, or reality, issues in Annette’s life, pointing
out that railing against racial discrimination was useless without a
commitment to work toward changing it. Annette’s need to remain
a victim, Harry said, shielded her from assuming any responsibility
for what happened in her life. She could feel justied in cursing the
fates rather than bravely investigating her own role in continuing to
be used by others. By wrapping herself in a veil of righteous anger,
Annette was avoiding any kind of frightening self-examination or
confrontation that might induce change, and thereby was perpetuat-
ing her impotency and helplessness. This left her incapable of making
changes “for her sake.”
At the next music therapy session, Annette did not stalk out of
the room. Instead, she confronted Harry and the other patients.
She suggested different songs to play. At the following meeting the
group agreed to play some civil-rights protest songs of Annette’s
choosing.
Harry’s response exemplied SET-UP principles and would have
been useful for Annette’s boss, her friends—anyone who faced her
angry outbursts on a regular basis.
SET-UP communication can free a borderline or anyone who is
locked into a victim role by pointing out the advantages of being
a victim (being cared for, appearing blameless for bad results, dis-
avowing responsibility) and the disadvantages (abdicating auton-
omy, maintaining obsequious dependency, remaining xated and
immobile amid life’s dilemmas). The borderline “victim” must,
however, hear all three parts of the message, otherwise the impact
of the message will be lost. If “The Truth will set you free,” then
Support and Empathy must accompany it to ensure it will be heard.
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116 I HATE YOUDON’T LEAVE ME
Quest for Meaning
Much of the borderline’s dramatic behavior is related to his inter-
minable search for something to ll the emptiness that continually
haunts him. Relationships and drugs are two of the mechanisms
the borderline uses to combat the loneliness and to capture a sense
of existing in a world that feels real.
CASE 4: RICH. “I g uess I just love too much!” sa id Rich i n descr ibing
his problems with his girlfriend. He was a thirty-year-old divorced
man who had a succession of disastrous affairs with women. He
would cling obsessively to these women, showering them with gifts
and attention. Through them he felt whole, alive, and ful lled. But he
demanded from them—and from other friends—total obedience.
In this way he felt in control, not only of them but more important
of his own existence.
He became distraught when these women acted independently.
He cajoled, insisted, and threatened. To stave off the omnipresent
sense of emptiness, he attempted to control others; if they refused
to comply with his wishes, Rich became seriously depressed and
out of control. He would turn to alcohol or drugs to recapture his
sense of being or authenticity. Sometimes he would pick ghts or
cut himself when he feared he was losing touch with his sensory
or emotional feelings. When the anger and pain no longer brought
changes, he would take up with another woman who perceived
him as “misunderstood” and merely needing “the love of a good
woman.” Then the process would start all over again.
Rich lacked insight into his dilemma, insisting that it was always
“the bitch’s fault.” He dismissed his friends as not caring or not
understanding—they were not able to convey Support or Empathy.
The women he became involved with were initially sympathetic,
but lacked the Truth component. Rich needed to be confronted
with all three aspects.
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COMMUNICATING WITH THE BORDERLINE 117
In this situation, the S message would convey caring about Rich.
The E part would accept without challenge Rich’s feeling of “loving
too much” but would also help him understand his sense of empti-
ness and his need to ll it.
The Truth message would attempt to point out the patterns in
Rich’s life that seem to repeat endlessly. Truth should also help Rich
see that he uses women as he does drugs and self-mutilation—as
objects or maneuvers to relieve numbness and feel whole. As long
as Rich continues to search outside himself for inner contentment,
he will remain frustrated and disappointed, because he cannot con-
trol outside forces and especially others, as he can control himself.
For instance, despite his most frenzied efforts to regulate her, a new
girlfriend will retain some independence outside the realm of Rich’s
control. Or, he could lose a new job due to economic factors that may
eliminate the position. But Rich can control his own creative powers,
intellectual curiosity, and so on. Independent personal interests—
books, hobbies, arts, sports, exercise—can serve as reliable and
enduring sources of satisfaction, which cannot easily be taken away.
Search for Constancy
Adjusting to a world that is continually inconsistent and untrust-
worthy is a major problem for the borderline. The borderline’s
universe lacks pattern and predictability. Friends, jobs, and skills
can never be relied upon. The borderline must keep testing and
retesting all of these aspects of his life; he is in constant fear that
a trusted person or situation will change into the total opposite—
absolute betrayal. A hero becomes a devil; the perfect job becomes
the bane of his existence. The borderline cannot conceive that indi-
vidual or situational object constancy can endure. He has no laurels
on which to rest. Every day he must begin anew trying desperately
to prove to himself that the world can be trusted. Just because the
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118 I HATE YOUDON’T LEAVE ME
sun has risen in the East for thousands of years does not mean it
will happen today. He must see it for himself each and every day.
CASE 5: PAT AND JAKE. Pat was an attractive twenty-nine-year-old
woman in the process of divorcing her second husband. As with
her rst husband, she accused him of being an alcoholic and of
abusing her. Her lawyer, Jake, saw her as an unfortunate victim in
need of protection. He called her frequently to be sure she was all
right. They began to have lunch together. As the case proceeded,
they became lovers. Jake moved out of his house and away from
his wife and two sons. Though not yet divorced, Pat moved in with
him.
At rst, Pat admired Jake’s intelligence and expertise. Where
she felt weak and defenseless, he seemed “big and strong.” But
over time she became increasingly demanding. As long as Jake was
protective, Pat cooed. But when he began to make demands, she
became hostile. She resented his going to work and particularly
his involvement in other divorce cases. She resisted his visits to his
children and accused him of choosing them over her. She would
initiate brutal arguments that often culminated in her rushing out
of the house to spend the night with a male “platonic friend.”
Pat lacked object constancy (see chapter 2 and Appendix B).
Friendships and love relationships had to be constantly tested
because she never felt secure with any human contact. Her need for
reassurance was insatiable. She had been through countless other
relationships in which she rst appeared ingenuous and in need of
caretaking and then tested them with outrageous demands. The
relationships all ended with precisely the abandonment she feared,
then she would repeat the process in her next romance.
At rst, when Pat perceived Jake as supportive and reassur-
ing, she idealized their relationship. But when he exhibited signs of
functioning separately, she became enraged, cursing and denigrat-
ing him. When he was at the ofce, she would call him incessantly
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COMMUNICATING WITH THE BORDERLINE 119
because, as she said, she was “forgetting him.” To her friends, Jake
sounded like two completely different people—for Pat, he was.
SET confrontations of object inconstancy require recognition
of this borderline dilemma. Support statements must convey that
caring is constant, unconditional. Unfortunately, the borderline
has difculty grasping that she does not need to earn acceptance
continuously. She is in constant fear that Support could be with-
drawn if at any point she displeases. Thus, attempts at reassurance
are never-ending and never enough.
The Empathy message should conrm an understanding that
Pat has not yet learned to trust Jake’s continual attempts at com-
fort. Jake has to communicate his awareness of the horri c anxi-
eties Pat is experiencing and how frightening it is for her to be alone.
Truth declarations must include attempts to reconcile the split
parts. Jake has to explain that he cares for Pat all the time, even
when he is frustrated by her. He must also declare his intention
not to allow himself to be abused. Capitulation to Pat’s demands
will only result in more demands. Trying to please and satisfy Pat
is an impossible task, for it is never nished—new insecurities will
always arise. Truth will probably mandate ongoing therapy for
both of them, if their relationship is to continue.
The Rage of Innocence
Borderline rage is often terrifying in its unpredictability and inten-
sity. It may be sparked by relatively insignicant events and explode
without warning. It may be directed at previously valued people. The
threat of violence frequently accompanies this anger. All of these
features make borderline rage much different from typical anger.
In an instant, Pat could transform from a docile, dependent,
childlike woman into a demanding, screaming harpy. On one occa-
sion she suggested that she and Jake have a quiet lunch together.
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120 I HATE YOUDON’T LEAVE ME
But when Jake told her he had to go to the of ce, she suddenly
began screaming at him, inches from his face, accusing him of
ignoring her needs. She viciously attacked his manhood, his fail-
ures as a husband and father, and his profession. She threatened
to report him to the bar association for misconduct. When Jake’s
attempts to placate her failed, he would silently leave the scene,
which infuriated Pat even more. But when he returned, both would
act as if nothing had ever happened.
SET-UP principles must rst of all address safety issues. Vola-
tility must be contained. In the scenario above, Jake’s Support and
Empathy messages should come rst, though Pat will probably
reject them as insincere. In such cases it is imprudent for Jake to
continue to argue that he cares and understands that she is upset.
He must move immediately to Truth statements, which must rst
mandate that neither of them will physically harm the other. He
must rmly tell her to back off, to allow some physical distance.
He can inform her of his wish to communicate calmly with her. If
she will not allow this, he can state his intention of leaving until the
situation quiets down, at which point they can resume discussions.
He must try to avoid physical conict, despite Pat’s provocations.
Although unconsciously Pat may actually want Jake to physically
overpower her, this need is based on unhealthy experiences from
her past, and will likely later be used to criticize him more.
Truth statements made during angry confrontations are often bet-
ter directed toward the underlying dynamics than toward the speci cs
of the clash. Further debate about whether taking Pat to lunch is more
important than going to the ofce will probably be unproductive.
However, Jake might address Pat’s apparent need to ght and her pos-
sible wish to be overpowered and hurt. He might also confront Pat’s
behavior as a need to be rejected. Is she so fearful of anticipating rejec-
tion that she is precipitating it in order to “hurry up and get it over
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COMMUNICATING WITH THE BORDERLINE 121
with”? The primary Truth message is that this behavior is driving
Jake away. He may ask if this is really what Pat wants.
The Need for Consistency
All Truth statements must, indeed, be true. For the borderline,
already living in a world of inconsistencies, it is much worse to
make idle threats about the unenforced consequences of an action
than to passively allow inappropriate behaviors to continue. In
Fatal Attraction, for example, Alex Forrest, the main female char-
acter in the popular 1987 lm (played by Glenn Close), exhibited
several “textbook” borderline traits in the extreme. Entering into
an affair with Dan Gallagher (Michael Douglas), a well-ensconced
married man, she refuses to let go, even after it is obvious Dan will
never leave his wife. By the end of the movie Dan, his family, and
Alex are destroyed or close to it. Alex was used to resisting rejec-
tion by manipulating others. For Dan to say he was going to end
the relationship without unequivocally doing so was destructive.
Of course, he didn’t know that following the termination of an
intense relationship, the borderline is unable to “just be friends”—
an “in-between” relationship that the borderline nds intolerable.
Because the borderline has such difculty with equivocation,
intentions must be backed up with clear, predictable actions. A par-
ent who threatens his adolescent with revocation of privileges for cer-
tain behaviors and then does not carry out his promises exacerbates
the problem. A therapist who purports to set limits for therapy—
establishing fees, limiting phone calls, etc.—but then does not follow
through invites increased borderline testing.
Borderlines are often reared in situations in which threats and
dramatic actions are the only ways to achieve what is sought. Just as
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122 I HATE YOUDON’T LEAVE ME
the borderline perceives acceptance as conditional, so rejection can
also be seen this way. The borderline feels that if only he is attractive
enough, or smart enough, or rich enough, or demanding enough, he
will ultimately get what he wants. The more outrageous behavior
is rewarded, the more the borderline will employ such maneuvers.
Although the SET-UP principles were developed for working
with borderline patients, they can be useful for dealing with others.
When communication is stalled, SET-UP can help focus on mes-
sages that are not being successfully transmitted. If an individual
feels that he is not supported or respected, or that he is misunder-
stood, or if he refuses to address realistic problems, speci c SET
steps can be taken to reinforce these agging areas. In today’s com-
plex world, a clear set of communication principles that includes
both love and reason are necessary to overcome the tribulations
of borderline chaos. Productive communication requires Under-
standing and Perseverence. Understanding the underlying dynam-
ics of the communication and the needs of the partner reinforce
SET principles. Perseverance is necessary to effect change. For
many borderlines, having a consistent, un appable gure in their
lives (neighbor, friend, therapist) may be one of the most important
requirements for healing. Such a gure may contribute little except
for his consistency and acceptance (in the face of frequent provoca-
tions), yet furnish the borderline with a model of constancy in the
borderline’s otherwise chaotic world.
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Chapter Six
Coping with the Borderline
But he’s a human being, and a terrible thing is happening to him.
So attention must be paid. He is not to be allowed to fall into his
grave like an old dog. Attention must be nally paid to such a
person.
—From Death of a Salesman, by Arthur Miller
No one knew quite what to do with Ray. He had been in and out of
hospitals and had seen many doctors over the years, but he could
never remain long in treatment. Nor could he stay with a job. His
wife, Denise, worked in a dentist’s ofce and spent most of her
leisure time with her friends, generally ignoring Ray’s complaints
of chest pains, headaches, backaches, and depression.
Ray was the only child of wealthy, protective parents. When
he was nine, his father’s brother committed suicide. Although he
never knew his uncle very well, he understood that his parents were
greatly affected by the suicide. After this event, his parents became
even more protective and would insist he stay home from school
whenever he felt ill. At the age of twelve, Ray announced he was
depressed and began seeing what evolved into a parade of therapists.
An indifferent student, he went on to college where he met
Denise. She was the only woman who had ever shown any interest
in him, and after a short courtship they were married. Both quit
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124 I HATE YOUDON’T LEAVE ME
college and dutifully went to work, but relied on Ray’s parents to
subsidize their household and Ray’s continuing therapy.
The couple moved frequently; whenever Denise got bored with a
job or a location, they would move to a different part of the country.
She would quickly acquire a new job and new friends, but Ray had
great difculty and would remain out of work for many months.
As they both began drinking more, their ghting intensi ed.
When they bickered, Ray would sometimes leave and return to
live with his parents, where he would stay until the family began
to quarrel, then he would come home to Denise.
Frequently Ray’s wife and parents would tell him how fed up they
were with his moodiness and multiple medical complaints, but then
he’d threaten to kill himself and his parents would become panic-
stricken. They insisted he see new doctors and ew him around the
country to consult with various experts. They arranged hospitaliza-
tions in several prestigious institutions, but after a short time Ray
always signed himself out against medical advice, and his parents
would send him plane fare home. They continuously vowed to with-
hold further nancial support but never stuck to their word.
Friends and jobs became an indistinguishable blur of unsat-
isfying encounters. Whenever a new acquaintance or occupation
disappointed in any way, Ray quit. His parents wrung their hands;
Denise basically ignored him. Ray continued spinning out of con-
trol with no one to restrain him, including himself.
Recognizing BPD in Friends and Relations
On the surface a borderline personality can be very difcult to iden-
tify, despite the underlying volcanic turbulence. Unlike many people
aficted with other mental disorders—such as schizophrenia, bipolar
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COPING WITH THE BORDERLINE 125
(manic-depressive) disease, alcoholism, or eating disorders—the
borderline can usually function extremely well in work and social
situations without appearing overtly pathological. Indeed, some of
the hallmarks of borderline behavior are the sudden, unpredictable
eruptions of anger, extreme suspiciousness, or suicidal depression
from someone who has appeared so “normal.”
The borderline’s sudden outbursts are usually very frighten-
ing and mystifying—both to the borderline himself and to those
closest to him. Because of the sudden and extreme nature of cer-
tain prominent symptoms, the concerned party can be easily mis-
led and not recognize that it is a common manifestation of BPD
rather than a separate primary illness. For example, a person who
attempts to kill himself by overdosing or cutting his wrists may be
diagnosed with depression and prescribed antidepressant medica-
tions and brief, supportive psychotherapy. If the patient is suffer-
ing from a chemical depression, this regimen should improve his
condition and he should recover relatively quickly and completely.
If, however, the destructive behaviors have been triggered by BPD,
his self-harming will continue, unabated by the treatment. Even if
he is both depressed and borderline (a common combination), this
approach will only partially treat the illness and further problems
will ensue. If the borderline features are not recognized, the con-
tinuation of suicidal or other destructive behaviors, despite treat-
ment, becomes puzzling and frustrating for the patient, the doctor,
and everyone concerned.
Abby, a twenty-three-year-old fashion model, was treated in
a chemical dependency unit for alcoholism. She responded very
well to this program, but as she continued to abstain from alcohol,
she became increasingly, compulsively bulimic. She then entered
an eating-disorders unit where she was again successfully treated.
A few weeks later, she began experiencing severe panic attacks
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126 I HATE YOUDON’T LEAVE ME
in stores, ofces, even while driving in her car, and eventually
became afraid to leave her house. In addition to these phobias,
she was becoming more depressed. As she considered entering a
phobia clinic, a psychiatric consultant recognized all of her symp-
toms to be representative of BPD and recommended instead that
she enter a psychiatric unit specializing in borderline conditions.
Where her previous treatments had focused exclusively on alcohol-
ism or bulimia, this hospitalization took a more holistic view of
her life and treatment.
Eventually, Abby was able to connect her problems to her con-
tinued ambivalent relationship with her parents, who had interfered
with her attempts to separate, mature, and be more independent.
She realized that her various illnesses were really means to escape
her parents’ demands without guilt. Her bulimia, drinking, and
anxieties occupied all her energy, distracting her from address-
ing the conicts with her parents. What’s more, her “sick” role
excused her from even feeling obligated to work on this relation-
ship. Ironically, the illnesses also kept her attached to her parents:
Because they had serious marital problems (her mother was an
alcoholic and her father was chronically depressed), she could stay
close to them by replicating their pathological roles.
After a brief hospitalization she continued individual outpa-
tient psychotherapy. Her mood improved and her anxieties and
phobias dissolved. She also continued to abstain from alcohol and
purging.
Abby’s case illustrates how a consuming, prominent behavior
may actually represent and camouage underlying BPD, in which
one or more of its features—unstable relationships, impulsivity,
mood shifts, intense anger, suicidal threats, identity disturbances,
feelings of emptiness, or frantic efforts to avoid abandonment—
result in psychiatric symptoms that might mistakenly lead to
incomplete diagnosis or even misdiagnosis.
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COPING WITH THE BORDERLINE 127
Coping and Helping
It is important to remember that BPD is an illness, not a willful
attempt to get attention. The borderline lacks the boots, much less
the bootstraps, with which to pull himself up. It is useless to get
angry or to cajole and plead with the borderline to change; without
help and motivation he cannot easily modify his behavior.
However, this does not imply that the borderline is helpless and
should not be held responsible for his conduct. Actually, the oppo-
site is true. He must accept, without being excused or protected,
the real consequences of his actions, even though initially he may
be powerless to alter them. In this way, BPD is no different from
any other handicap. The individual conned to a wheelchair will
elicit sympathy, but he is still responsible for nding wheelchair
accessibility to the places he wishes to go, and for keeping his vehi-
cle in good enough condition to take him there.
The borderline’s extremes of behavior typically lead to either
a hard-nosed “You lazy good-for-nothing SOB, pull yourself
together and y right” response, or a cajoling “You poor baby, you
can’t do it; I’ll take care of you” pat on the head. All must be aware
of how their interactions may encourage or inhibit borderline
behaviors. Those who interact with a borderline must attempt to
walk a very thin line between, on the one hand, providing reassur-
ance of the borderline’s worthiness and, on the other, con rming
the necessary expectations. They must try to respond supportively,
but without overreacting. Affection and physical touching, such as
hugging and holding a hand, can communicate to the borderline
that he is a valued person, but if it is exploitative, it will hinder
trust. If caring results in overprotectiveness, the borderline stops
feeling responsible for his behavior.
In most settings, concentrating on the Truth seg ments of SET-U P
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128 I HATE YOUDON’T LEAVE ME
principles (see chapter 5) can allow for reasonable guidelines. But
when suicide is threatened, it is usually time to contact a mental
health professional or suicide-prevention facility. Suicide threats
should not be allowed to become “emotional blackmail,” whereby
the friend or relation is manipulated to behave as the borderline
demands. Threats should be taken seriously and met with prompt,
predictable, realistic reactions, such as demanding that the border-
line obtain professional help (a Truth response).
Jack, a forty-one-year-old single man, worked part-time while
attempting to return to school. His widowed mother continued to
support him nancially, and whenever he failed at work, school, or
with a relationship, she would reinforce his helplessness, by insist-
ing he could not succeed in achieving his goals and suggesting he
return “home” to live with her. Therapy involved not only helping
Jack understand his wish to remain helpless and reap the inherent
benets of helplessness but also confronted his mother’s need to
maintain control, and her role in perpetuating his dependency.
It takes only one actor in the drama to initiate change. Jack’s
mother can respond to his dependency with SET-UP responses
that express her caring (Support), understanding (Empathy), and
acknowledgment of reality (Truth)—the need for Jack to take
responsibility for his own actions. If his mother is unwilling to
alter her behavior, Jack must recognize her role in his problems
and distance himself from her.
Contending with Borderline Rage
After a while, for someone close to a borderline, unpredictable
behaviors may become commonplace and therefore “predictably
unpredictable.” One of the most common, the angry outburst, usu-
ally comes with no warning and appears way out of proportion.
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COPING WITH THE BORDERLINE 129
The close friend, relation, or coworker should resist the temp-
tation to “ ght re with re.” The louder and angrier the bor-
derline gets, the quieter and more composed the other person
should become, thereby refusing to collaborate in aggravating the
emotional atmosphere, and spotlighting the comparative outland-
ish intensity of the borderline’s rage. If the concerned individual
senses the potential for physical violence, he should leave the scene
immediately. Borderline rage often cannot be reasoned with, so
discussion and debate are unnecessary and may only in ame
the situation. Instead, one should try to cool off the con ict by
acknowledging the difference in opinion and agreeing to disagree.
Further discussion can come later when the atmosphere is more
settled.
Living with Borderline Mood Swings
Rapid mood changes can be equally perplexing to the borderline
and to those around him. From an early age, Meredith had always
been aware of her moodiness. Without reason she could soar to great
heights of excitement and joy, only to plummet, without warning,
to the lower reaches of despair. Her parents indulged her moodiness
by tiptoeing softly around her, never challenging her irritability. In
school, friends would come and go, put off by her unpredictability.
Some called her “the manic-depressive” and tried to kid her out of
her surliness.
Her husband, Ben, said he was attracted to her “kindness” and
“sense of fun.” But Meredith could change dramatically, from play-
ful to suicidal. Similarly, her interactions with Ben would change
from joyful sharing to gloomy isolation. Her moods were totally
unpredictable, and Ben was never sure how he would nd her upon
his return at the end of the day. At times he felt that he should
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130 I HATE YOUDON’T LEAVE ME
enter their home by putting his hat on a stick and poking it into the
doorway to see if it would be embraced, ignored, or shot at.
Ben was locked into a typical borderline “damned if you do and
damned if you don’t” scenario. Confronting her depression would
prompt more withdrawal and anger, but ignoring it might show
lack of concern. Relying on SET-UP principles, however, would
address his dilemma by insisting on Meredith’s input into how he
(and others) should react to her moods.
For Meredith, these shifts in mood, unresponsive to a variety
of medications, were equally distressing. Her task was to recog-
nize such swings, take responsibility for having them, and learn
to adapt by compensating for their presence. When in a state of
depression, she could subsequently identify it and learn to explain
to others around her that she was in a down phase and would try
to function as well as she could. If she was with people to whom
she could not comfortably explain her situation, Meredith could
maintain a low prole and actively try to avoid dealing with some
of the demands on her. A major goal would involve establishing
constancy—consistent, reliable attitudes and behaviors—toward
herself and others.
Handling Impulsivity
Impulsive acts can be extremely frustrating for the borderline’s
friends and relations, particularly if the acts are self-destructive.
Impulsivity is especially unnerving when it emerges (as it often
does) at a relatively stable point in the borderline’s life. Indeed,
impulsive behaviors may emanate precisely because life is settling
and the borderline feels uncomfortable in a crisis-free state.
Larry, for example, was in a marriage that was comfortably
boring. Married for over twenty years, he and Phyllis rarely inter-
acted. She reared their sons while Larry toiled for a large company.
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COPING WITH THE BORDERLINE 131
His life was a self-imposed prison of daily routine and compulsive
behaviors. He took hours to dress, in order to arrange his cloth-
ing just so. At night before bed, he engaged in rituals to maintain
a sense of control—the closet doors had to be opened in a special
way, the bathroom sink had to be carefully cleaned, and the soap
and toilet articles arranged in a certain pattern.
But within this tightly regimented routine, Larry would impul-
sively get drunk, pick ghts, or abruptly leave town for an entire
day without warning. On two occasions he impulsively overdosed
on his heart medicine “to see what it felt like.” Usually he would
absorb Phyllis’s anger by turning somber and quiet, but every so
often he would strike out at her, frequently over trivial matters.
He would remain dry for several months and then, just as he was
receiving praise for abstaining, he would get abusively and loudly
drunk. His wife, friends, and counselors pleaded and threatened,
but to no avail.
SET-UP techniques might help Phyllis deal with Larry’s impul-
sivity. Rather than beg and threaten, she might emphasize her
caring for Larry (Support) and her growing realization that he
is becoming more and more dissatised with his life (Empathy).
Truth statements would communicate her own unhappiness with
their current situation and the crucial need to do something about
it, such as enter therapy.
It is also often helpful to be able to predict impulsive behav-
iors from past experiences. For example, after a period of sobriety,
Phyllis might remind Larry, in a neutral, matter-of-fact way, that
in the past, when things have gone well, he has built up pressures
that have exploded into drinking binges. By pointing out previous
patterns, one can help the borderline become more aware of feel-
ings that preview the onset of impulsivity. This should be accom-
panied by Support statements, so it is not interpreted as defeating,
“there you go again” criticism. In such a way, the borderline learns
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132 I HATE YOUDON’T LEAVE ME
that behaviors that he has perceived as chaotic and unpredictable
can actually be anticipated, understood, and thereby controlled.
However, even if the borderline does feel criticized, predicting can
stimulate a contrariness that motivates her to not repeat destruc-
tive patterns, “just to show you!”
Finally, in therapy, Larry began to see that his seemingly unpre-
dictable behaviors represented anger at himself and others. He real-
ized how he would become abusive to his wife or begin drinking
when frustrated with himself. This impulsive behavior would result
in guilt and self-chastisement, which, in turn, served to expiate his
sins. As Larry began to value himself more highly and respect his
own ideals and beliefs, his destructive activities diminished.
Understanding Your Own Emotions
When you join the borderline on his roller-coaster ride, you also
must expect to experience a variety of emotions, especially guilt,
fear, and anger. When self-destructive, the borderline may appear
helpless and project responsibility for his behavior onto others,
who may all too readily accept it. Guilt is a strong inhibitor of
honest confrontation. Similarly, fear of physical harm—to the bor-
derline, others, or yourself—may also be a powerful deterrent to
initiating interactions. Anger is a common reaction when, as fre-
quently occurs, you feel manipulated or simply don’t like or under-
stand a certain behavior.
Lois’s mother called Lois frequently, complaining of severe
headaches, loneliness, and an overall disgust with life. With her
father long dead and her siblings estranged from the family, Lois
was the “good daughter,” the only child who cared.
Lois felt guilty when her mother was alone and in pain. Despite
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COPING WITH THE BORDERLINE 133
Lois’s love for her mother and the feelings of guilt her mother trig-
gered, Lois began feeling angry when she saw her mother becoming
progressively more helpless and unwilling to take care of herself. Lois
began to recognize that she was being taken advantage of by her
mother’s increasing dependency. But when Lois expressed her anger,
her mother just became more tearful and helpless, and Lois felt more
guilty, and the cycle repeated again. Only when Lois untangled her-
self from this interlocking system was her mother forced to achieve a
healthier self-suf ciency.
Special Parenting Problems
Most borderlines describe childhoods with characteristic features.
Often, one parent was missing or frequently absent; had time-
consuming outside interests, hobbies, or career demands; or abused
alcohol or drugs.
If both parents did live in the home, their relationship was often
not harmonious. There was frequently a lack of consensus about
child rearing and, subsequently, one parent, usually the mother,
assumed the primary parenting role. Such parents are rarely capable
of presenting a united, collaborative front to their children. For such
children, the world abounds with inconsistencies and invalidation.
When the child requires structure, he receives contradictions; when
he needs rmness, he gets ambivalence. Thus, the future borderline
is deprived of the opportunity to develop a consistent, core identity.
The mother of a borderline may be blatantly ill, but more often
her pathology is quite subtle. She may even be perceived by others as
the “perfect mother” because of her total “dedication” to her chil-
dren. Deeper observation, however, reveals her over-involvement
in her children’s lives, her encouragement of mutual dependencies,
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134 I HATE YOUDON’T LEAVE ME
and her unwillingness to allow her children to mature and separate
naturally.
Attempting to maintain consistent child rearing after separation
or divorce is especially challenging. Consistency may be dif cult
for the borderline parent, who may consciously or unconsciously
use the children to continue the battle with her spouse. The other
parent should try to minimize conicts by being highly selective
in “choosing one’s battles.” Trying to defend oneself or debate
accusations will not alter the resentment and will only confuse the
children. Often, the best approach is to redirect conversation away
from the personal relationship. Try to get the spouse to focus only
on “what’s best for the kids.” Usually, common ground can be
found and conict can be minimized.
Separations
Separations from parents, particularly during the rst few years of
life, are common in the borderline biography. On the surface, these
separations may appear insignicant, yet they have profound effects.
For example, the birth of a sibling takes the mother away from her
normal activities for a few weeks, but when she returns, she is no
longer as responsive to the older child; in the eyes of the older child,
mother has disappeared, replaced by someone different—one who
now has mothering duties with a younger sibling. For the healthy
child in a healthy environment, this trauma is easily overcome, but
for the borderline in a borderline setting, it may be one of a series
of losses and perceived abandonments. Extended illnesses, frequent
travels, divorce, or the death of a parent also deprive the developing
infant of consistent mothering at crucial times, which may interfere
with his abilities to develop trust and constancy in his unstable and
unreliable world.
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COPING WITH THE BORDERLINE 135
The Trauma of Child Abuse
Severe physical and/or sexual abuse is a common trauma in the his-
tory of the borderline personality. When a child is abused, he invari-
ably blames himself because (consciously or subconsciously) that is
the best of the available alternatives. If he blames the adult, he will
be terried by his dependency on incompetents who are unable to
take care of him. If he blames no one, pain becomes random and
unpredictable and therefore even more frightening because he has
no hope of controlling it. Blaming himself makes the abuse easier
to understand and therefore possible to control—he can feel that he
somehow causes the abuse and therefore will be able to nd a way
to end it, or he will give up and accept that he is “bad.”
In these situations, the borderline learns early in life that he
is bad, that he causes bad things to happen. He begins to expect
punishment and may only feel secure when being punished. Later,
self-mutilation may sometimes be the borderline’s way of perpetu-
ating this familiar, secure feeling of being chastised. He may see
abuse as a kind of love and repeat the abuse with his own children.
As an adult, he remains locked in the child’s confusing world, in
which love and hate comingle, only good and bad exist with no
in-between, and only inconsistency is consistent.
Abuse can take subtler forms than physical violence or deviant
sexuality. Emotional abuse—expressed as verbal harassment, sar-
casm, humiliation, or frigid silence—can be equally devastating.
Stephanie could never please her father. When she was young,
he called her “Chubby” and laughed at her clumsy tomboy attempts
to please him by playing sports. She was “stupid” when her grades
were less than perfect and when she broke dishes while trying to
clear the kitchen. He ridiculed her strapless gown on prom night
and, on graduation day, insisted that she would amount to nothing.
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136 I HATE YOUDON’T LEAVE ME
As an adult, Stephanie was always unsure of herself, never trust-
ing attering comments and hopelessly trying to please people who
were impossible to please. After a long string of destructive relation-
ships, Stephanie nally met Ted, who seemed caring and supportive.
At every turn, however, Stephanie tried to sabotage the relationship
by constantly testing his loyalty and questioning his commitment,
convinced that no one whom she valued could value her.
Ted needed to understand Stephanie’s background and recog-
nize that trust could not realistically be established except over
long periods of time. Not everyone is willing to wait. Ted was.
Recognizing BPD in Adolescence
By denition, the struggles of adolescence and BPD are very similar:
both the normal adolescent and the borderline struggle for individu-
ality and separation from parents, seek bonds with friends and iden-
tication with groups, try to avoid being alone, tend to go through
dramatic mood changes, and are generally prone to impulsivity. The
teenager’s easy distractibility is analogous to the borderline’s dif -
culty to commit himself to a goal and follow through. Adolescents’
eccentric dress styles, prehistoric eating habits, and piercing music
are usually attempts to carve out a distinctive identity and relate to
specic groups of peers, efforts similar to those of borderlines.
A normal adolescent may listen to gloomy music, write pes-
simistic poetry, glorify suicidal celebrities, dramatically scream,
cry, and threaten. However, the normal adolescent does not cut his
wrists, binge and purge several times a day, become addicted to
drugs, or attack his mother; and it is these extremes that anticipate
the development of BPD.
Some parents will deny the seriousness of an adolescent’s prob-
lems (a drug overdose, for example) by dismissing them as a typ-
ical teenager’s bid for attention. Though it is true that children
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COPING WITH THE BORDERLINE 137
often seek attention in dramatic ways, neither suicide attempts nor
any destructive behaviors are “normal.” They instead suggest the
possibility of incipient borderline personality or another disorder
and should be evaluated by a professional. Compared to teenagers
with other psychiatric disorders, borderline adolescents experience
some of the most severe pathology and dysfunction. Borderline
adolescents exhibit higher lifetime rates of sexually transmitted
infections and medical problems. They are more likely to abuse
alcohol, cigarettes, and other drugs.
1
Usually others—parents, teachers, employers, friends—will rec-
ognize when the normal teenager crosses the border into border-
line behavior, even before the adolescent himself. Continuous drug
abuse, serial tumultuous relationships, or anorexic fasting are reli-
able indicators that deeper problems may be involved. The teen’s
whole style of functioning should be the focus of examination,
rather than individual symptoms. This is especially crucial when
considering the potential for suicide.
Suicide is a leading cause of death among teenagers, and is par-
ticularly prevalent in children who are depressed, abuse drugs, act
impulsively or violently, and maintain few support systems—all
prominent features of BPD.
2,3
Threats of self-harm should always be
taken seriously. Attempts to self-mutilate or harm oneself “only for
attention” can go tragically awry. Parents who try to distinguish “real
suicide” from “attention-seeking” miss the point—both are seriously
pathological behaviors and require treatment, often hospitalization.
Working with the Borderline
In the work environment, borderlines are often perceived as “strange”
or “eccentric”: they may tend to isolate themselves, avoid personal
contacts, and keep others away with an aura of surliness, suspicion,
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138 I HATE YOUDON’T LEAVE ME
or eccentricity. Some habitually complain of physical ailments or per-
sonal problems, and occasionally have ts of paranoia and rage. Still
others may act perfectly normal in the work situation, but appear
awkward or uncomfortable around coworkers outside the workplace.
Many employers have implemented Employee Assistance Pro-
grams (EAPs), in-house counselors, and referral departments ini-
tially designed to help employees deal with alcohol and drug abuse
problems. Today, many EAPs are also available to help workers
confront other emotional problems as well as legal and nancial
dif culties.
Many EAP counselors are well equipped to identify features of
alcohol or drug abuse, or of prominent psychiatric illnesses such
as depression or psychosis, but they may be less familiar with the
more intricate symptoms of BPD. Though the employee’s supervi-
sor, coworkers, counselor, even the employee himself may be aware
of some dysfunctional or disruptive behaviors, the borderline
might not be referred for treatment because his behaviors cannot
be clearly associated with a more commonly recognized disorder.
The prospective employer may suspect borderline characteris-
tics in an applicant who has a history of frequent job changes.
These terminations will often be explained by “personality con-
icts” (which, indeed, is often accurate). Other job separations
may be sparked by a signicant change—a new supervisor, new
computer system, or an adjustment in job description—that dis-
rupted a very structured (perhaps even monotonous) routine.
Because the borderline may be very creative and dedicated, he
can be a most valuable employee. When functioning on a higher
level, he can be colorful, stimulating, and inspiring to others. Most
borderlines function optimally in a well-dened, structured envi-
ronment in which expectations are clearly delineated.
Coworkers will be most comfortable with the borderline when
they recognize his tendency to see the world as black or white and
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COPING WITH THE BORDERLINE 139
accept his need for well-dened structure. They should avoid “kid-
ding around” with him and stay away from “good-natured” mock-
ing, which the borderline may often misconstrue. It may be helpful
to intercede if the borderline becomes the target of others’ jokes.
Frequent compliments for good work, and matter-of-fact, non-
condemning recognition of mistakes with suggestions for improve-
ment can aid the borderline’s functioning in the workplace.
Similarly, when the borderline is in an executive position, it is
important for employees to recognize and learn to deal with his
black-or-white thinking. Employees should learn to expect and
accept his changeability with a minimum of hurt feelings. They
should avoid entanglement in logical arguments, because consis-
tency may not always be possible for the borderline. They should
look for allies elsewhere in the organization to provide reliable
feedback and evaluations.
Playing with the Borderline
At play the borderline is typically unpredictable and sometimes very
disconcerting. He may have great difculty with recreation and play
with a seriousness that is out of proportion to the relaxed nature of
the activity. He may be your newly assigned tennis doubles partner
who at rst seems nice enough, but as the game goes on becomes
increasingly frustrated and angry. Though you continually remind
him that “it’s just a game,” he may stomp around, curse himself,
throw the racket, and swear to give up the sport. He may be your
son’s Little League coach who works well with the kids, but suddenly
becomes wildly abusive to the teenage umpire or angrily humiliat-
ing to his own son—seen as an extension of himself—who strikes
out with the bases loaded. Although these examples may describe
borderline-like traits in some people who in fact are not borderline,
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140 I HATE YOUDON’T LEAVE ME
when these behaviors are extreme or represent a consistent pattern,
they may be indications of a true borderline personality.
The borderline’s intensity interferes with his ability to relax
and have fun. Others’ attempts at humor may frustrate him and
make him angry. It is virtually impossible “to kid him out of it.” If
you elect to continue playing tennis with your borderline partner,
judicious use of SET-UP principles may make the experience more
tolerable.
The Maturing Borderline
Higher functioning adult borderlines who do not fully recover may
still have successful careers, assume traditional family roles, and
have a cadre of friends and support systems. They may live gen-
erally satisfactory lives within their own separate corner of exis-
tence, despite recurrent frustrations with themselves and others
who inhabit that niche.
Lower functioning borderlines, however, have more dif culty
maintaining a job and friends, and may lack family and support
systems; they may inhabit lonelier and more desperate “black
holes” within their own personal universe.
Common to most borderlines is an element of unpredictability
and erratic behavior. It may be more obvious in the lonely, isolated
individual, but those who know the contented family man well can
also detect inconsistencies in his behavior that belie the super cial
rationality. At work, even the borderline who is a successful busi-
nessman or professional may be known by those working closely
with him to be a bit strange, even if they can’t quite localize what
it is that projects that aura of imbalance.
As many borderlines grow older, they may “mellow out.” Impul-
sivity, mood swings, and self-destructive behaviors seem to diminish
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COPING WITH THE BORDERLINE 141
in dramatic intensity. This pattern might be an objective re ection of
change or a subjective evaluation of those living or working with the
borderline; the borderline’s friends and lovers may have adjusted to
his erratic actions over time and no longer notice or respond to the
outrageousness.
Maybe it is because he has settled into a more routine lifestyle
that no longer requires periodic outbursts—drinking binges, suicide
threats, or other dramatic gestures—to achieve his needs. Perhaps
with age the borderline loses the energy or stamina to maintain the
frenetic pace of borderline living. Or perhaps there is simply a natu-
ral healing process that takes place for some borderlines as they
mature. In any event, most borderlines get better over time, with
or without treatment. Indeed, most could be considered “cured” in
the sense that they no longer ful ll ve of the nine de ning criteria.
Long-term prognosis for this devastating disease is very hopeful
(see chapter 7).
Thus, those sharing life with the borderline can expect his
behaviors over time to become more tolerable. At this point the
unpredictable reactions become more predictable and therefore
easier to manage, and it becomes possible for the borderline to
learn how to love and be loved in a healthier fashion.
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Chapter Seven
Seeking Therapy
I’m gonna give him one more year, and then I’m going to Lourdes.
—From Annie Hall, by Woody Allen, about his psychiatrist
Dr. Smith, a nationally known psychiatrist, had called me about
his niece. She was depressed and in need of a good psychothera-
pist. He was calling to say that he had recommended me.
Arranging an appointment was difcult. She could not rearrange
her schedule to t my openings, so I juggled and rearranged my
schedule to t hers. I felt pressure to be accommodating and bril-
liant, so that Dr. Smith’s faith in me would be justied. I had just
opened my practice and needed some validation of my professional
skills. Yet I knew that these feelings were a bad sign: I was nervous.
Julie was strikingly attractive. Tall and blond, she easily could
have been a model. A law student, she was twenty- ve, bright,
and articulate. She arrived ten minutes late and neither apologized
for nor even acknowledged this slight on her part. When I looked
closely, I could see that her eye makeup was a little too heavy, as if
she were trying to conceal a sadness and exhaustion inside.
Julie was an only child, very dependent on her successful parents,
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SEEKING THERAPY 143
who were always traveling. Because she couldn’t stand being alone,
she cruised through a series of affairs. When a man would break off
the relationship, she’d become extremely depressed until embarking
on the next affair. She was now “between relationships.” Her most
recent man had left her and “there was no one to replace him.”
It wasn’t long before her treatment fell into a routine. As a ses-
sion would near its end, she’d always bring up something impor-
tant, so our appointments would end a little late. The phone calls
between sessions became more frequent and lasted longer.
Over the next six weeks we met once a week, but then mutually
agreed to increase the frequency to twice a week. She talked about
her loneliness and her difculties with separations, but continued
to feel hopeless and alone. She told me that she often exploded in
rage against her friends, though these outbursts were hard for me
to imagine because she was so demure in my ofce. She had prob-
lems sleeping, her appetite decreased, and she was losing weight.
She began to talk about suicide. I prescribed antidepressant medi-
cations for her, but she felt even more depressed and was unable to
concentrate in school. Finally, after three months of treatment, she
reported increasing suicidal thoughts and began to visualize hang-
ing herself. I recommended hospitalization, which she reluctantly
accepted. Clearly, more intense work was needed to deal with this
unremitting depression.
The rst time I saw the anger was the day of her admission,
when Julie was describing her decision to come to the hospital.
Crying softly, she spoke of the fear she had experienced when
explaining her hospitalization to her father.
Then suddenly her face hardened, and she said, “Do you know
what that bitch did?” A moment passed before I realized that Julie
was now referring to Irene, the nurse who had admitted her to the
unit. Furiously, Julie described the nurse’s lack of attention, her
awkwardness with the blood pressure cuff, and a mix-up with a
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144 I HATE YOUDON’T LEAVE ME
lunch tray. Her ethereal beauty mutated into a face of rage and ter-
ror. I jumped when she pounded the table.
After a few days, Julie was galvanizing the hospital unit with
her demands and tirades. Some of the nurses and patients tried
to calm and placate her; others bristled when she threw tantrums
(and objects) and walked out of group sessions. “Do you know
what your patient did this morning, Doctor?” asked one nurse as
I stepped onto the oor. The emphasis was clearly on the “your,”
as if I were responsible for Julie’s behavior and deserved the staff’s
reprimands for not controlling her. “You’re overprotective. She’s
manipulating you. She needs to be confronted.”
I immediately came to my own—and Julie’s—defense. “She
needs support and caring,” I replied. “She needs to be re-parented.
She needs to learn trust.” How dare they question my judgment!
Do I dare question it?
Throughout the rst few days, Julie complained about the nurses,
the other patients, the other doctors. She said I was understanding
and caring and I had much greater insight and knowledge than the
other therapists she had seen.
After three days, Julie insisted on discharge. The nurses were
skeptical; they didn’t know her well enough. She hadn’t talked
much about herself either to them or in group therapy. She was
talking only to her doctor, but she insisted her suicidal thoughts
had dissipated and she needed “to get back to my life.” In the end
I authorized the discharge.
The next day she wobbled into the emergency room drunk with
cuts on her wrist. I had no choice but to re-admit her to the ward.
Though the nurses never actually said, “I told you so,” their haughty
looks were unmistakable and insufferable. I began to avoid them
even more than I had until that point. I resumed Julie’s therapy on
an individual basis and dropped her from group sessions.
Two days later she demanded discharge. When I turned down
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SEEKING THERAPY 145
the request, she exploded. “I thought you trusted me,” she said. “I
thought you understood me. All you care about is power. You just
love to control people!”
Maybe she’s right, I thought. Perhaps I am too controlling, too
insecure. Or was she just attacking my vulnerability, my need to
be perceived as caring and trusting? Was she just stoking my guilt
and masochism? Was she the victim here, or was I?
“I thought you were different,” she said. “I thought you were
special. I thought you really cared.” The problem was, I thought
so too.
By the end of the week the insurance company was calling me
daily, questioning her continued stay. Nursing notes recorded her
insistence that she was no longer self-destructive, and she contin-
ued to lobby for discharge. We agreed to dismiss her from the hos-
pital, but have her continue in the day hospital program, in which
she could attend the hospital scheduled groups during the day and
go home in the afternoon. On her second day in the outpatient
program she arrived late, disheveled, and hungover. She tearfully
related the previous night’s sleazy encounter with a stranger in a
bar. The situation was becoming clearer to me. She was begging
for limits and controls and structure but couldn’t acknowledge this
dependency. So she acted outrageously to make controls necessary,
and then got angry and denied her desire for them.
I could see this, but she couldn’t. Gradually I stopped look-
ing forward to seeing her. At each session, I was reminded of my
failure, and I found myself wishing that she would either get well
or disappear. When she told me that maybe her old roommate’s
doctor would be better for her, I interpreted this as a wish to run
away from herself and the real issues she faced. A change at this
point would be counterproductive for her I knew, but silently I
hoped that she would change doctors for my sake. She still talked
of killing herself, and I guiltily fantasized that it would be almost
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146 I HATE YOUDON’T LEAVE ME
a relief for me if she did. Her changes had changed me—from a
masochist to a sadist.
During her third week in the day hospital, another patient
hanged himself while home over the weekend. Frightened, Julie
ew into a rage: “Why didn’t you and these nurses know he was
going to kill himself?” she screamed. “How could you let him do
it? Why didn’t you protect him?”
Julie was devastated. Who was going to protect her? Who
would make the pain go away? I nally realized that it would have
to be Julie. No one else lived inside her skin. No one else could
totally understand and protect her. It was starting to make some
sense, to me and, after a while, to Julie.
She could see that no matter how hard she tried to run away
from her feelings, she could not escape being herself. Even though
she wanted to run away from the bad person she thought she was,
she had to learn to accept herself, aws and all. Ultimately she
would see that just being Julie was okay.
Julie’s anger at the staff gradually migrated toward the suicide
patient, who “didn’t give himself a chance.” When she saw his
responsibility, she began to see hers. She discovered that people who
really cared about her did not let her do whatever she wanted, as her
parents had done. Sometimes caring meant setting limits. Sometimes
it meant telling her what she didn’t want to hear. And sometimes it
meant reminding her of her accountability to herself.
It wasn’t much longer before all of us—Julie, the staff, and I—
began working together. I stopped trying so hard to be likeable,
wise, and unerring; it was more important to be consistent and
reliable—to be there.
After several weeks, Julie left the hospital outpatient program
and returned to our of ce therapy. She was still lonely and afraid,
but she didn’t need to hurt herself anymore. Even more important,
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SEEKING THERAPY 147
she was accepting the fact that she could survive loneliness and
fear but could still care about herself.
After a while, Julie found a new man who really seemed to care
about her. As for me, I learned some of the same things Julie did—
that distasteful emotions determine who I am to a great extent and
that accepting these unpleasant parts of myself helps me to better
understand my patients.
Beginning Treatment
Therapists who treat borderline personality often nd that the rig-
ors of treatment place a great strain on their professional abilities,
as well as on their patience. Treatment sessions may be stormy,
frustrating, and unpredictable. The treatment period proceeds at a
snail-like pace and may require years to achieve true change. Many
borderline patients drop out of therapy in the rst few months.
Treatment is so difcult because the borderline responds to it
in much the same way as to other personal relationships. The bor-
derline will see the therapist as caring and gentle one moment,
deceitful and intimidating the next.
In therapy, the borderline can be extremely demanding, depen-
dent, and manipulative. It is not uncommon for a borderline patient
to telephone incessantly between sessions and then appear unex-
pectedly in the therapist’s ofce, threatening bodily harm to him-
self unless the therapist meets with him immediately. Angry tirades
against the therapist and the process of therapy are common.
Often, the borderline can be very perceptive about the sensitivity of
the therapist and eventually goad him into anger, frustration, self-
doubt, and hopelessness.
Given the wide range of possible contributing causes of BPD, and
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148 I HATE YOUDON’T LEAVE ME
the extremes of behavior involved, there is a predictably wide range
of treatment methods. According to the American Psychiatric Asso-
ciation’s “Practice Guideline for the Treatment of Patients with Bor-
derline Personality Disorder,” “The primary treatment for borderline
personality disorder is psychotherapy, complemented by symptom-
targeted pharmacotherapy.”
1
Psychotherapy can take place in indi-
vidual, group, or family therapy settings. It can proceed in or out
of a hospital setting. Therapy approaches can be combined, such as
individual and group. Some therapy approaches are more “psychody-
namic,” that is, emphasize the connection between past experiences
and unconscious feelings with current behaviors. Other approaches
are more cognitive and directive, focused more on changing current
behaviors than necessarily exploring unconscious motivations. Some
therapies are time-limited, but most are open-ended.
Some treatments are usually avoided. Strict behavior modi ca-
tion is seldom utilized. Classical psychoanalysis on the couch with
use of “free association” in an unstructured environment can be
devastating for the borderline whose primitive defenses may be
overwhelmed. Because hypnosis can produce an unfamiliar trance
state resulting in panic or even psychosis, it is also usually avoided
as a therapeutic technique.
Goals of Therapy
All treatment approaches strive for a common goal: more effec-
tive functioning in a world that is experienced as less mystifying,
less harmful, and more pleasurable. The process usually involves
developing insight into the unproductiveness of current behaviors.
This is the easy part. More difcult is the process of reworking old
re exes and developing new ways of dealing with life’s stresses.
The most important part of any therapy is the relationship between
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SEEKING THERAPY 149
the patient and therapist. This interaction forms the foundation for
trust, object constancy, and emotional intimacy. The therapist must
become a trusted gure, a mirror to reect a developing consistent
identity. Starting with this relationship, the borderline learns to extend
to others appropriate expectations and trust.
The primary goal of the therapist is to work toward losing (not
keeping) his patient. This is accomplished by directing the patient’s
attention to certain areas for examination, not by controlling him.
Though the therapist serves as the navigator, pointing out land-
scapes of interest and helping to re-route the itinerary around storm
conditions, it is the patient who must remain rmly in the pilot’s
seat. Family and loved ones are also sometimes included on this
journey. A major objective is for the patient to return home and
improve relationships, not to abandon them.
Some people are fearful of psychiatry and psychotherapy, per-
ceiving the process as a form of “mind control” or behavior modi -
cation perpetrated on helpless, dependent patients who are molded
into robots by bearded, Svengali-like mesmerists. The aim of psycho-
therapy is to help a patient individuate and achieve more freedom
and personal dignity. Unfortunately, just as some people erroneously
believe that you can be hypnotized against your will, so some believe
you can be “therapized” against your will. Popular culture, espe-
cially cinema, frequently portrays the “shrink” as either a bumbling
fool, more in need of treatment than his patients, or a nefarious,
brilliant criminal. Such irrational fears may deprive people of oppor-
tunities to escape self-imposed captivity and achieve self-acceptance.
Length of Therapy
Because of the past prominence of psychoanalysis, which charac-
teristically requires several years of intensive, frequent treatment,
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150 I HATE YOUDON’T LEAVE ME
most people view any form of psychotherapy as being extended
and drawn out, and therefore very expensive. The addition of
medications and specialized treatments to the therapeutic arma-
mentarium are responses to the need for practical and affordable
treatment methods. Broken bones heal and infections clear up, but
scars on the psyche may require longer treatment.
If therapy terminates quickly, one may question if it was too
supercial. If it extends for many years, one may wonder if it is
merely intellectual game playing that enriches psychotherapists
while nancially enslaving their dependent and helpless patients.
How long should therapy last? The answer depends on the speci c
goals. Resolution of specic, targeted symptoms—such as depres-
sion, severe anxiety, or temper outbursts—may be accomplished in
relatively brief time spans, such as weeks or months. If the goal is
more profound restructuring, a longer duration will be required.
Over time BPD is usually “cured.” This means that the patient, by
strict denition, no longer exhibits ve of the nine de ning DSM-
IV criteria. However, some individuals may continue to suffer from
disabling symptoms, which can require continued treatment.
Therapy may be interrupted. It is not unusual for borderlines to
engage in several separate rounds of therapy, with different thera-
pists and different techniques. Breaks in therapy may be useful to
solidify ideas, or to try out new insights, or merely to catch up with
life and allow time to grow and mature. Financial limitations, sig-
ni cant life changes, or just a need for a respite from the intensity
of treatment may mandate a time-out. Sometimes years of therapy
may be necessary to achieve substantive changes in functioning.
When the changes come slowly, it can be difcult to determine
whether more work should proceed, or if “this is as good as it
gets.” The therapist must consider both the borderline’s propensity
to run from confrontations with his unhealthy behaviors and his
tendency to cling dependently to the therapist (and others).
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SEEKING THERAPY 151
For some borderlines, therapy may never formally end. They may
derive great benet from continuing intermittent contacts with a
trusted therapist. Such arrangements would be considered “refuel-
ing stops” on the road to greater independence, provided the patient
does not rely on these contacts to drive his life.
How Psychotherapy Works
As we shall see later in this and the next chapter, there are several
established therapeutic approaches for the treatment of BPD. They
may proceed in individual, group, or family settings. Most of these
are derived from two primary orientations: psychodynamic psycho-
therapy and cognitive-behavioral therapy. In the former, discussion
of the past and present are utilized to discover patterns that may forge
a more productive future. This form of therapy is more intensive,
with sessions conducted several times a week and usually continuing
for a longer period. Effective therapy must employ a structured, con-
sistent format with clear goals. Yet there must also be exibility to
adapt to changing needs. Cognitive-behavioral approaches focus on
changing current thinking processes and repetitive behaviors that
are disabling; this type of therapy is less concerned about the past.
Treatment is more problem-focused and often time-limited. Some
therapy programs combine both orientations.
Whatever the structure, the therapist tries to guide clients to
examine their experience and serves as a touchstone for experi-
menting with new behaviors. Ultimately, the patient begins to
accept his own choices in life and to change his self-image as a
helpless pawn moved by forces beyond his control. Much of this
process emerges from the primary relationship between therapist
and patient. Often, in any therapy, both develop intense feelings,
called transference and countertransference.
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152 I HATE YOUDON’T LEAVE ME
Transference
Transference refers to the patient’s unrealistic projections onto
the therapist of feelings and attitudes previously experienced from
other important persons in the patient’s life. For example, a patient
may get very angry with the doctor, based not on the doctor’s
communications, but on feelings that the doctor is much like his
mother, who in the past elicited much anger from him. Or, a patient
may feel she has fallen in love with her therapist, who represents a
fantasied, all-powerful, protective father gure. By itself, transfer-
ence is neither negative nor positive, but it is always a distortion, a
projection of past emotions onto current objects.
Borderline transference is likely to be extremely inconsistent, just
like other aspects of the patient’s life. The borderline will see the ther-
apist as caring, capable, and honest one moment, deceitful, devious,
and unfeeling the next. These distortions make the establishment of
an alliance with the therapist most difcult. Yet establishing and sus-
taining this alliance is the most important part of any treatment.
In the beginning stages of therapy, the borderline both craves
and fears closeness to the therapist. He wants to be taken care of
but fears being overwhelmed and controlled. He attempts to seduce
the doctor into taking care of him and rebels against his attempts
to “control his life.” As the therapist remains steadfast and con-
sistent in withstanding his tirades, object constancy develops—the
borderline begins to trust that the therapist will not abandon him.
From this beachhead of trust, the borderline can venture out with
new relationships and establish more trusting contacts. Initially,
however, such new friendships can be difcult to sustain for the
borderline, who, in the past, may have perceived his formation of
new alliances as a form of disloyalty. He may even fear that his
mate, friend, or therapist may become jealous and enraged if he
broadens his social contacts.
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SEEKING THERAPY 153
As the borderline progresses, he settles into a more comfortable,
trusting dependency. As he prepares for termination, however, there
may again be a resurgence of turmoil in the relationship. He may pine
for his previous ways of functioning and resent needing to proceed
onward; he may feel like a tiring swimmer who realizes he has already
swum more than halfway across the lake, and now rather than return
to the shore must continue on to the other side before resting.
At this point the borderline must also deal with his separate-
ness and recognize that he, not the therapist, has effected change.
Like Dumbo, who rst attributes his ying ability to his “magic
feather” but then realizes it is due to his own talents, the border-
line must begin to recognize and accept his own abilities to func-
tion independently. And he must develop new coping mechanisms
to replace the ones that no longer work.
As the borderline improves, the intensity of the transference
diminishes. The anger, impulsive behaviors, and mood changes—
often directed at, or for the benet of, the therapist—become less
severe. Panicky dependency may gradually wither and be replaced
by a growing self-condence; anger erupts less often, replaced by
greater determination to be in charge of one’s own life. Impatience
and caprice diminish, because the borderline begins to develop
a separate sense of identity that can evolve without the need for
parasitic attachment.
Countertransference
Countertransference refers to the therapist’s own emotional reac-
tions to the patient, which are based less on realistic considerations
than on the therapist’s past experiences and needs. An example is the
doctor who perceives the patient as more needy and helpless than is
truly the case because of the doctor’s need to be a caretaker, to per-
ceive himself as compassionate, and to avoid confrontation.
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154 I HATE YOUDON’T LEAVE ME
The borderline is often very perceptive about others, including the
therapist. This sensitivity often provokes the therapist’s own unre-
solved feelings. The doctor’s needs for appreciation, affection, and
control can sometimes prompt him into inappropriate behavior. He
may be overly protective of the patient and encourage dependency.
He may be overly controlling, demanding that the patient carry out
his recommendations. He may complain of his own problems and
induce the patient to take care of him. He may extract information
from the patient for nancial gain or mere titillation. He may even
enter into a sexual relationship with the patient “to teach intimacy.”
The therapist may rationalize all these as necessary for a “very sick”
patient, but in reality they are satisfying his own needs. It is these
countertransference feelings that result in most examples of unethi-
cal behavior between a trusted doctor or therapist and patient.
The borderline can provoke feelings of anger, frustration,
self-doubt, and hopelessness in the therapist that mirror his own.
Goaded into emotions that challenge his professional self-worth,
the therapist may experience genuine countertransference hate for
the patient and view him as untreatable. Treatment of the bor-
derline personality can be so infuriating that the term “border-
line” has been inaccurately used sometimes by professionals as a
derogatory label for any patient who is extremely irritating or who
does not respond well to therapy. In these cases “borderline” more
accurately reects the countertransference frustration of a thera-
pist than a scientic diagnosis of his patient.
The Patient-Therapist “Fit”
All of the treatments described in this book can be productive
approaches to the borderline patient, though no therapeutic tech-
niques have been shown to be uniformly curative in all cases. The
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SEEKING THERAPY 155
only factor that seems to correlate consistently with improvement
is a positive, mutually respectful relationship between patient and
therapist.
Even when a doctor is successful in treating one or many bor-
derline patients, this does not guarantee automatic success in treat-
ing others. The primary determining factor of success is usually
a positive, optimistic feeling shared between the participants—a
kind of patient-therapist “ t.”
A good t is dif cult to dene precisely, but refers to the abilities
of both the patient and therapist to tolerate the predictable turbulence
of therapy, while maintaining a sturdy alliance as therapy proceeds.
The Therapist’s Role
Because treatment of BPD may entail a combination of several
therapies—individual, group, and family psychotherapies, medica-
tions, and hospitalization—the therapist’s role in treatment may
be as varied as the different therapies available. The doctor may
be confrontational or nondirective; he may either spontaneously
exhort and suggest or initiate fewer exchanges and expect the
patient to assume a heavier burden for the therapy process. More
important than the particular doctor or treatment method is the
feeling of comfort and trust experienced by both patient and thera-
pist. Both must perceive commitment, reliability, and true partner-
ship from the other.
To achieve this feeling of mutual comfort, both patient and doc-
tor must understand and share common objectives. They should
agree upon methods and have compatible styles. Most important,
the therapist must recognize when he is treating a borderline patient.
The therapist should suspect that he is dealing with BPD when
he takes on a patient whose past psychiatric history includes contra-
dictory diagnoses, multiple past hospitalizations, or trials of many
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156 I HATE YOUDON’T LEAVE ME
medications. The patient may report being “kicked out” of previous
therapies and becoming persona non grata in the local emergency
room, having frequented the ER enough times to have earned a nick-
name (such as “Overdose Eddie”) from the medical staff.
The experienced doctor will also be able to trust his counter-
transference reactions to the patient. Borderlines usually elicit very
strong emotional reactions from others, including therapists. If
early on in the evaluation, the therapist experiences strong feel-
ings of wanting to protect or rescue the patient, of responsibility
for the patient, or of extreme anger toward the patient, he should
recognize that his intense responses may signify reactions to a bor-
derline personality.
Choosing a Therapist
Therapists with differing styles may perform equally well with
borderlines. Conversely, doctors who possess special expertise or
interest in BPD and who generally do well with borderline patients
cannot guarantee success with every patient.
A patient can choose from a variety of mental health profes-
sionals. Though psychiatrists, following their medical training,
have years of exposure to psychotherapy techniques (and, as physi-
cians, are the only professionals capable of dealing with concur-
rent medical illnesses, prescribing medications, and arranging
hospitalization), other skilled professionals—psychologists, social
workers, counselors, psychiatric nurse-clinicians—may also attain
expertise in psychotherapy with borderline patients.
In general, a therapist who works well with BPD possesses certain
qualities that a prospective patient can usually recognize. He should
be experienced in the treatment of BPD and remain tolerant and
accepting in order to help the patient develop object constancy (see
chapter 2). He should be exible and innovative, in order to adapt to
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SEEKING THERAPY 157
the contortions through which therapy with a borderline may twist
him. He should possess a sense of humor, or at least a clear sense of
proportion, to present an appropriate model for the patient and to
protect himself from the relentless intensity that such therapy requires.
Just as the doctor evaluates the patient during the initial assess-
ment interviews, so should the patient evaluate the doctor to deter-
mine if they can work together effectively.
First, the patient should consider whether he is comfortable
with the therapist’s personality and style. Will he be able to talk
with him openly and candidly? Is he too intimidating, too pushy,
too wimpy, too seductive?
Secondly, do the therapist’s assessment and goals coincide with
the patient’s? Treatment should be a collaboration in which both
parties share the same view and use the same language. What
should therapy hope to achieve? How will you know when you get
there? About how long should it take?
Finally, are the recommended methods acceptable to the
patient? There should be agreement on the type of psychotherapy
advocated and the suggested frequency of meetings. Will the doc-
tor and patient meet individually or together with others? Will
there be a combination of approaches, which might include, say,
individual therapy on a weekly basis, along with intermittent con-
joint meetings with the spouse? Will therapy be more exploratory
or more supportive? Will medications or hospitalization likely be
employed? What kinds of medicines and which hospitals?
This initial assessment period usually requires at least one inter-
view, often more. Both the patient and the doctor should be evalu-
ating their ability and willingness to work with the other. Such an
evaluation should be recog nized as a kind of “no-fault” interchange:
it is irrelevant and probably impossible to blame the therapist or the
patient for the inability to establish rapport. It is necessary only to
determine whether a therapeutic alliance is possible. However, if a
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158 I HATE YOUDON’T LEAVE ME
patient continues to nd every psychotherapist he interviews unac-
ceptable, his commitment to treatment should be questioned. Per-
haps he is searching for the “perfect” doctor who will take care of
him or whom he can manipulate. Or he should consider the possi-
bility that he is merely avoiding therapy and should perhaps choose
an admittedly imperfect doctor and get on with the task of getting
better.
Obtaining a Second Opinion
Once therapy is under way, it is not unusual for treatment to stop
and start, or for the form of therapy to change over time. Adjust-
ments may be necessary because the borderline may require changes
in his treatment as he progresses.
Sometimes, however, it is difcult to distinguish when therapy
is stuck from when it is working through painful issues; it is some-
times difcult to separate dependency and fear of moving on from
the agonizing realization of unnished business. At such times
there will arise a question of whether to proceed along the same
lines or to take a step back and regroup. Should treatment begin
to involve family members? Should group therapy be considered?
Should therapist and patient reevaluate medications? At this point
a consultation with another doctor may be indicated. Often the
treating therapist will suggest this, but sometimes the patient must
consider this option on his own.
Although the patient may fear that a doctor is offended by a
request for a second opinion, a competent and con dent therapist
would not object to, or be defensive about, such a request. It is,
however, an area for exploration in the therapy itself, in order to
assess whether the patient’s wish for a second evaluation might con-
stitute a running away from difcult issues or represent an uncon-
scious angry rebuke. A second opinion may be helpful for both the
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SEEKING THERAPY 159
patient and the doctor in providing a fresh outlook on the progress
of treatment.
Getting the Most from Therapy
Appreciating treatment as a collaborative alliance is the most impor-
tant step in maximizing therapy. The borderline frequently loses
sight of this primary principle. Instead, she sometimes approaches
treatment as if the purpose were to please the doctor or to ght with
him, to be taken care of or to pretend to have no problems. Some
patients look at therapy as the opportunity to get away, get even,
or get an ally. But the real goal of treatment should be to get better.
The borderline may need to be frequently reminded of the
parameters of therapy. He should understand the ground rules,
including the doctor’s availability and limitations, the time and
resource constraints, and the agreed-upon mutual goals.
The patient must not lose sight of the fact that he is bravely com-
mitting himself, his time, and his resources to the frightening task
of trying to understand himself better and to effect alterations in his
life pattern. Honesty in therapy is therefore of paramount impor-
tance for the patient’s sake. He must not conceal painful areas or
play games with the therapist to whom he has entrusted his care. He
should abandon his need to control, or wish to be liked by, the thera-
pist. In the borderline’s quest to satisfy a presumed role, he may lose
sight of the fact that it is not his obligation to please the therapist but
to work with him as a partner.
Most important, the patient should always feel that he is actively
collaborating in his treatment. He should avoid either the extreme
of assuming a totally passive role, deferring completely to the doc-
tor, or that of becoming a competitive, contentious rival, unwill-
ing to listen to contributions from the therapist. Molding a viable
relationship with the therapist becomes the borderline’s rst and,
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160 I HATE YOUDON’T LEAVE ME
initially, most important task in embarking on a journey toward
mental health.
Therapeutic Approaches
Many clinicians divide therapy orientations into exploratory and
supportive treatments. Though both styles overlap, they are distin-
guished by the intensity of therapy and the techniques utilized. As
we will see in the next chapter, a number of therapy strategies are
used for the treatment of BPD. Some employ one style or the other;
some combine elements of both.
Exploratory Therapy
Exploratory psychotherapy is a modication of classical psycho-
analysis. Sessions are usually conducted two or more times per
week. This form of therapy is more intensive than supportive
therapy (see page 161), and has a more ambitious goal—to alter
personality structure. The therapist provides little direct guid-
ance to the patient, utilizing confrontation instead to point out the
destructiveness of specic behaviors and to interpret unconscious
precedents in the hopes of eradicating them.
As in less intensive forms of therapy, a primary focus is on here-
and-now issues. Genetic reconstruction, with its concentration on
childhood and developmental issues, is important, but emphasized
less than in classical psychoanalysis. The major goals in the early,
overlapping stages of treatment are to diminish behaviors that are
self-destructive and disruptive to the treatment process (including
prematurely terminating therapy), to solidify the patient’s commit-
ment to change, and to establish a trusting, reliable relationship
between patient and doctor. Later stages emphasize the processes
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SEEKING THERAPY 161
of formulating a separate, self-accepting sense of identity, establish-
ing constant and trusting relationships, and tolerating aloneness
and separations (including those from the therapist) adaptively.
2,3
Transference in exploratory therapy is more intense and promi-
nent than in supportive therapy. Dependency on the therapist,
together with idealization and devaluation, are experienced more
passionately, as in classical psychoanalysis.
Supportive Therapy
Supportive psychotherapy is usually conducted on a once-weekly
basis. Direct advice, education, and reassurance replace the con-
frontation and interpretation of unconscious material typically
used in exploratory therapy.
This approach is meant to be less intense and to bolster more
adaptive defenses than exploratory therapy. In supportive psycho-
therapy the doctor may reinforce suppression, discouraging dis-
cussion of painful memories that cannot be resolved. Rather than
question the roots of minor obsessive concerns, the therapist may
encourage them as “hobbies” or minor eccentricities. For example,
a patient’s need to keep his apartment spotless may not be dis-
sected as to causes, but be acknowledged as a useful means to
retain a sense of mastery and control when feeling overwhelmed.
This contrasts with psychoanalysis, in which the aim is to analyze
defenses and then eradicate them.
Focusing on current, more practical issues, supportive therapy
tries to quash suicidal and other self-destructive behaviors rather
than to explore them fully. Impulsive actions and chaotic interper-
sonal relationships are identied and confronted, without necessar-
ily acquiring insight into the underlying factors that caused them.
Supportive therapy may continue on a regular basis for some
time before dwindling to an as-needed frequency. Intermittent
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162 I HATE YOUDON’T LEAVE ME
contacts may continue indenitely, and the therapist’s continued
availability may be very important. Therapy gradually terminates
when other lasting relationships form and gratifying activities
become more important in the patient’s life.
In supportive therapy the patient tends to be less dependent on
the therapist and to form a less intense transference. Though some
clinicians argue that this form of therapy is less likely to institute
lasting change in borderline patients, others have induced signi -
cant behavioral modications in borderline patients with this kind
of treatment.
Group Therapies
Treating the borderline in a group makes perfect sense. A group
allows the borderline patient to dilute the intensity of feelings
directed toward one individual (such as the therapist) by recogniz-
ing emotions stimulated by others. In a group the borderline can
more easily control the constant struggle between emotional close-
ness and distance; unlike individual therapy, in which the spotlight
is always on him, the borderline can attract or avoid attention in a
group. Confrontations by other group members may sometimes be
more readily accepted than those from the idealized or devalued
therapist, because a peer may be perceived as someone “who really
understands what I’m going through.” The borderline’s demand-
ing nature, egocentrism, isolating withdrawal, abrasiveness, and
social deviance can all be more effectively challenged by group
peers. In addition, the borderline may accept more readily the
group’s expressions of hope, caring, and altruism.
4,5,6
The progress of other group members can serve as a model for
growth. When a group patient attains a goal, he serves as an inspira-
tion to others in the group, who have observed his growth and have
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SEEKING THERAPY 163
vicariously shared his successes. The rivalry and competition so
characteristic of borderline relationships are vividly demonstrated
within the group setting and can be identied and addressed in ways
that would be inaccessible in individual therapy. In a mixed group
(that is, one containing lower and higher functioning borderlines
or non-borderlines), all participants may benet. Healthier patients
can serve as models for more adaptive ways of functioning. And, for
those who have difculty expressing emotion, the borderline can
reciprocate by demonstrating greater access to emotion. Finally, a
group provides a living, breathing experimental laboratory in which
the borderline can attempt different patterns of behavior with other
people, without the risk of penalties from the “outside world.”
However, the features that make group therapy a potentially
attractive treatment for borderlines are the very reasons many such
patients resist group settings. The demand for individual attention,
the envy and distrust of others, the contradictory wish for, and
fear of, intense closeness all contribute to the reluctance of many
borderline patients to enter group treatment. Higher functioning
borderlines can tolerate these frustrations of group therapy and
use the “in vivo” experiences to address defects in interrelating.
Lower functioning borderlines, however, often will not join and, if
they do, will not stay.
The borderline patient may experience signi cant obstacles
in psychodynamic group therapy. His self-absorption and lack of
empathy often prevent involvement with others’ problems. If the
borderline’s concerns are too deviant or the material too intense,
he may feel isolated and disconnected. For example, a patient who
discusses childhood incest, or deviant sexual practices, or severe
chemical abuse may fear that he may shock the other group mem-
bers. And, indeed, some members may have difculty relating to
upsetting material. Some borderlines may share the feeling that
their needs are not being met by the therapist. In such situations
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164 I HATE YOUDON’T LEAVE ME
they may attempt to take care of each other in the ways that they
fantasized they could be cared for. This may lead to contacts
between patients outside of the group setting and perpetuation
of dependency needs as they try to “treat” each other. Romances
or business dealings between group members usually end disas-
trously, because these patients will not be able to use the group
objectively to explore the relationship, which is often a continua-
tion of unproductive searches to be cared for.
Elaine, a twenty-nine-year-old woman, was referred for group
therapy after two years of individual psychotherapy. The oldest of
four daughters, Elaine was sexually abused by her father, starting
around age ve and continuing for over ten years. She perceived her
mother as weak and ineffectual and her father as demanding and
unable to be pleased. In adolescence, she became the caretaker for
the whole family. As her sisters married and had children, Elaine
remained single, entering college and then graduate school. She had
few girlfriends and dated infrequently. Her only romantic relation-
ships involved two married, much older supervisors. Most of her
off-work time was devoted to organizing family functions, caring
for ill family members, and generally taking care of family problems.
Isolated and depressed, Elaine sought individual therapy. Recog-
nizing the limitations in her social functioning, she later requested
a referral for group therapy. There, she quickly established a posi-
tion as the helper for the others, denying any problems of her own.
She often became angry with the therapist, whom she perceived as
not helpful enough to the group members.
The group members encouraged Elaine to examine issues she
had previously been unable to confront—her constant scowling
and intimidating facial expressions and her subtly angry verbal
exchanges. Although this process took many frustrating months,
she was eventually able to acknowledge her disdain for women,
which became obvious in the group setting. Elaine realized that her
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SEEKING THERAPY 165
anger at the male therapist was actually transferred anger from her
father and recognized her compulsive attempts to repeat this father-
daughter relationship with other men. Elaine began to experiment
in the group with new ways of interacting with men and women.
Simultaneously, she was able to pull back from the suffocating immer-
sion in her family’s problems.
Most standardized therapies (see chapter 8) combine group with
individual treatment. Some approaches (such as Mentalization-Based
Therapy [MBT]) are psychodynamic and exploratory with less
direction from the therapist. Others (such as Dialectical Behavioral
Therapy [DBT] and Systems Training for Emotional Predictability
and Problem Solving [STEPPS]) are more supportive, behavioral, and
educational, emphasizing lectures, “homework” assignments, and
advice, as opposed to nondirective interactions.
Family Therapies
Family therapy is a logical approach for the treatment of some bor-
derline patients, who often emerge from disturbed relationships
with parents engaged in persistent conicts that may eventually
entangle the borderline’s own spouse and children.
Though family therapy is sometimes implemented with outpa-
tients, it is often initiated at a time of crisis, or during hospital-
ization. At such a point the family’s resistance to participating in
treatment may be more easily overcome.
The families of borderlines often balk at treatment for sev-
eral reasons. They may feel guilt over the patient’s problems and
fear being blamed for them. Also the bonds in borderline fam-
ily systems are often very rigid; family members are often suspi-
cious of outsiders and fearful of change. Though family members
may be colluding in the perpetuation of the patient’s behaviors
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166 I HATE YOUDON’T LEAVE ME
(consciously or unconsciously), the attitude of the family is often
“Make him better, but don’t blame us, don’t involve us, and most
of all, don’t change us.”
Yet it is imperative to gain some support from the family, for
without it therapy may be sabotaged. For adolescents and young
adults, family therapy involves the patient and his parents, and
sometimes his siblings. For the adult borderline who is married or
involved seriously in a romantic relationship, family therapy will
often include the spouse or lover and sometimes the couple’s chil-
dren. (Unfortunately, many insurance policies will not cover treat-
ment that is labeled “marriage therapy” or family treatment.) The
dynamics of borderline family interaction usually adopt one of two
extremes—either very strongly entangled or very detached. In the
former case, it is important to build an alliance with all family
members, for without their support the patient may not be able to
maintain treatment independently. When the family is estranged,
the therapist must carefully assess the potential impact of family
involvement: if reconciliation is possible and healthy, it may be an
important goal; if, however, it appears that reconciliation may be
detrimental or hopelessly unrealistic, the patient may need to relin-
quish fantasies of reunion. In fact, mourning the loss of an idealized
family interrelationship may become a major milestone in therapy.
7
Family members who resist an exploratory psychotherapy may nev-
ertheless be willing to engage in a psycho-educational format, such
as presented in the STEPPS therapy program (see chapter 8).
Debbie, a twenty-six-year-old woman, entered the hospital with
a history of depression, self-mutilation, alcoholism, and bulimia.
Family assessment meetings revealed an ambivalent but basically
supportive relationship with her husband. The course of therapy
began to focus on previously undisclosed episodes of sexual abuse
by an older neighbor boy, starting when the patient was about
eight years old. In addition to sexually abusing her, this boy had
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SEEKING THERAPY 167
also forced her to share liquor with him and then would make her
drink his urine from the bottle, which she would later vomit. He
had also cut her when she tried to refuse his advances.
These past incidents were reenacted in her current pathology.
As these memories unfolded, Debbie became more conscious of
long-standing rage at her alcoholic, passive father and at her weak,
disinterested mother, whom she perceived as unable to protect her.
Although she had previously maintained a distant, super cial rela-
tionship with her parents, she now requested an opportunity to
meet with them in family therapy to reveal her past hurts and dis-
appointment in them.
As she predicted, her parents were very uncomfortable with
these revelations. But for the rst time Debbie was able to confront
her father’s alcoholism and her disappointment in him and in her
mother’s detachment. At the same time all conrmed their love
for each other and acknowledged the difculties in expressing it.
Although she recognized there would be no signi cant changes
in their relationship, Debbie felt she had accomplished much and
was more comfortable in accepting the distance and failures in the
family interactions.
Therapeutic approaches to family therapy are similar to those
for individual treatment. A thorough history is important and may
include the construction of a family tree. Such a diagram may stim-
ulate exploration of how grandparents, godparents, namesakes, or
other important relatives may have inuenced family interactions
across generations.
As in individual and group therapy, family therapy approaches may
be primarily supportive-educational or exploratory-reconstructive. In
the former, the therapist’s primary goals are to ally with the family;
minimize conicts, guilt, and defensiveness; and unite them in work-
ing toward mutually supportive objectives. Exploratory-reconstructive
family therapy is more ambitious, directed more toward recognizing
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168 I HATE YOUDON’T LEAVE ME
the members’ complementary roles within the family system and
attempting actively to change these roles.
At one point in therapy, Elaine focused on her relationship
with her parents. After confronting them with the revelation of her
father’s sexual abuse, she continued to feel frustrated with them.
Both parents refused further discussion about the abuse and dis-
couraged her from continuing in therapy. Elaine was puzzled by
their behavior—sometimes they were very dependent and clinging;
other times she felt infantilized, especially when they continually
referred to her by her childhood nickname. Elaine requested fam-
ily meetings, to which they reluctantly agreed.
During these meetings Elaine’s father gradually admitted that
her accusations were true, though he continued to deny any direct
recollection of his assaults. Her mother realized that in many
ways she had been emotionally unavailable to her husband and
children and recognized her own indirect responsibility for the
abuse. Elaine learned for the rst time that her father had also
been sexually abused during his childhood. The therapy succeeded
in releasing skeletons from the family closet and establishing better
communication within the family. Elaine and her parents began
for the rst time speaking to each other as adults.
Artistic and Expressive Therapies
Individual, group, and family therapies require patients to express
their thoughts and feelings with words, but the borderline patient
is often somewhat handicapped in this area, more likely to exhibit
inner concerns through actions rather than verbalization. Expres-
sive therapies utilize art, music, literature, physical movement, and
drama to encourage communication in nontraditional ways.
In art therapy, patients are encouraged to create drawings,
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SEEKING THERAPY 169
paintings, collages, self-portraits, clay sculpture, dolls, and so on
that express inner feelings. Patients may be presented with a book
of blank pages, in which they are invited to draw representations
of a variety of experiences, such as inner secrets, closeness, or
hidden fears. Music therapy uses melodies and lyrics to stimulate
feelings that may otherwise be inaccessible. Music often unlocks
emotions and promotes meditation in a calm environment. Body
movement and dance use physical exertion to express emotions. In
another type of expressive therapy called psychodrama, patients
and the “therapist-director” act out a patient’s speci c problems.
Bibliotherapy is another therapy technique in which patients read
and discuss literature, short stories, plays, poetry, movies, and vid-
eos. Edward Albee’s Who’s Afraid of Virginia Woolf? is a popular
play to read, and especially perform, because its emotional scenes
provide a catharsis as patients recite lines of rage and disappoint-
ment that re ect problems in their own lives.
Irene’s chronic depression was related to sexual abuses that she
had endured at an early age from her older brother and that she
had only recently begun to remember. At twenty-ve and living
alone, she was ooded with recollections of these early encounters
and eventually required hospitalization as her depression wors-
ened. Because she felt overwhelmed by guilt and self-blame, she
was unable to verbalize her memories to others or allow herself to
experience the underlying anger.
During an expressive-therapy program that combined art and
music, the therapists worked with Irene to help her become more
aware of the fury that she was avoiding. She was encouraged to
draw what her anger felt like while loud, pulsating rock music
played in the background. Astonishing herself, she drew penises,
to which she then added mutilated disgurements. Initially fearful
and embarrassed about these drawings, they soon made her aware
and more accepting of her rage and obvious wish for retaliation.
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170 I HATE YOUDON’T LEAVE ME
As she discussed her emotional reactions to the drawings, she
began to describe her past abuse and the accompanying feelings.
Eventually, she began to talk more openly, individually with doc-
tors, and in groups, which afforded her the opportunity to develop
mastery over these frightening experiences and to place them in
proper perspective.
Hospitalization
Borderline patients constitute as much as 20 percent of all hospital-
ized psychiatric patients, and BPD is far and away the most com-
mon personality disorder encountered in the hospital setting.
8
The
borderline’s propensities for impulsivity, self-destructive behaviors
(suicide, drug overdoses), and brief psychotic episodes are the usual
acute precipitants of hospitalization.
The hospital provides a structured milieu to help contain and
organize the borderline’s chaotic world. The support and involve-
ment of other patients and staff present the borderline with impor-
tant feedback that challenges some of his perceptions and validates
others.
The hospital minimizes the borderline’s conicts in the external
world and provides greater opportunity for intensive self-examination.
It also allows a respite from the intense relationships between the
borderline and the outside world (including with his therapist), and
permits diffusion of this intensity onto other staff members within
the hospital setting. In this more neutral milieu the patient can
reevaluate his personal goals and program of therapy.
At rst, the inpatient borderline typically protests admission
but by the time of discharge may be fully ensconced in the hospital
setting, often fearful of discharge. He has an urgent need to be
cared for, yet at the same time may become a leader of the ward
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SEEKING THERAPY 171
trying to control and “help” other patients. At times he appears
overwhelmed by his catastrophic problems; on other occasions he
displays great creativity and initiative.
Characteristically, the hospitalized borderline creates a fasci-
nating pas de deux of splitting and projective identi cation (see
chapter 2 and Appendix B) with staff members. Some staff per-
ceive the borderline as a pathetic but appealing gamin; others see
him as a calculating, sadistic manipulator. These disparate views
emerge when the patient splits staff members into all-good (sup-
portive, understanding) and all-bad (confrontive, demanding) pro-
jections, much like he does with other people in his life. When staff
members accept the assigned projections—both “good” (“You’re
the only one who understands me”) and “bad” (“You don’t really
care; you’re only in it for the paycheck”)—the projective identi ca-
tion circle is completed: conict erupts between the “good” staff
and the “bad” staff.
Amid this struggle the hospitalized borderline recapitulates his
external world interpersonal patterns: a seductive wish for protec-
tion, which ultimately leads to disappointment, then to feelings of
abandonment, nally to self-destructive behaviors and emotional
retreat.
Acute Hospitalization
Since the 1990s, increasing costs of hospital care and greater insur-
ance restrictions have restructured hospital-based treatment pro-
grams. Most hospital admissions today are precipitated by acute,
potentially dangerous crises, including suicide attempts, violent
outbursts, psychotic breaks, or self-destructive episodes (drug abuse,
uncontrolled anorexia/bulimia, etc.).
Short-term hospitalization usually lasts for several days. A
complete physical and neurological assessment is performed. The
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172 I HATE YOUDON’T LEAVE ME
hospital milieu focuses on structure and limit-setting. Support and
positive rapport are emphasized. Treatment concentrates on prac-
tical, adaptive responses to turmoil. Vocational and daily living
skills are evaluated. Conjoint meetings with family, when appro-
priate, are initiated. A formalized contract between patient and
staff may help solidify mutual expectations and limits. Such a con-
tract may outline the daily therapy program, which the patient is
obligated to attend, and the patient’s specic goals for the hospital-
ization, which the staff agrees to address with him.
The primary goals of short-term hospitalization include resolv-
ing the precipitating crises and terminating destructive behaviors.
For example, the spouse of a patient who has thoughts of shooting
himself will be asked to remove guns from the house. Personal and
environmental strengths are identied and bolstered. Important
treatment issues are uncovered or reevaluated, and modi cations of
psychotherapy approaches and medications may be recommended.
Deeper exploration of these issues is limited on a short-term, inpa-
tient unit, and is more thoroughly pursued on an outpatient basis
or in a less intensive program, such as partial hospitalization (see
page 174). Since the overriding concern is to return the patient to
the outside world as quickly as possible and avoid regression or
dependence on the hospital, plans for discharge and aftercare com-
mence immediately upon admission.
Long-Term Hospitalization
Today, extensive hospitalization has become quite rare and is reserved
for the very wealthy or for those with exceptional insurance coverage
for psychiatric illness. In many cases where continued, longer-term
care is indicated, but connement in a twenty-four-hour residence is
not necessary, therapy can continue in a less restrictive milieu, such
as partial hospitalization. Proponents of long-term hospitalization
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SEEKING THERAPY 173
recognize the dangers of regression to a more helpless role, but argue
that true personality change requires extensive and intensive treat-
ment in a controlled environment. Indications for long-term con-
nement include chronically low motivation, inadequate or harmful
social supports (such as enmeshment in a pathological family sys-
tem), severe impairments in functioning that preclude holding a job
or being self-sufcient, and repeated failures at outpatient therapy
and short hospitalizations. Such features make early return to the
outside environment unlikely.
During longer hospitalizations, the milieu may be less highly
structured. The patient is encouraged to assume more shared respon-
sibility for treatment. In addition to current, practical concerns, the
staff and patient explore past, archetypal patterns of behavior and
transference issues. The hospital can function like a laboratory, in
which the borderline identi es specic problems and experiments
with solutions in his interactions with staff and other patients.
Eventually, Jennifer (see chapter 1) entered a long-term hospital.
She spent the rst few months in the closet—literally and gura-
tively. She would often sit in her bedroom closet, hiding from the
staff. After a while she became more involved with her therapist,
getting angry at him and attempting to provoke his rage. She alter-
nately demanded and begged to leave. As the staff held rm, she
talked more about her father, how he was like her husband, how
he was like all men. Jennifer began to share her feelings with the
female staff, something that had always been difcult because of
her distrust of and disrespect for women. Later during the hospi-
talization, she decided to divorce her husband and give up custody
of her son. Although these actions hurt her, she considered them
“unsel sh selshness”—trying to take care of herself was the most
self-sacricing and caring thing she could do for those she loved. She
eventually returned to school and obtained a professional degree.
The goals of longer hospitalization extend those of short-term
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174 I HATE YOUDON’T LEAVE ME
care—not only to identify dysfunctional areas but also to modify
these characteristics. Increased control of impulses, fewer mood
swings, greater ability to trust and relate to others, a more de ned
sense of identity, and better tolerance of frustration are the clearest
signs of a successful hospital treatment. Educational and vocational
objectives may be achieved during an extensive hospitalization.
Many patients are able to begin a work or school commitment
while transitioning from the hospital. Changes in unhealthy liv-
ing arrangements—moving out of the home, divorce, etc.—may
be completed.
The greatest potential hazard of long-term hospitalization is
regression. If staff do not actively confront and motivate the patient,
the borderline can become mired in an even more helpless position,
in which he is even more dependent on others to direct his life.
Partial Hospitalization
Partial (or day) hospital care is a treatment approach in which the
patient attends hospital activities during part or most of the day
and then returns home in the evening. Partial hospital programs
may also be held in the evening, following work or school, and may
allow sleeping accommodations when alternatives are not available.
This approach allows the borderline to continue involvement in
the hospital program, benetting from the intensity and structure
of hospital care, while maintaining an independent living situa-
tion. Hospital dependency occurs less frequently than in long-term
hospitalization. Because partial hospitalization is usually much
less expensive than traditional inpatient care, it is usually preferred
for cost considerations.
Borderlines who require more intensive care, but not twenty-
four-hour supervision, who are in danger of severe regression if
hospitalized, who are making a transition out of the hospital to the
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SEEKING THERAPY 175
outside world, who must maintain vocational or academic pursuits
while requiring hospital care, or who experience severe nancial
limitations on care may all bene t from this approach. The hospi-
tal milieu and therapy objectives are similar to those of the associ-
ated inpatient program.
The Rewards of Treatment
As we shall see in the next two chapters, treatment of BPD usually
combines standardized psychotherapeutic approaches and medi-
cations targeting specic symptoms. While at one time BPD was
thought to be a diagnosis of hopelessness and irritation, we now
know that the prognosis is generally much better than previously
thought. And we know that most of these patients leave the chaos
of their past and go on to productive lives.
The process of treatment may be arduous. But the end of the
journey opens up new vistas.
“You always spoke of unconditional acceptance,” said one bor-
derline patient to her therapist, “and somewhere in the recent past
I nally began to feel it. It’s wonderful. . . . You gave me a safe
place to unravel—to unfold. I was lost somewhere inside my mind.
You gave me enough acceptance and freedom to nally let my true
self out.”
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Chapter Eight
Speci c Psychotherapeutic
Approaches
There is a Monster in me. . . . It scares me. It makes me go up and
down and back and forth, and I hate it. I will die if it doesn’t let
me alone.
—From the diary of a borderline patient
True life is lived when tiny changes occur.
—Leo Tolstoy
Borderline Personality Disorder is the only major psychiatric ill-
ness for which there are more evidence-based studies demonstrat-
ing ef cacy from psychosocial therapies than for pharmacological
(drug) treatments. Thus, unlike the treatment for most other dis-
orders, medications are viewed as secondary components to psy-
chotherapy. Not only have several psychotherapy approaches
been shown to be effective, the arduous and sometimes extensive
endeavor of psychotherapy has also been shown to be cost-effective
for the treatment of personality disorders.
1
Psychotherapy as a treatment for BPD has come a long way
since the publication of this book’s rst edition. Spurred by rig-
orous research and constant renement by clinicians, two pri-
mary schools of therapy have emerged—the cognitive-behavioral
and psychodynamic approaches. In each category several distinct
strategies have been developed, each supported by its own set
9780399536212_IHateYou_TX_p1-272.indd 177 20/09/10 11:06 AM
SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 177
of theoretical principles and techniques. Several psychotherapy
strategies combine group and individual sessions. Though some
are more psychodynamic, some more behavioral, most combine
elements of both. All embrace communication that re ects SET-
UP features that were developed by the primary author and dis-
cussed in detail in chapter 5: Support for the patient, Empathy
for his struggles, confrontation of Truth or reality issues, together
with Understanding of issues and a dedication to Persevere in the
treatment.
Proponents of several therapy approaches have attempted to
standardize their therapeutic techniques by, for example, compiling
instructional manuals to help guide practitioners in conducting the
specic treatment. In this way, it is hoped that the therapy is con-
ducted consistently and equally effectively, irrespective of the prac-
titioner. (An obvious, though perhaps crass, analogy may be made
to a franchise food company, such as Starbucks or McDonald’s,
which standardizes its ingredients so that its coffee or hamburgers
taste the same regardless of where it is purchased.) Standardization
also facilitates gathering evidence in controlled studies, which can
support, or refute, the effectiveness of a particular psychotherapy
approach.
The underlying theory of standardization is that, just as it would
make little difference who physically gives the patient the Prozac
(as long as he ingested it), it would make little difference who
administered the psychotherapy, as long as the patient was in
attendance. However, interpersonal interactions are surely differ-
ent from taking and digesting a pill, so it is probably naive to pre-
sume that all psychotherapists following the same guidelines will
produce the same results with patients. Indeed, John G. Gunder-
son, MD, a pioneer in the study of BPD, has pointed out that the
original developers of these successful techniques are blessed with
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178 I HATE YOUDON’T LEAVE ME
prominent charisma and condence, which followers may not nec-
essarily possess.
2
Additionally, many therapists might nd such a
constrained approach too in exible.
3
Although the different psychotherapy strategies emphasize
distinctions, they possess many commonalities. All attempt to
establish clear goals with the patient. A primary early goal is to
disrupt self-destructive and treatment-destructive behaviors. All of
the formal, “manualized” therapies are intensive, requiring con-
sistent contact usually one or more times per week. All of these
therapies recognize the need for the therapist to be highly and spe-
cially trained and supported, and many require supervision and/or
collaboration with other team members. Therapists are more vig-
orously interactive with patients than in traditional psychoanaly-
sis. Because these therapies are time and labor intensive, usually
expensive, and often not fully covered by insurance (e.g., insurance
does not cover team meetings between therapists, as required in
formal DBT—see page 179), most of the studies exploring their
efcacy have been performed in university or grant-supported
environments. Most community and private treatment protocols
attempting to reproduce a particular approach are truncated mod-
ications of the formal programs.
It is no longer simply a matter of “nding any shrink who can
cure me” (though it is possible, of course, to get lucky this way).
In our complex society, all sorts of factors are, and should be,
considered by the patient: time and expense, therapist’s experi-
ence and specialization, and so on. Most important, the patient
should be comfortable with the therapist and her speci c approach
to treatment. So the reader is advised to read the remainder of this
chapter with an eye toward at least becoming familiar with speci c
approaches, as she will likely see them (and their acronyms) again
at some point during the therapeutic process.
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SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 179
Cognitive and Behavioral Treatments
Cognitive-behavioral approaches focus on changing current think-
ing processes and repetitive behaviors that are disabling; this type
of therapy is less concerned about the past than psychodynamic
approaches (see page 183). Treatment is more problem-focused and
often time-limited.
Cognitive-Behavioral Therapy (CBT)
A system of treatment developed by Aaron Beck, CBT focuses on
identifying disruptive thoughts and behaviors and replacing them
with more desirable beliefs and reactions.
4
Active attempts to point
out distorted thinking (“I’m a bad person”; “Everyone hates me”)
and frustrating behaviors (“Maybe I can have just one drink”) are
coupled with homework assignments designed to change these
feelings and actions. Assertiveness training, anger-management
classes, relaxation exercises, and desensitization protocols may all
be used. Typically, CBT is time-limited, less intensive than other
protocols, and therefore usually less expensive. The following
treatment programs are derived from CBT.
Dialectical Behavioral Therapy (DBT)
Developed by Marsha M. Linehan, PhD, at the University of Wash-
ington, DBT is the derivation of standard cognitive-behavioral ther-
apy that has furnished the most controlled studies demonstrating its
ef cacy. The dialectic of the treatment refers to the goal of resolving
the inherent “opposites” faced by BPD patients; that is, the need to
negotiate the borderline’s contradictory feeling states, such as loving,
then hating the same person or situation. A more basic dialectic in
this system is the need to resolve the paradox that the patient is trying
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180 I HATE YOUDON’T LEAVE ME
as hard as she can and is urged to be satised with her efforts, and yet
is simultaneously striving to change even more and do even better.
5
DBT posits that borderline patients possess a genetic/biological
vulnerability to emotional over-reactivity. This view hypothesizes
that the limbic system, the part of the brain most closely associ-
ated with emotional responses, is hyperactive in the borderline.
The second contributing factor, according to DBT practitioners, is
an invalidating environment; that is, others dismiss, contradict, or
reject the developing individual’s emotions. Confronted with such
interactions, the individual is unable to trust others or her own
reactions. Emotions are uncontrolled and volatile.
In the initial stages of treatment DBT focuses on a hierarchical
system of targets, confronting rst the most serious, and then later
the easiest, behaviors to change. The highest priority addressed
immediately is the threat of suicide and self-injuring behaviors. The
second-highest target is to eliminate behaviors that interfere with
therapy, such as missed appointments or not completing homework
assignments. The third priority is to address behaviors that inter-
fere with a healthy quality of life, such as disruptive compulsions,
promiscuity, or criminal conduct; among these, easier changes are
targeted rst. Fourth, the focus is on increasing behavioral skills.
The structured program consists of four main components:
1. Weekly individual psychotherapy to reinforce learned new
skills and to minimize self-defeating behaviors.
2. Weekly group skills therapy that utilizes educational mate-
rials about BPD and DBT, homework assignments, and
discussion to teach techniques to better control emotions,
improve interpersonal contacts, and nurture mindfulness—
a term to describe objective consideration of present feelings,
uncontaminated by ruminations on the past or future or by
emotional lability.
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SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 181
3.
Telephone coaching (a unique feature of DBT) to help patients
work through developing stresses before they become emer-
gencies; calls can be made to on-call coaches at any time, but
are deemed inappropriate if made after a patient has acted
out in a destructive manner.
4. Weekly meetings among all members of the therapist team to
enhance skills and motivation, and to combat burnout. Each
week, patients are given a DBT “diary card” to ll out daily.
The diary is meant to document self-destructive behaviors,
drug use, disruptive emotions, and how the patient coped
with such daily stresses.
Systems Training for Emotional Predictability and
Problem Solving (STEPPS)
Another manual-based variation of CBT is STEPPS, developed at the
University of Iowa. Like DBT, STEPPS focuses on the borderline’s
inability to modulate emotions and impulses. The unique modi ca-
tions of STEPPS were partly built on a wish to develop a less costly
program. STEPPS is a group therapy paradigm, without individual
sessions. It is also designed to be shorter—consisting of twenty two-
hour weekly groups (compared to the typical one-year commitment
expected in DBT). This program also emphasizes the importance of
involving the borderline’s social systems in treatment. Educational
training sessions “can include family members, signi cant others,
health care professionals, or anyone they regularly interact with,
and with whom they are willing to share information about their
disorder.”
6
STEPPS embodies three primary components:
1. Sessions educate about BPD and schema (cognitive distor-
tions about oneself and others, such as a sense of unlovability,
mistrust, guilt, lack of identity, fear of losing control, etc.).
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182 I HATE YOUDON’T LEAVE ME
2. Skills to better control emotions, such as problem manage-
ment, distracting, and improving communication, are taught.
3. The third component teaches basic behavioral skills, such as
healthy eating, healthy sleep regimen, exercise, and goal setting.
A second phase of STEPPS is STAIRWAYS (Setting goals; Trust-
ing; Anger management; Impulsivity control; Relationship behavior;
Writing a script; Assertiveness training; Your journey; Schemas revis-
ited). This is a twice-monthly one-year extension of skills-training
“seminars,” which reinforce the STEPPS model. Unlike DBT, which is
designed to be self-contained and discourages other therapy contribu-
tions, STEPPS is designed to complement other therapy involvement.
Schema-Focused Therapy (SFT)
SFT combines elements of cognitive, Gestalt, and psychodynamic
theories. Developed by Jeffrey Young, PhD, a student of Aaron
Beck’s, SFT conceptualizes maladaptive behavior arising from sche-
mas. In this model, a schema is dened as a worldview developed
over time in a biologically vulnerable child who encounters insta-
bility, overindulgence, neglect, or abuse. Schemas are the child’s
attempts to cope with these failures in parenting. Such coping mech-
anisms become maladaptive in adulthood. The concept of schemas
derives from psychodynamic theories. SFT attempts to challenge
these distorted responses and teach new ways of coping through a
process denoted as re-parenting.
7
Multiple schemas can be grouped into ve primary schema
modes, with which borderline patients identify and which corre-
late with borderline symptoms:
1. Abandoned and Abused Child (abandonment fears)
2. Angry Child (rage, impulsivity, mood instability, unstable
relationships)
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SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 183
3.
Punitive Parent (self-harm, impulsivity)
4. Detached Protector (dissociation, lack of identity, feelings of
emptiness)
5. Healthy Adult (therapist’s role to model for the patient—
soothes and protects the other modes)
Specic treatment strategies are appropriate for each mode. For
example, the therapist emphasizes nurturing and caring for the Aban-
doned and Abused Child mode. Expressing emotions is encouraged for
the Detached Protector mode. “Re-parenting” attempts to supply unmet
childhood needs. Therapists are more open than in traditional therapies,
often sharing gifts, phone numbers, and other personal information,
projecting themselves as “real,” “honest,” and “caring.” Conveying
warmth, praise, and empathy are important therapist features. Patients
are encouraged to read about schema and BPD. Gestalt techniques,
such as role-playing, acting out dialogue between modes, and visual-
ization techniques (visualizing and role-playing stressful scenarios) are
employed. Assertiveness training and other cognitive-behavioral meth-
ods are utilized. A possible danger in SFT is the boundary confrontation
in “re-parenting.” Therapists must be extremely vigilant regarding the
risk of transference and countertransference regression (see chapter 7).
Psychodynamic Treatments
Psychodynamic approaches typically employ discussion of the past
and present, with the goal of discovering patterns that may forge
a more productive future. This form of therapy is usually more
intensive—with sessions conducted several times a week—than the
cognitive-behavioral approach. The therapist should implement
a structured, consistent format with clear goals, yet be exible
enough to adapt to changing needs.
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184 I HATE YOUDON’T LEAVE ME
Mentalization-Based Therapy (MBT)
Mentalization, a term elaborated by Peter Fonagy, PhD, describes
how people understand themselves, others, and their environment.
Using mentalization, an individual understands why she and oth-
ers interact the way they do, which in turn leads to the ability
to empathize with another’s feelings.
8
The term overlaps with the
concept of psychological mindedness (understanding the connec-
tion between feelings and behaviors) and mindfulness (a goal in
DBT; see above). Fonagy theorizes that when the normal develop-
ment of mentalization beginning in early childhood is disrupted,
adult pathology develops, particularly BPD. This conceptualiza-
tion is based on psychodynamic theories of a healthy attachment
to a parenting gure (see chapter 3). When the child is unable to
bond appropriately with a parent, he has dif culty understand-
ing the parent’s or his own feelings. He has no healthy context on
which to base emotions or behaviors. Object constancy cannot be
sustained. The child develops abandonment fears or detaches from
others. This developmental failure may arise either from the child’s
temperament (biological or genetic limitations) or from the par-
ent’s pathology, which may consist of physical or emotional abuse
or abandonment, or inappropriate smothering of independence, or
from both.
MBT is based on the supposition that beliefs, motives, emotions,
desires, reasons, and needs must rst be understood in order to func-
tion optimally with others. Conrming data on the effectiveness of
this method has been documented by Bateman and Fonagy, pri-
marily within a daily partial hospital setting in England.
9,10
In this
design, patients attend the hospital during the day, ve days a week
for eighteen months. Treatment includes psychoanalytically oriented
group therapy three times a week, individual psychotherapy, expres-
sive therapy consisting of art, music, and psychodrama programs,
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SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 185
and medications as needed. Daily staff meetings are held and consul-
tations are available. Therapists, employing a manual-based system,
focus on the patient’s current state of mind, identify distortions in
perception, and collaboratively attempt to generate alternative per-
spectives about himself and others. While much of the behavioral
techniques recalls DBT, some of the psychodynamic structure of
MBT overlaps with Transference-Focused Psychotherapy (TFP).
Transference-Focused Psychotherapy (TFP)
TFP is a manual-based program that Otto Kernberg, MD, and
colleagues at Cornell have developed from more traditional psy-
choanalytic roots.
11,12
The therapist focuses initially on developing
a contract of understanding of the roles and limitations in the ther-
apy. Like DBT, early concerns revolve around suicide danger, inter-
ruption of therapy, dishonesty, and so on. Like other treatment
approaches, TFP acknowledges the role of biological and genetic
vulnerability colliding with early psychological frustrations. A
primary defense mechanism seen in borderline patients is identity
diffusion, which refers to a distorted and unstable sense of self
and, consequently, others. Identity diffusion suggests a perception
of oneself and others as if they were fuzzy, ghostlike distortions
in a fun-house mirror, barely perceptible and insubstantial to the
touch. Another feature of BPD is persistent splitting, dividing per-
ceptions into extreme and opposite dyads of black or white, right
or wrong, resulting in the belief that oneself, another, or a situa-
tion is all-good or all-bad. Accepting that a good person could dis-
appoint is difcult to comprehend; thus, the formerly good person
mutates into an all-bad person. (The professional reader will note
that distortions in MBT’s mentalization would include the con-
cepts of identity diffusion and splitting; the difculty with dyadic
extremes recalls the dialectical paradoxes theorized in DBT.)
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186 I HATE YOUDON’T LEAVE ME
TFP theorizes that identity diffusion and splitting are early, pri-
mary elements in normal development. However, in BPD, normal,
developing integration of opposite feelings and perceptions is dis-
rupted by frustrating caregiving. The borderline is stuck at an imma-
ture level of functioning. Feelings of emptiness, severe emotional
swings, anger, and chaotic relationships result from this black-and-
white thinking. Therapy consists of twice-weekly individual sessions,
in which the relationship with the therapist is examined. This here-
and-now transference experience (see chapter 7) allows the patient to
experience in the moment the splitting that is so prevalent in his life
experience. The therapist’s ofce becomes a kind of laboratory, in
which the patient can examine his feelings in a safe, protected envi-
ronment, and then extend his understanding to the outside world.
The combination of intellectual understanding and the emotional
experience in working with the therapist can lead to the healthy inte-
gration of identity and perceptions of others.
Comparing Treatments
A vignette may help demonstrate how therapists utilizing these
various approaches might handle the same situation in therapy:
Judy, a twenty-nine-year-old single accountant, arrived at her
therapist’s ofce quite upset, after having an intense argument
with her father, during which he called her a “slut.” When her
doctor inquired about what prompted his slur, Judy became
more upset, accusing the therapist of taking her father’s side
and throwing a box of tissues across the room.
A DBT therapist might focus on Judy’s anger and physical
outburst. He might empathize with her frustration, accept her
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SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 187
impulsive gesture, and then work with her to vent her frustration
without becoming violent. He might also discuss ways to deal with
her frustration with her father.
The SFT therapist might rst try to correct Judy’s mispercep-
tion of him and reassure her that he is not angry at her and is
totally on her side.
In MBT, the doctor may try to get Judy to relate what she is
feeling and thinking at this moment. He may also attempt to direct
her to thinking (mentalizing) about what she supposed her father
was reacting to during their conversation.
The TFP therapist may explore how Judy is comparing him to
her father. He might focus on her severely changing feelings about
him at that moment in therapy.
Other Therapies
A number of other therapy approaches, less studied, have also been
described. Robert Gregory and his group at the State University
of New York in Syracuse have developed a manual-based proto-
col, Dynamic Deconstructive Psychotherapy (DDP), speci cally
directed toward borderline patients who are more challenging or
have complicating disorders such as substance abuse.
13
Weekly indi-
vidual, psychodynamically oriented sessions are directed toward
activating impaired cognitive perceptions and helping the patient
develop a more coherent, consistent sense of self and others.
Alliance-Based Therapy (ABT) developed at Austen Riggs Cen-
ter in Stockbridge, Massachusetts, is a psychodynamic approach
that focuses specically on suicidal and self-destructive behav-
iors.
14
Much like TFP, the emphasis is on the therapeutic relation-
ship and how it impacts the borderline’s self-harming actions.
Intensive Short-Term Dynamic Psychotherapy (ISTDP), designed
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188 I HATE YOUDON’T LEAVE ME
for the treatment of patients with borderline and other personal-
ity disorders, has been elaborated by a Canadian group.
15
Weekly
individual sessions concentrate on unconscious emotions that are
responsible for defenses and the connections between these feelings
and past traumas. Treatment is generally expected to continue for a
period of around six months.
Practitioners from Chile, recognizing the difculty of providing
intensive individual care for borderline patients, developed a group
therapy system, Intermittent-Continuous Eclectic Therapy (ICE).
16
Weekly ninety-minute group therapy sessions are conducted in
ten-session cycles. Patients may continue with further rounds,
as they and their therapists choose. A psychodynamic viewpoint
guides understanding of the patient, but interpretations are mini-
mized. The rst part of each session is an open, supportive period
in which unstructured discussion is encouraged; the second half
is arranged like a classroom, in which skills are taught to handle
difcult emotions (as in DBT and STEPPS).
Which Therapy Is Best?
All of these “alphabet-soup” treatment designs endeavor to stan-
dardize the therapy, most utilizing manual-based programs, and
have attempted to develop controlled studies to determine ef -
cacy. All have evolved studies demonstrating the superiority of
the formalized therapy over a comparative, nonspeci c, support-
ive “treatment as usual.” Some research has studied comparative
results among these treatments.
One study compared the results of yearlong outpatient treat-
ments for borderline patients with three different approaches:
DBT, TFP, and a psychodynamic supportive therapy.
17
Patients in
all three groups demonstrated improvement in depression, anxiety,
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SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 189
social interactions, and general functioning. Both DBT and TFP
showed signicant reduction in suicidal thinking. TFP and sup-
portive therapy did better in reducing anger and impulsivity. TFP
performed best in reducing irritability and verbal and physical
assault.
A three-year Dutch study compared results of treating border-
line patients with SFT versus TFP.
18
After the rst year, both treat-
ment groups experienced comparable signicant reductions in BPD
symptoms and improvement in quality of life. By the third year,
however, SFT patients exhibited signicantly greater improvement
and had fewer dropouts. A later study from the Netherlands com-
pared cost-effectiveness of these two psychotherapy designs.
19
This
investigation attempted to measure cost of treatment with improve-
ment in quality of life over time (determined by a self-administered
questionnaire). Although quality of life measures after TFP were
slightly higher than after SFT, the overall cost for comparable
improvement was signicantly more efcient with SFT.
Although these studies are admirable attempts to compare dif-
ferent treatments, all can be criticized. Patient and therapist selec-
tion, validity of measures used, and the plethora of uncontrolled
variables that impact on any scientic study make attempts to com-
pare human behavioral responses very difcult. Continued studies
on larger populations will illuminate therapeutic approaches that
will be benecial for many patients in aggregate. But given the
complex variations rooted in our DNA, which make one person so
different from another, unveiling the “best” treatment that will be
ideal for every individual is surely impossible. The treatment that
demonstrates superiority in a majority of patients in a study may
not be the ideal choice for you. This is no less true in the area of
medications, where we nd one size does not t all.
Thus, the primary point to be gleaned from these studies is not
which treatment works best, but that psychotherapeutic treatment
9780399536212_IHateYou_TX_p1-272.indd 190 20/09/10 11:06 AM
190 I HATE YOUDON’T LEAVE ME
does work! Unfortunately, psychotherapy has been guratively and
literally devalued over the years. Psychological services, in general,
are reimbursed at a remarkably lower rate than medical services.
Insurance payment to a clinician for an hour of noninterventional
interaction with a patient (diet and behavioral adjustments to dia-
betes, instruction on caring for a healing wound, or psychother-
apy) is a fraction of the payment for a routine medical procedure
(minor surgical intervention, steroid injection, etc.). For one hour
of psychotherapy, Medicare and most private insurance compa-
nies pay less than one-tenth of the reimbursement rate directed for
many minor outpatient surgical procedures.
As the United States continues its quest to provide health care
to more people in more affordable ways, there will be temptations
to mandate treatments that are shown to be grossly equivalent, but
less expensive. It will be important to maintain exibility in such
a system, so that we do not denigrate the art of medicine, which
allows individuality in the sacred relationship between doctor and
patient.
Future Research and Specialized Therapies for BPD
In the future, advances in genetic and biological research may sug-
gest how therapies can be “individualized” for speci c patients.
Just as no single medicine is recognized as better than the others
in treating all BPD patients, no single therapeutic approach can
be better for all, despite attempts to compare approaches. Thera-
pists should direct specic therapy approaches to different patient
needs, rather than try to apply the ctional best approach to every-
one. For example, borderline patients who are signi cantly sui-
cidal or engaged in serious self-mutilating behaviors may initially
respond best to cognitive/behavioral approaches, such as DBT.
Higher functioning patients may respond better to psychodynamic
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SPECIFIC PSYCHOTHERAPEUTIC APPROACHES 191
protocols. Financial or scheduling limitations may favor time-
limited therapies, whereas repeated destructive life patterns might
dictate a need for longer-term, more intensive protocols.
Just as most medical specialties (e.g., ophthalmology) have
developed subspecialty areas for complicated situations or for the
parts of the organ involved (e.g., retina, cornea), optimal treatment
of BPD may be heading in the same direction. Specialized centers of
care for BPD, for example, featuring experienced, specially trained
professionals could offer more efcient treatment regimens.
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Chapter Nine
Medications: The Science
and the Promise
One pill makes you larger, and one pill makes you small . . .
—From “White Rabbit,” by Je erson Airplane
Doctors are men who prescribe medicines of which they know
little, to cure disease of which they know less, in human beings
of whom they know nothing.
—Voltaire
While psychotherapy is the recognized primary treatment for BPD,
most treatment plans include recommendations for inclusion of
drug therapy. However, medications often present highly charged
dilemmas for borderline patients. Some are bewitched by the allur-
ing promise of drugs to “cure” their “borderline.” Others fear being
transformed into zombies and resist any medication. As scientists
have not yet isolated the borderlinus virus, there is no single “anti-
biotic” that treats all aspects of BPD. However, medications are use-
ful for treating associated symptoms (such as antidepressants for
depression), and for taming self-defeating characteristics, such as
impulsivity.
Despite Voltaire’s plaint, doctors are learning more and more
about how and why medications treat disease. New discoveries in
the genetics and neurobiology of BPD help us understand how and
why these medications can be effective.
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MEDICATIONS: THE SCIENCE AND THE PROMISE 193
Genetics
Nature-nurture arguments about the cause of physical and mental
disease have raged for decades, of course, but with the expansion
of knowledge of heritability, gene mapping, and molecular genetics
over the past quarter century, the role of nature has become better
understood. One approach to this controversy is through the use
of “twin studies”: in this type of study, identical twins (possessing
the same genetic makeup) who are adopted into different house-
holds are examined years later for the presence of the disease. If
one twin exhibits BPD, the likelihood that the other, reared in a
different environment, will also be diagnosed with BPD is as much
as 35 percent to almost 70 percent in some studies, thus giving
greater weight to the nature argument.
1
Specic borderline traits,
such as anxiety, emotional lability, suicidal tendencies, impulsivity,
anger, sensation-seeking, aggression, cognitive distortions, identity
confusion, and relationship problems, can also be highly genetic.
Heritability also extends to family members. Relatives of bor-
derlines exhibit signicantly greater rates of mood and impulse
disorders, substance abuse, and personality disorders, especially
BPD and antisocial personality.
2
Our humanness emerges from the elaborate and unique chain
of chromosomes that determine the individual. Although one
specic gene alone does not determine our fate, a combination
of DNA codings on different chromosomes do contribute to vul-
nerability for illness. Individual genes have been associated with
Alzheimer’s disease, breast cancer, and other maladies; however,
other chromosomal loci and environmental factors also contrib-
ute. Molecular genetics has identi ed specic gene alterations
(polymorphisms) that are associated with BPD. Interestingly, these
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194 I HATE YOUDON’T LEAVE ME
genes are involved with production and metabolism of the neu-
rotransmitters, serotonin, norepinephrine, and dopamine. These
neurotransmitters facilitate communication between brain cells
and inuence which genes are turned on or off. Alterations in these
neurotransmitters have been associated with mood disorders,
impulse dysregulation, dissociation, and pain sensitivity.
Neuroendocrinology
Other endocrine (hormone) neurotransmitters have been impli-
cated in borderline pathology. NMDA (N-methyl-D-aspartate)
dysregulation has been noted in BPD (as well as in some other ill-
nesses) and implicated with dissociation, psychotic episodes, and
impaired cognition.
3
Disruptions in the body’s opioid (endorphin)
system has been demonstrated in BPD and associated with dis-
sociative experiences, pain insensitivity (particularly among self-
mutilating individuals), and opiate abuse.
4
Acetylcholine is another
neurotransmitter affecting memory, attention, learning, mood,
aggression, and sexual behavior, which has been linked to BPD.
5
Chronic or repeated stress can also disrupt the neuroendocrine
balance. Stress activates the hypothalamic-pitiutary-adrenal (HPA)
axis, which secretes cortisol and activates the body’s immune sys-
tem. In the usual acute stress situation, this system activates the
“ ght-ight” mechanisms of the body in a productive way. An
internal feedback mechanism acts like a thermostat to then turn
down the axis and return the body to equilibrium. However, ongo-
ing stress dismantles the regenerative circuit and the stress alarms
continue unabated, in icting negative impact on the body, includ-
ing shrinkage in characteristic areas of the brain. This pattern has
been observed in several disorders, including BPD, PTSD, major
depression, and certain anxiety disorders.
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MEDICATIONS: THE SCIENCE AND THE PROMISE 195
Neurological Dysfunction
Disturbances in brain function have been frequently associated
with BPD. A signicant subset of borderline patients have expe-
rienced a history of head trauma, encephalitis, epilepsy, learning
disability, EEG (electroencephalogram, or brain wave) abnormali-
ties, sleep pattern dysfunction, and abnormal, subtle neurologic
“soft signs.”
6,7
Sophisticated brain imaging—such as fMRI (functional mag-
netic resonance imaging), CT (computerized tomography), PET
(positron emission tomography), and SPECT (single photon emis-
sion computed tomography)—has elucidated some of the anatomi-
cal and physiological deviations associated with BPD. As already
noted (see chapter 3), these studies seem to imply overactivity of
those parts of the brain involved with emotional response (the
limbic system), which includes such deep brain structures as the
amygdala, hippocampus, and cingulate gyrus, while demonstrat-
ing underactivity of the outer parts of the brain involved with
executive thinking and control, such as the prefrontal cortex.
8
Future Considerations
With these advances in genetics and neurobiology, scientists will
eventually be able to subtype more discretely different presenta-
tions of pathology, and, based on this knowledge, doctors may be
able to more precisely “customize” a particular drug to a particular
patient. To use an analogy: Our current understanding of psychiatric
illnesses is roughly similar to our understanding of infections in the
early and mid-1900s, before doctors could adequately culture the
infecting agent. At that time, it was generally acknowledged that all
antibiotics were equally benecial—penicillin was just as effective,
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196 I HATE YOUDON’T LEAVE ME
among all patients with infections, as any other antibiotic. However,
when scientists discovered how to culture individual strains of bac-
teria and establish their sensitivities to particular antibiotics, doc-
tors could prescribe a specic drug with the greatest likelihood of
success. In other words, doctors were not simply treating infection
or pneumonia; they were treating the speci c strain, staphylococcus
aureus. Similarly, in the future, the hope is that we will be able to
“culture” the psychiatric illness and determine the best treatment.
We will be treating the individual’s unique biology, not simply the
diagnosis. As a result, the concept of “off-label” (in which a medi-
cine is prescribed for a condition not formally approved—see page
200) will become moot, since the medicine will be directed toward a
specic biological process, rather than a particular diagnosis.
Medications
Discoveries in the exploding elds of genetics and brain physiology
have led to new drugs for many physical and mental conditions.
Great advances have been achieved in pharmacology, especially in
the area of biotechnology; in short, numerous psychotherapeutic
drugs have been developed in the last twenty years, and the evidence
suggests that some have proved effective in treating BPD. Although
no medication is targeted specically for BPD, research has dem-
onstrated that three primary classes of medicines—antidepressants,
mood stabilizers, and neuroleptics (antipsychotics)—ameliorate
many of the maladaptive behaviors associated with the disorder.
9
Antidepressants
Most research has examined the use of antidepressants, par-
ticularly serotonin reuptake inhibitors (SSRIs or SRIs). These
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MEDICATIONS: THE SCIENCE AND THE PROMISE 197
medicines include Prozac (uoxetine), Zoloft (sertraline), Paxil or
Pexeva (paroxetine), Luvox (uvoxamine), Celexa (citalopram),
and Lexapro (escitalopram—related to citalopram). Predictably,
these drugs have been effective for mood instability and related
symptoms of depression, such as feelings of emptiness, rejection
sensitivity, and anxiety. Additionally, SRIs have been shown to
decrease inappropriate anger and temper outbursts, aggressive
behavior, destructive impulsivity, and self-mutilating actions, even
in the absence of depressive symptoms. In many studies, higher
than usual doses of these medicines (for example, >80 mg of Pro-
zac; >200 mg of Zoloft per day) were necessary to have a positive
effect. A related group of drugs, serotonin-norepinephrine reup-
take inhibitors (SNRIs), have not been as extensively studied, but
may have similar positive effects. These include Effexor (venlafax-
ine), Pristiq (desvenlafaxine—related to venlafaxine), and Cym-
balta (duloxetine).
Older antidepressants, such as tricyclic antidepressants (TCAs)
and monoamine oxidase inhibitors (MAOIs), have also been
studied. TCAs include Elavil (amitriptylene), Tofranil (imipra-
mine), Pamelor or Aventyl (nortriptylene), Vivactil (protriptylene),
Sinequan (doxepin), Norpramin (desipramine), Asendin, (amoxa-
pine), Surmontil (trimipramine), and others. These drugs have
generally been less effective and in some cases have decreased emo-
tional control. Therefore, the patient diagnosed with BPD should
be wary of prescribed drugs in the TCA class.
MAOIs—Nardil (phenelzine) and Parnate (tranylcypromine)
being the most commonly used in the United States—have shown
efcacy in BPD comparable to that of SRIs. However, MAOIs tend
to have more side effects, are more dangerous in overdose, and
require dietary and concurrent medication restrictions, and are
therefore utilized much less.
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198 I HATE YOUDON’T LEAVE ME
Mood Stabilizers
This group of medications includes Lithium, a naturally occurring
element, and antiseizure drugs—Depakote (valproate), Tegretol (car-
bamazepine), Trileptal (oxcarbazepine—related to carbamazepine),
Lamictal (lamotrigine), and Topamax (topiramate). APA guidelines
recommend this group as adjunctive treatment when SRIs or other
interventions are ineffective or only partially effective. These medi-
cines, in typical doses, help stabilize mood, decrease anxiety, and bet-
ter control impulsivity, aggression, irritability, and anger. Neurontin
(gabapentin), Dilantin (phenytoin), Gabatril (tiagabine), Keppra (leve-
tiracetam), and Zonegran (zonisamide) are also in this class of drugs,
but studies testing their effectiveness in BPD patients have been limited.
Neuroleptics
These drugs are recommended for initial treatment of cognitive-
perceptual distortions in borderline patients. Paranoia, dissociative
symptoms, and feelings of unreality (criteria 9 in the DSM-IV-TR—
see chapter 2) are primary targets. In combination with SRIs, these
medicines, usually in lower than common doses, relieve feelings of
anger and aggressiveness; stabilize mood; and decrease anxiety,
obsessional thinking, impulsivity, and interpersonal sensitivity.
Early studies were done with older neuroleptics, such as Thora-
zine (chlorpromazine), Stelazine (triuoperazine), Trilafon (perphe-
nazine), Haldol (haloperidol), Navane (thiothixene), and Loxitane
(loxapine). Newer medicines, called atypical antipsychotics, have
also demonstrated efcacy with generally less complicated side
effects. These include Zyprexa (olanzapine), Seroquel (quetiapine),
Risperdal (risperidone), Abilify (aripiprazole), and Clozaril (cloza-
pine). Other medicines in this class—Invega (paliperidone—related to
risperidone), Fanapt (iloperidone), Saphris (asenapine), and Geodon
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MEDICATIONS: THE SCIENCE AND THE PROMISE 199
(ziprasidone)—have either not been studied or have yielded contra-
dictory results.
Anxiolytics
Antianxiety agents, although acutely helpful for anxiety, have
been shown to increase impulsivity and can be abused and addic-
tive. These tranquilizers, primarily in the class known as ben-
zodiazepines, include Xanax (alprazalom), Ativan (lorazepam),
Valium (diazepam), and Librium (chlordiazepoxide), among oth-
ers. Klonopin (clonazepam), a longer-acting benzodiazepine that
may have greater effect on serotonin, has had success in treating
symptoms of aggression and anxiety and so is perhaps the only
benzodiazepine that may be useful for BPD.
Opiate Antagonists
Revia (naltrexone) blocks the body’s release of its own endorphins,
which induce analgesia and euphoric feelings. Some reports sug-
gest that this medicine may inhibit self-mutilating behavior.
Other Treatments
Homeopathic or herbal treatments have generally been unsuccess-
ful, with the exception of omega-3 fatty acid preparation. One
small study found that the substance did decrease aggressiveness
and depression among women.
10
Two substances that modulate the neurotransmitter glutamate
have been investigated in BPD. The amino acid N-acetylcysteine and
Rilutek (riluzole)—a drug used for the treatment of amyotrophic
lateral sclerosis (Lou Gehrig’s disease)—were reported to signi -
cantly diminish self-injurious behavior in two borderline patients.
11
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200 I HATE YOUDON’T LEAVE ME
The APA’s Practice Guideline recommends that medications
target a specic symptom cluster. Guidelines divide BPD symp-
toms into three primary groups: Mood Instability, Impulse Dys-
control, and Cognitive-Perceptual Distortions. An algorithm of
recommended treatment approaches, with alternative tactics if the
previous choice is ineffective, is summarized in Table 9-1.
TABLE 91. Pharmacotherapy for treating BPD symptoms
Symptom 1st Choice 2nd Choice 3rd Choice 4th Choice
Mood Instability SRI dierent SRI or SNRI add NL,
clonazepam;
or switch to MAOI
add MS
Impulse
Dyscontrol
SRI add NL add MS; or switch
to MAOI
Cognitive-
Perceptual
Distortions
NL add SRI or MAOI or
di erent NL
SRI=serotonin reuptake inhibitor; may require higher than usual doses
NL=neuroleptic; usually in low doses
MAOI=monoamine oxidase inhibitor
MS=mood stabilizer
A Word About “O -Label” Use
The FDA (Food and Drug Administration) has not formally
approved any drug for the treatment of BPD, so all of the medi-
cines commonly used for treating BPD are considered “off-label.”
Though the term “off-label” may be off-putting, if not seem down-
right risky to the uninitiated, off-label prescribing is quite com-
mon for a wide variety of conditions. Because a pharmaceutical
company spends almost $1 billion on average to bring a drug to
market, many companies do not seek approval for a wide range
of conditions or outside narrow dosage ranges, as these strategies
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MEDICATIONS: THE SCIENCE AND THE PROMISE 201
might narrow the chances for FDA approval and greatly increase
the cost of development. For example, even though it is known
that SRIs benet several conditions, including depression, PTSD,
anxiety illnesses, and some pain disorders, the drug manufac-
turer may not want to absorb the extra expense of gaining FDA
approval—nor risk FDA rejection—by applying for label use for
all of these indications and/or broad dosage ranges. Whenever a
physician prescribes a medicine for an unapproved condition, or
at a dose outside of recommendations, it is considered “off-label.”
Unfortunately, managed care agencies may refuse approval of these
(sometimes expensive) “off-label” prescriptions.
Generic Drugs
In simplest terms, a generic drug contains the same primary or
active ingredient as the original formulation; generally speaking,
it is almost always less expensive. However, this does not mean
that a generic medication is identical to its brand-name counter-
part. The FDA considers a generic drug “equivalent” to a branded
medicine if blood levels in healthy volunteers are within 20 percent
variation, a signicant difference in some patients. A generic may
also differ from the original in its inactive ingredients and its deliv-
ery system (e.g., tablet or capsule). Moreover, one generic may vary
widely from another (theoretically, up to a 40 percent variation in
blood level). The lesson here is that if a switch to a generic drug
will result in signicant savings, it may be worth trying. However,
if symptoms recur, it is best to return to the brand medicine. Addi-
tionally, if you are taking a generic medicine that is working, do
not change to a different generic. Also, be aware that some phar-
macies and some doctors receive bonuses for switching patients to
generic drugs.
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202 I HATE YOUDON’T LEAVE ME
Split Treatment
Many patients receive care from more than one provider. Often,
therapy may be administered by a nonmedical professional (psy-
chologist, social worker, or counselor), while medications are
administered by a physician (psychiatrist or primary care doctor).
Advantages of this protocol include less expense (thus accounting
for its encouragement by managed care companies), involvement
of more professionals, and separation of therapy and medica-
tion issues. But this separation can also be a disadvantage, since
it allows the potential for patients to split providers into “good
doctors” and “bad doctors” and to become confused about the
treatment. Close communication among professionals treating the
same patient is essential for the process to be successful. In most
cases, a psychiatrist skilled in both medical management and psy-
chotherapy techniques may be the preferred approach.
Can Borderlines Be Cured?
Much like the disorder itself, professionals’ opinion about the
prognosis for those aficted with BPD has whipsawed from one
extreme to the other. In the 1980s Axis II personality disorders
were generally thought to be enduring and stable over time. DSM-
III asserted that personality disorders “begin in childhood or ado-
lescence and persist in stable form (without periods of remission or
exacerbation) into adult life.”
12
This perception was in contrast to
most Axis I disorders (such as major depression, alcoholism, bipo-
lar disorder, schizophrenia, etc.), which were thought to be more
episodic and responsive to pharmacological treatment. Suicide
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MEDICATIONS: THE SCIENCE AND THE PROMISE 203
rates in BPD approached 10 percent.
13
All of these considerations
suggested that prognosis for BPD was likely to be poor.
However, longer-term studies published over the last several
years demonstrated signicant improvement over time.
14,15
In these
studies, tracking borderlines over a ten-year period, up to two-
thirds of the patients no longer exhibited ve of the nine de ning
criteria for BPD, and therefore could be considered “cured,” since
they no longer fullled the formal DSM de nition. Improvement
occurred with or without treatment, although treated patients
achieved remission sooner. Most patients remained in treatment,
and relapses diminished over time. Despite these optimistic nd-
ings, it was also discovered that although these patients no longer
could be formally designated as “borderline,” some continued to
have difculty with interpersonal functioning that impaired their
social and vocational relationships. This suggests that the more
acute and prominent symptoms of BPD (which primarily de ne the
disorder), such as suicidal or self-mutilating behaviors, destruc-
tive impulsivity, and quasi-psychotic thinking, are more quickly
responsive to treatment or time than the more enduring tempera-
mental symptoms (fears of abandonment, feelings of emptiness,
dependency, etc.). In short, although the prognosis is clearly much
better than originally thought, some borderlines continue to strug-
gle with ongoing issues.
Those who conquer the illness display a greater capacity to
trust and establish satisfactory (even if sometimes not very close)
relationships. They have a clearer sense of purpose and a more
stable understanding of themselves. In a sense, then, even if bor-
derline issues remain, they become better borderlines.
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Chapter Ten
Understanding and Healing
Now here, you see, it takes all the running you can do to keep in
the same place. If you want to get somewhere else, you must run
at least twice as fast as that.
—From Through the Looking-Glass, by Lewis Carroll
“I feel like I have a void in me that I can never quite ll.” Elizabeth,
an attractive, witty twenty-eight-year-old woman, was originally
referred for therapy by her family doctor. She had been married for
six years to a man who was ten years older than her and had been
her boss at one time. Five months before, she had given birth to her
rst child, a daughter, and was now severely depressed.
She yearned for something she could call her own, something
that would “show that the rest of the world knew I was here.” Inside,
she felt her “real self” was a swamp of childish emotions, and that
she was always hiding her feelings, which were “ugly and bad.” These
realizations turned into self-hate; she wanted to give up.
By her count, Elizabeth had engaged in nine extramarital affairs
over the previous six years—all with men she met through work.
They began soon after the death of her father. Most were relation-
ships that she totally controlled, rst by initiating them and later
by ending them. She had found it exciting that these men seemed
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UNDERSTANDING AND HEALING 205
so puzzled by her advances and then by her sudden rejections. She
enjoyed the physical closeness, but acknowledged she dreaded being
too emotionally involved. Although she controlled these relation-
ships, she never found them sexually satisfying; nor was she sexually
responsive to her husband. She admitted that she used sex to “equal-
ize” relationships, to stay in control; she felt safer that way. Her
intellect and personality, she felt, were not enough to hold a man.
Reared in a working-class Catholic family, Elizabeth had three
older brothers and a younger sister, who had drowned in a swim-
ming accident at age ve. Elizabeth was only eight at the time and
had little understanding of the event except to observe her mother
becoming more withdrawn.
For as long as Elizabeth could remember, her mother had been
hypercritical, constantly accusing Elizabeth of being “bad.” When
she was a young girl, her mother insisted that she attend church
with her, and forced her father to construct an altar in Elizabeth’s
bedroom. Elizabeth felt closer to her father, a passive and quiet
man, who was dominated by his wife. As she entered puberty, he
became more distant and less affectionate.
Growing up, Elizabeth was quiet and shy. Her mother disap-
proved of her involvement with boys and closely watched her friend-
ships with girls; she was expected to have “acceptable” friends. Her
brothers were always her mom’s favorites; Elizabeth would kid
with them, trying to be “one of the guys.” Elizabeth achieved good
grades in high school but was discouraged from going to college.
After graduation, she began working full-time as a secretary.
As time went on, the conicts with her mother escalated. Even
in high school, Elizabeth’s mother had denounced her as a “tramp”
and constantly accused her of promiscuity even though she had
had no sexual experience. After a while, having endured the shout-
ing contests with her mother, she saved enough money to move out
on her own.
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206 I HATE YOUDON’T LEAVE ME
During this turmoil, Elizabeth’s boss, Lloyd, separated from
his wife and became embroiled in a painful divorce. Elizabeth
offered solace and sympathy. He reciprocated with encourage-
ment and support. They began dating and married soon after his
divorce was nalized. Naturally, her mother berated her for mar-
rying a divorced man, particularly one who was ten years older
and a lapsed Catholic.
Her father remained detached. One year after Elizabeth mar-
ried, he died.
Five years later, her marriage was disintegrating, and Elizabeth
was blaming her husband. She saw Lloyd as a “thief” who had
stolen her youth. She was only nineteen when she met him, and
needed to be taken care of so badly that she traded in her youth
for security—the years when she could have been “experimenting
with what I wanted to be, could be, should have been.”
In the early stages of treatment, Elizabeth began to talk of David,
her most recent and most important affair. He was twelve years
older, a longtime family friend, and the parish priest. He was some-
one known and loved by her whole family, especially by her mother.
He was the only man to whom Elizabeth felt connected. This was
the only relationship that she did not control. On and off, over a
period of two years, he would abruptly terminate the affair and then
resurrect it. Later, she confessed to her psychiatrist that David was
the father of her child. Her husband was apparently unaware.
Elizabeth became more withdrawn. Her relationship with her
husband, who was frequently away traveling, deteriorated. She
became more alienated from her mother and brothers and allowed
her few friendships to ounder. She resisted attempts to include
her husband in therapy, feeling that Lloyd and her doctor colluded
and favored “his side.” So, even therapy reinforced her belief that
she couldn’t trust or place faith in anyone because she would only
be disappointed. All her thoughts and feelings seemed to be laden
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UNDERSTANDING AND HEALING 207
with contradictions, as if she were in a labyrinth of dead-end paths.
Her sexuality seemed the only way out of the maze.
Her therapist was often the target of her complaints because
he was the one “in control.” She would yell at him, accuse him
of being incompetent, and threaten to stop therapy. She hoped he
would get mad, yell back, and stop seeing her, or become defen-
sive and plead with her to stay. But he did neither, and she railed
against his unappability as evidence that he had no feelings.
Even though she was accustomed to her husband’s frequent
business trips, she started to become more frightened when left
alone. During these trips, for reasons not yet clear to her, she slept
on the oor. When Lloyd returned, she raged constantly at him.
She became more depressed. Suicide became less an option than a
destiny, as if everything were leading to that end.
Elizabeth’s perception of reality became more frail: She yearned
to be psychotic, to live in a fantasy world where she could “go
anywhere” in her mind. The world would be so far removed from
reality, no one—not even the best psychiatrist—could get to her
and “see what’s underneath.”
In her daydreams she envisioned herself protected by a power-
ful, handsome man who actively appreciated all of her admirable
qualities and was endlessly attentive. She fantasized him as a pre-
vious teacher, then her gynecologist, then the family veterinarian,
and eventually her psychiatrist. Elizabeth perceived all these men
as powerful, but she also knew in the back of her mind that they
were unavailable. Yet, in her fantasies, they were overwhelmed by
her charm and drawn irresistibly to her. When reality did not fol-
low her script—when one of these men did not aggressively return
her irtations—she became despondent and self-loathing, feeling
she was not attractive enough.
Everywhere she looked she saw women who were prettier, smarter,
better. She wished her hair was prettier, her eyes a different color,
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208 I HATE YOUDON’T LEAVE ME
her skin clearer. When she looked in a mirror, she did not see the
reection of a beautiful young woman but an old hag with sagging
breasts, a wide waist, plump calves. She despised herself for being a
woman whose only value was her beauty. She longed to be a man,
like her brothers, “so my mind would count.”
In her second year of outpatient therapy, Elizabeth experienced
several losses, including the death of a favorite uncle to whom she
had grown close. She was haunted by recurring dreams and night-
mares that she could not remember when she awoke. She became
more depressed and suicidal and was nally hospitalized.
With more intensive therapy she began recalling traumatic
childhood events, opening up a Pandora’s box of ooding memo-
ries. She recalled severe physical beatings by her mother and then
began to remember her mother’s sexual abuses—episodes in which
her mother had inicted vaginal douches and enemas and fondled
her in order to “clean” her vagina. These rituals began when Eliza-
beth was about eight, shortly after her sister’s death, and persisted
until puberty. Her memories included looking into her mother’s
face and noting a benign, peaceful expression; these were the only
times Elizabeth could remember when it appeared her mother was
not disapproving.
Elizabeth recalled sitting alone in the closet for many hours and
often sleeping on the oor for fear of being molested in her bed.
Sometimes she would sleep with a ribbon or award she had won
in school. She found these actions to be comforting and continued
them as an adult, often preferring the oor to her bed and spend-
ing time alone in a quiet room or dark closet.
In the hospital Elizabeth spoke of the different sides to her per-
sonality. She described fantasies of being different people and even
gave these personality fragments separate names. These personae
were independent women, had unique talents, and were either
admired by others or snobbishly avoided social contacts. Elizabeth
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UNDERSTANDING AND HEALING 209
felt that whenever she accomplished something or was successful,
it was due to the talents of one of these separate personality seg-
ments. She had great difculty integrating these components into
a stable self-concept.
Nonetheless, she did recognize these as personality fragments,
and they never took over her functioning. She suffered no clear peri-
ods of amnesia or dissociation, nor were her symptoms considered
aspects of dissociative identity disorder (multiple personality)—
although this syndrome is frequently associated with BPD.
Elizabeth used these “other women” to express the desires and
feelings that she herself was forced to repress. Believing she was
worthless, she felt these other partial identities were separate,
stronger entities. Gradually, in the hospital, she learned that they
were always a part of her. Recognizing this gave her relief and hope.
She began to believe that she was stronger and less crazy than she
had imagined, marking a turning point in her life.
But she could not claim victory yet. Like a eld of cer, she
commanded the various sides of her personality to stand before
her and concluded that they could not go into battle without a uni-
fying resolve. Elizabeth—the core of her being—was still afraid of
change, love, and success, still searched in vain for safety, still ed
from relationships. Coming to accept herself was going to be more
difcult than she had ever imagined.
After several weeks Elizabeth left the hospital and continued in
outpatient care. As she improved, her relationship with her husband
deteriorated. But instead of blaming herself, as she typically did,
she attempted to resolve the differences and to stay with him. She
distanced herself from unhealthy contacts with family members.
She developed more positive self-esteem. She began taking college
courses and did remarkably well, achieving academic awards. She
slept with her rst award under her pillow, as she did when she was
a child. Later she entered law school and received merit awards for
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210 I HATE YOUDON’T LEAVE ME
being the top student in her class. She developed new relationships,
with men and women, and found she was comfortable in these,
without having to be in control. She became more content with her
own femaleness.
Little by little, Elizabeth started to heal. She felt “the curtains
raising.” She compared the feeling to looking for a valuable antique
in a dark attic lled with junk—she knew that it was in there some-
where but couldn’t see it because of all the clutter. When she nally
did spot it, she couldn’t get to it because it was “buried under a pile
of useless garbage.” But now and then she could see a clear path to
the object, as if a ash of lightning had illuminated the room for a
brief instant.
The ashes were all too brief. Old doubts reared up like ugly
faces in an amusement-park fun house. Many times she felt as if
she were going up a down escalator, struggling up one step only to
fall down two. She kept wanting to sell herself short and give credit
to others for her accomplishments. But her rst real challenge—
becoming an attorney—was almost a reality. Five years before,
she wouldn’t have been able to talk about school, much less have
had the courage to enroll. The timbre of her depressions began to
change: her depression over failing was now evolving, she recog-
nized, into a fear of success.
Growing and Changing
“Change is real hard work!” Elizabeth often noted. It requires
conscious retreat from unhealthy situations and the will to build
healthier foundations. It entails coping with drastic interruption of
a long-established equilibrium.
Like Darwinian evolution, individual change happens almost
imperceptibly, with much trial and error. The individual instinctively
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UNDERSTANDING AND HEALING 211
resists mutation. He may live in a kind of swamp, but it is his swamp;
he knows where the alligators are, what’s in all the bogs and marshes.
To leave his swamp means venturing into the unknown and perhaps
falling into an even more dangerous swamp.
For the borderline, whose world is so clearly demarcated by
black-and-white parameters, the uncertainty of change is even
more threatening. She may clutch at one extreme for fear of falling
uncontrollably into the abyss of another. The borderline anorexic,
for example, starves herself out of the terror that eating—even a tiny
morsel—will lead to total loss of control and irrevocable obesity.
The borderline’s fear of change involves a basic distrust of his
“brakes.” In healthier people these psychic brakes allow a gradual
descent from the pinnacle of a mood or behavior to a gentle stop in
the “gray zone” of the incline. Afraid that his set of brakes won’t
hold, the borderline believes that he won’t be able to stop, that he
will slide out of control to the bottom of the hill.
Change, however gradual, requires the alteration of automatic
reexes. The borderline is in a situation much like a child playing
a game of “Make me blink” or “Make me laugh,” struggling val-
iantly to stie a blink or a laugh while another child waves his hand
or makes funny faces. Such reexes, established over many years,
can be adjusted only with conscious, motivated effort.
Adults sometimes engage in similar contests of will. A man who
encounters an angry barking dog in a strange neighborhood resists
the automatic reex to run away from the danger. He recognizes
that if he runs, the dog would likely catch up with him and intro-
duce an even greater threat. Instead, he takes the opposite (and
usually more prudent) action—he stands perfectly still, allows the
dog to sniff him, and then walks slowly on.
Psychological change requires resisting unproductive automatic
re exes and consciously and willfully choosing other alternatives—
choices that are different, even opposite, from the automatic re ex.
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212 I HATE YOUDON’T LEAVE ME
Sometimes these new ways of behaving are frightening, but they
typically are more efcient ways of coping. Elizabeth and her psy-
chiatrist embarked on her journey of change in regular weekly indi-
vidual psychotherapy. Initial contacts focused on keeping Elizabeth
safe. Cognitive techniques and suggestions colored early contacts.
For several weeks Elizabeth resisted the doctor’s recommendation
of starting antidepressant medicine, but soon after she agreed to
the medication, she noticed signicant improvement in her mood.
The Beginnings of Change: Self-Assessment
Change for the borderline involves more of a ne-tuning than
a total reconstruction. In rational weight-loss diet plans, which
almost always resist the urge to lose large amounts of weight very
quickly, the best results come slowly and gradually over time when
the weight loss will more likely endure. Likewise, change for the
borderline is best initiated gradually, with only slight alterations at
rst, and must begin with self-assessment: before plotting a new
course, one must rst recognize his current position and under-
stand in which direction modication must progress.
Imagine personality as a series of intersecting lines, each repre-
senting a specic character trait (see Figure 10-1). The extremes of
each trait are located at the ends of the line, with the middle ground in
the center. For example, on the “conscientiousness at work” line, one
end might indicate obsessive over-concern or “workaholism,” and
the other end “irresponsibility” or “apathy”; the middle would be an
attitude somewhere between these two extremes, such as “calm pro-
fessionalism.” If there were a “concern about appearance” line, one
end might exemplify “narcissistic attention to surface looks,” and
the other end, “total disinterest.” Ideally, one’s personality makeup
would look like the spokes of a perfectly round wheel, with all these
lines intersecting near their midpoints in the wheel “hub.”
9780399536212_IHateYou_TX_p1-272.indd 213 20/09/10 11:06 AM
UNDERSTANDING AND HEALING 213
Of course, no one is completely “centered” all the time. It is
important to identify each line in which change is desired and
locate one’s position on that line in relation to the middle. Change
then becomes a process of knowing where you are and how far
you want to go toward the middle. Except at the extreme ends, no
particular locus is intrinsically “better” or “worse” than another.
It is a matter of knowing oneself (locating oneself on the line) and
moving in the adaptive direction.
OVERINVOLVEMENT WITH OTHERS
IMPULSIVITY
EX CESSIVE GUIL T
SELFISHNESS
PROFESSIONAL APATHY
COMPULSIVE EATING
FEAR OF INTIMACY
FEAR OF TAKING ACTION
BLAMING O THERS
CARING FOR O THERS
CONSCIENTIOUSNESS AT WORK
COMPULSIVE DIETING
FIGURE 101. Personality as a series of intersecting lines.
For example, if we isolate the “caring for others” line (see Figure
10-2), one end (“self-sacricing over-concern”) represents the point
where concern for others interferes with taking care of oneself; such
a person may need to dedicate himself totally to others in order to
feel worthwhile. This position may be perceived as a kind of “sel sh
9780399536212_IHateYou_TX_p1-272.indd 214 20/09/10 11:06 AM
214 I HATE YOUDON’T LEAVE ME
unselshness,” because such a person’s “caring” is based on subcon-
scious self-interest. At the other end (“don’t give a damn”) is a per-
son who has little regard for others, who only “looks out for number
one.” In the middle is a kind of balance—a combination of concern
for others and the obligation to take care of one’s own needs as well.
A person whose compassion trait resides in this middle zone recog-
nizes that only by taking care of his own important needs rst can
he hope to help others, a kind of “unsel sh sel shness.”
“self-sacricing over-concern” “don’t give a damn”
FIGURE 102. The “caring for others” personality trait line.
Change occurs when one acquires the awareness to objectively
place oneself on the spectrum and then compensate by adjusting
behavior in a direction toward the middle. An individual who realisti-
cally locates his present position to the left of the midpoint would try
to say “no” to others more often and generally attempt to be more
assertive. One who places himself to the right of the midpoint would
compensate toward the middle by choosing a course of action that is
more sensitive to the needs of others. This position re ects the admo-
nitions of the ancient scholar Hillel—“If I am not for myself, who will
be for me? But if I am only for myself, who am I? If not now, when?”
Of course, no one resides “in the middle” all the time; one must
constantly adjust his position on the line, balancing the teeter-
totter when it tilts too far in one direction or the other.
Practicing Change
True change requires more than experimenting with isolated attempts
to alter automatic reexes; it involves replacing old behaviors with
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UNDERSTANDING AND HEALING 215
new ones that eventually become as natural and comfortable as the
old ones. It is more than quietly stealing away from the hostile dog;
it is learning how to make friends with that dog and take it for a
walk.
Early on, such changes are usually uncomfortable. To use an
analogy, a tennis player may decide that his unreliable backhand
is in need of renement. So he embarks on a series of tennis les-
sons to improve his stroke. The new techniques that he learns to
improve his game initially yield poor results. The new style is not
as comfortable as his old stroke. He is tempted to revert to his
previous technique. Only after continuous practice is he able to
eradicate his prior bad habits and instill the more effective and
eventually more comfortable “muscle memory.” Likewise, psycho-
logical change requires the adoption of new re exes to replace old
ones. Only after persistent practice can such a substitution effec-
tively, comfortably, and therefore permanently occur.
Learning How to Limp
If a journey of a thousand miles begins with a single step, the bor-
derline’s journey through the healing process begins with a single
limp. Change is a monumental struggle for the borderline, much
more difcult than for others because of the unique features of the
disorder. Splitting and the lack of object constancy (see chapter 2)
combine to form a menacing barricade against trusting oneself and
others and developing comfortable relationships.
In order to initiate change, the borderline must break out of
an impossible catch-22 position: To accept himself and others, he
must learn to trust, but to trust others really means starting to
trust himself, that is, his own perceptions of others. He must also
learn to accept their consistency and dependability—quite a task
for someone who, like a small child, believes others “disappear”
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216 I HATE YOUDON’T LEAVE ME
when they leave the room. “When I can’t see you,” Elizabeth told
her psychiatrist early in her treatment, “it’s like you don’t exist.”
Like someone with an injured leg, the borderline must learn to
limp. If he remains bedridden, his leg muscles will atrophy and con-
tract; if he tries to exercise too vigorously, he will reinjure the leg
even more severely. Instead, he must learn to limp on it, putting just
enough weight on the leg to build strength gradually, but not so much
as to strain it and prevent healing (tolerating leg pain that is slight,
but not overwhelming). Likewise, healing in the borderline requires
placing just enough pressure by challenging himself to move forward.
As Elizabeth’s therapy progressed, cognitive interventions gave way
to a more psychodynamic approach, with more attention focused on
connections between her past experiences and current functioning.
During this transition, the therapist’s interventions diminished and
Elizabeth became responsible for more of the therapy.
Leaving the Past Behind
The borderline’s view of the world, like that of most people, is
shaped by his childhood experiences in which the family served as
a microcosm of the universe. Unlike healthier individuals, however,
the borderline cannot easily separate himself from other family
members, nor can he separate his family from the rest of the world.
Unable to see his world through adult eyes, the borderline con-
tinues to experience life as a child—with a child’s intense emotions
and perspective. When a young child is punished or reprimanded, he
sees himself as unquestionably bad; he cannot conceive of the pos-
sibility that mother might be having a bad day. As the healthy child
matures, he sees his expanding world as more complex and less dog-
matic. But the borderline remains stuck—a child in an adult’s body.
“There is always one moment in childhood when the door
opens and lets in the future,” wrote Graham Greene in The Power
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UNDERSTANDING AND HEALING 217
and the Glory. In most borderlines’ childhoods, the responsibili-
ties of adulthood arrive too early; the door opens ever more widely,
but he cannot face the light. Or perhaps it is the unrelenting open-
ing that makes facing it so dif cult.
Change for the borderline comes when he learns to see current
experiences—and review past memories—through adult “lenses.”
The new “vision” is akin to watching an old horror lm on TV that
you haven’t seen in years: the movie, once so frightening on the big
screen, seems tame—even silly—on a small screen with the lights
on; you can’t fathom why you were so scared when you saw it the
rst time.
When Elizabeth was well into her journey in psychotherapy, she
began to look at her early childhood feelings in a different light. She
began to accept them, to recognize the value of her own experience;
if not for those early feelings and experiences, she realized, she would
not have been able to bring the same fervor and motivation she was
bringing to her new career in law. “Feelings born in my childhood,”
she said, “still continue to haunt me. But I’m even seeing that in a dif-
ferent light. The very ways I have hated I now accept as part of me.”
Playing the Dealt Hand
The borderline’s greatest obstacle to change is his tendency to eval-
uate in absolute extremes. The borderline must either be totally
perfect or a complete failure; he grades himself either an A+ or,
more commonly, an F. Rather than learning from his F, he wears
it like a scarlet letter and so makes the same mistakes again and
again, oblivious to the patterns of his own behavior, patterns from
which he could learn and grow.
Unwilling to play the hand that is dealt him, the borderline
keeps folding every time, losing his ante, waiting to be dealt four
aces. If he cannot be assured of winning, he won’t play out the
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218 I HATE YOUDON’T LEAVE ME
hand. Improvement comes when he learns to accept the hand for
what it is, and recognize that, skillfully played, he can still win.
The borderline, like many people, is sometimes paralyzed by
indecisiveness. Various alternatives seem overwhelming, and the
borderline feels incapable of making any decisions. But as she
matures, choices appear less frightening and may even become a
source of pride and growing independence. At that point the bor-
derline recognizes that she faces decisions that only she is capable
of making. “I’m nding,” Elizabeth noted, “that the roots of my
indecisiveness are the beginning of success. I mean, the agony of
choosing is that I suddenly see choices.”
Boundary Setting: Establishing an Identity
One of the borderline’s primary goals is to establish a separate
sense of identity and to overcome the proclivity to merge with
others. In biological terms, it is like advancing from a parasitic
life-form to a state of symbiosis and even independence. Either
symbiosis or independence can be terrifying, and most borderlines
nd that relying on themselves is like walking for the rst time.
In biology the parasite’s existence is entirely dependent on the
host organism. If the parasitic tick sucks too much blood from the
host dog, the dog dies and the tick soon follows. Human relation-
ships function best when they are less parasitic and more symbiotic.
In symbiosis two organisms thrive better together, but may subsist
independently. For example, moss growing on a tree may help the
tree by shading it from direct sunlight, and help itself by having
access to the tree’s large supply of underground water. But if either
the moss or the tree dies, the other may continue to survive, though
less well. The borderline sometimes functions as a parasite whose
demanding dependence may eventually destroy the person to whom
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UNDERSTANDING AND HEALING 219
he so strongly clings; when this person leaves, the borderline may be
destroyed. If he can learn to establish more collaborative relation-
ships with others, all may learn to live more contentedly.
Elizabeth’s increasing comfort with others started with her
relationship with her psychiatrist. After months of testing his
loyalty by berating and criticizing him and threatening to termi-
nate therapy, Elizabeth began to trust his commitment to her. She
began to accept his aws and mistakes, rather than see them as
proof of the inevitability of his failing her. After a while, Elizabeth
began to extend the same developing trust to others in her life.
And she began to accept herself, imperfections and all, just as she
was accepting others the same way.
As Elizabeth continued to improve, she became more con dent
that she would not lose her “inner core.” Where once she would
squirm in a group of people, feeling self-conscious and out of place,
she could now feel comfortable with others, letting them take respon-
sibility for themselves and she for herself. Where once she felt com-
pelled to adopt a role in order to t into the group, she could now hold
on to her more constant, immutable sense of self; now she could “stay
the same color” more easily. Establishing a constant identity means
developing the ability to stand alone without relying on someone else
to lean upon. It means trusting one’s own judgment and instincts and
then acting rather than waiting for the feedback of others and then
reacting.
Building Relationships
As the borderline forges a distinct, core sense of identity, he also
differentiates himself from others. Change requires the apprecia-
tion of others as independent persons and the empathy to under-
stand their struggles. Their aws and imperfections must not only
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220 I HATE YOUDON’T LEAVE ME
be acknowledged but also understood as separate from the border-
line himself, part of the process of mentalization (see chapter 8).
When this task fails, relationships falter. Princess Diana mourned
the loss of her fantasy of a fairy-tale marriage to Prince Charles: “I
had so many dreams as a young girl. I wanted, and hoped . . . that
my husband would look after me. He would be a father gure, and
he’d support me, encourage me. . . . But I didn’t get any of that. I
couldn’t believe it. I got none of that. It was role reversal.”
1
The borderline must learn to integrate the positive and nega-
tive aspects of other individuals. When the borderline wants to get
close to another person, he must learn to be independent enough
to be dependent in comfortable, not desperate, ways. He learns
to function symbiotically, not parasitically. The healing borderline
develops a constancy about himself and about others; trust—of
others and of his own perceptions—develops. The world becomes
more balanced, more in between.
Just as in climbing a mountain, the fullest experience comes
when the climber can appreciate all the vistas: to look up and keep
his goal rmly in view, to look down and recognize his progress as
he proceeds. And nally, to rest, look around, and admire the view
from right where he is at the moment. Part of the experience is rec-
ognizing that no one ever reaches the pinnacle; life is a continuous
climb up the mountain. A good deal of mental health is being able
to appreciate the journey—to be able to grasp the Serenity Prayer
invoked at most twelve-step meetings: “God grant me the serenity
to accept the things I cannot change, the courage to change the
things I can, and the wisdom to know the difference.”
Recognizing the Eect of Change on Others
When an individual rst enters therapy, he often does not under-
stand that it is he, not others, who must make changes. However,
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UNDERSTANDING AND HEALING 221
when he does make changes, important people in his life must
also adjust. Stable relationships are dynamic, uctuating systems
that have attained a state of equilibrium. When one person in that
system makes signicant changes in his ways of relating, others
must adjust in order to recapture homeostasis, a state of balance.
If these readjustments do not occur, the system may collapse and
the relationships may shatter.
For example, Alicia consults a psychotherapist for severe
depression and anxiety. In therapy, she rails against her alcoholic
husband, Adam, whom she blames for her feelings of worthless-
ness. Eventually she recognizes her own role in the crumbling
marriage—her own need to have others become dependent upon
her, her reciprocal need to shame them, and her fears of reaching
for independence. She begins to blame Adam less. She develops
new, independent interests and relationships. She stops her crying
episodes; she stops initiating ghts over his drinking; the equilib-
rium of the marriage is altered.
Adam may now nd that the situation is much more uncom-
fortable than it was before. He may escalate his drinking in an
unconscious attempt to reestablish the old equilibrium and compel
Alicia to return to her martyred, caretaking role. He may accuse
her of seeing other men and try to disrupt their relationship, now
intolerable to him.
Or, he too can begin to see the necessity for change and his
own responsibility in maintaining this pathological equilibrium.
He may take the opportunity to see his own actions more clearly
and reevaluate his own life, just as he has seen his wife do.
Participation in therapy may be a valuable experience for every-
one affected. The more interesting and knowledgeable Elizabeth
became, the more ignorant her husband seemed to her. The more
opened-minded she became—the more gray she was able to per-
ceive in a situation—the more black and white he became in order
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222 I HATE YOUDON’T LEAVE ME
to reestablish equilibrium. She felt that she was “leaving someone
behind.” That person was her—or, more closely, a part of her she
no longer needed or wanted. She was, in her words, “growing up.”
As Elizabeth’s treatment wound down, she met less regularly
with her doctor, yet still had to contend with other important
people in her life. She fought with her brother, who refused to
own up to his drug problem. He accused her of being “uppity,” of
“using her new psychological crap as ammunition.” They argued
bitterly over the lack of communication within the family. He told
her that even after all the “shrinks,” she was still “screwed up.”
She fought with her mother, who remained demanding, complain-
ing, and incapable of showing her any love. She contended with
her husband, who professed his love but continued to drink heav-
ily and criticize her desire to pursue her education. He refused to
help with their son and after a while she suspected his frequent
absences were related to an affair with another woman.
Finally, Elizabeth began to recognize that she did not have
the power to change others. She utilized SET techniques to try to
better understand these family members and maintain protective
boundaries for herself, which could shield her from being pulled
into further conicts. She began to accept them for who they were,
love them as best she could, and go on with her own life. She
recognized the need for new friends and new activities in her life.
Elizabeth called this “going home.”
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Appendix A
DSM-IV-TR Classications
The Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR), was published by the
American Psychiatric Association in 2000. This work attempts to
evaluate psychiatric illnesses along ve axes.
Axis I lists most psychiatric disorders, except personality disor-
ders and mental retardation.
Axis II lists personality disorders and degrees of mental retarda-
tion.
Axis III consists of any accompanying general medical conditions.
Axis IV denotes psychosocial and environmental problems that
may complicate the diagnosis and treatment.
Axis V reports the clinician’s assessment of the patient’s overall
level of functioning on the Global Assessment of Functioning
9780399536212_IHateYou_TX_p1-272.indd 224 20/09/10 11:06 AM
224 APPENDIX A
(GAF) Scale, which evaluates the range of functioning from 0
to 100.
Axis I Diagnoses
(Partial listing with some examples)
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Learning Disorder
Attention De cit/Hyperactivity Disorder
Autism
Touret te’s
Delirium, Dementia, and Amnesic and Other Cognitive Disorders
Substance Intoxication Delirium
Alzheimer’s
Dementia Due to Head Trauma
Substance-Related Disorders
Alcoholism
Cocaine Abuse
Cannabis Abuse
Amphetamine Abuse
Hallucinogen Intoxication
Schizophrenia and Other Psychotic Disorders
Schizophrenia
Mood Disorders
Major Depressive Disorder
Dysthymic Disorder
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APPENDIX A 225
Bipolar I Disorder
Bipolar II Disorder
Anxiety Disorders
Panic Disorder
Phobia
Post-Traumatic Stress Disorder
Social Anxiety Disorder
Obsessive-Compulsive Disorder
Generalized Anxiety Disorder
Somatoform Disorders
Somatization Disorder
Hypochondriasis
Conversion Disorder
Body Dysmorphic Disorder
Factitious Disorders
Dissociative Disorders
Dissociative Identity Disorder
(Multiple Personality)
Dissociative Amnesia
Dissociative Fugue
Sexual and Gender Identity Disorders
Premature Ejaculation
Vaginismus
Exhibitionism
Pedophilia
Fetishism
9780399536212_IHateYou_TX_p1-272.indd 226 20/09/10 11:06 AM
226 APPENDIX A
Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Sleep Disorders
Primary Insomnia
Sleepwalking Disorder
Impulse-Control Disorders
Intermittent Explosive Disorder
Kleptomania
Pathological Gambling
Trichotillomania (hair or eyebrow pulling)
Adjustment Disorders
With Depressed Mood
With Anxiety
Axis II Diagnoses of Personality Disorders
(Complete listing)
Cluster A (Odd, Eccentric)
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Cluster B (Dramatic, Emotional)
Antisocial Personality Disorder
Borderline Personality Disorder
9780399536212_IHateYou_TX_p1-272.indd 227 20/09/10 11:06 AM
APPENDIX A 227
Histrionic Personality Disorder
Narcissistic Personality Disorder
Cluster C (Anxious, Fearful)
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
Future Diagnostic De nitions
Our current nomenclature dening BPD relies on fullling a thresh-
old of descriptive symptoms listed in the APA’s DSM-IV-TR: An
individual has BPD if he exhibits at least ve of the nine criteria
(see chapter 2). Thus, the person who reects, say, ve symptoms
and is then able to eliminate just one is immediately relieved of the
diagnosis.
This categorical paradigm, however, does not reect the tra-
ditional perception of personality, which is that personality is not
altered so abruptly. Thus, it is highly likely that future DSM de ni-
tions of BPD will integrate dimensional features. In this paradigm
the degree of functioning or disability may be considered. More
specically, the doctor will be able to factor into an evaluation the
degree of specic characteristics (such as impulsiveness, emotional
lability, reward dependence, harm avoidance, etc.)—not just the
presence of these symptoms—to diagnose (or not diagnose) BPD.
The intent of such DSM changes is that these adaptations will more
accurately measure changes and degrees of improvement, rather
than merely determine the presence or absence of the disorder.
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9780399536212_IHateYou_TX_p1-272.indd 229 20/09/10 11:06 AM
Appendix B
Evolution of the
Borderline Syndrome
The concept of the borderline personality has evolved primarily
through the theoretical formulations of psychoanalytic writers.
Current DSM-IV-TR criteria—observable, objective, and statis-
tically reliable principles for dening this disorder—are derived
from the more abstract, speculative writings of psychoanalytic
theorists over the past hundred years.
Freud
During Sigmund Freud’s era at the turn of the century, psychiatry was
a branch of medicine closely aligned with neurology. Psychiatric syn-
dromes were de ned by directly observable behaviors, as opposed to
unobservable, mental, or “unconscious” mechanisms, and most forms
of mental illness were attributed to neurophysiological aberrations.
Though Freud himself was an experienced neurophysiologist,
9780399536212_IHateYou_TX_p1-272.indd 230 20/09/10 11:06 AM
230 APPENDIX B
he explored the mind through different portals. He developed the
concept of the unconscious and initiated a legacy of psychological—
rather than physiological—exploration of human behavior. Yet he
remained convinced that physiological mechanisms would eventu-
ally be uncovered to coincide with his psychological theories.
Over a century after Freud’s landmark work, we have come
almost full circle: today, diagnostic classications are once again
dened by observable phenomena, and new frontiers of research
into BPD and other types of mental illness are again exploring
neurophysiological factors, while acknowledging the impact of
psychological and environmental factors.
Freud’s explication of the unconscious mind is the underpin-
ning of psychoanalysis. He believed that psychopathology resulted
from the conict between primitive, unconscious impulses and the
conscious mind’s need to prevent these abhorrent, unacceptable
thoughts from entering awareness. He rst used hypnosis, and
later “free association” and other classical psychoanalytical tech-
niques, to explore his theories.
Ironically, Freud intended classical psychoanalysis to be primar-
ily an investigative tool rather than a form of treatment. His colorful
case histories—“The Rat Man,” “The Wolf Man,” “Little Hans,”
“Anna O,” etc.—were published to support his evolving theories as
much as to promote psychoanalysis as a treatment method. Many
current psychiatrists believe that these patients, whom Freud felt
exhibited hysteria and other types of neuroses, would today clearly
be identied as borderline.
Post-Freud Psychoanalytic Writers
Psychoanalysts who followed Freud were the main contributors
to the modern concept of the borderline syndrome.
1
In 1925,
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APPENDIX B 231
Wilhelm Reich’s Impulsive Character described attempts to apply
psychoanalysis to certain unusual characterological disorders that
he encountered in his clinic. He found that the “impulsive char-
acter” was often immersed in two sharply contradictory feeling
states at the same time, but was able to maintain the states without
apparent discomfort via the splitting mechanism—a concept that
has become central to all subsequent theories on the borderline
syndrome, particularly Kernberg’s (see page 234).
In the late 1920s and early 1930s, the followers of the British psy-
choanalyst Melanie Klein investigated the cases of many patients who
seemed just beyond the reach of psychoanalysis. The Kleinians focused
on psychological dynamics as opposed to biological-constitutional
factors.
The term borderline was rst coined by Adolph Stern in 1938
to describe a group of patients who did not seem to t into the
primary diagnostic classications of “neuroses” and “psychoses.”
2
These individuals were obviously more ill than neurotic patients—
in fact, “too ill for classical psychoanalysis”—yet they did not, like
psychotic patients, continually misinterpret the real world. Though,
like neurotics, they displayed a wide range of anxiety symptoms,
neurotic patients usually had a more solid, consistent sense of iden-
tity and used more mature coping mechanisms.
Throughout the 1940s and 1950s, other psychoanalysts began
to recognize a population of patients who did not t existing patho-
logical descriptions. Some patients appeared to be neurotic or mildly
symptomatic, but when they engaged in traditional psychotherapy,
especially psychoanalysis, they “unraveled.” Similarly, hospitaliza-
tion would also exacerbate symptoms and increase the patient’s
infantile behavior and dependency on the therapist and hospital.
Other patients would appear to be severely psychotic, often
diagnosed schizophrenic, only to make a sudden and unexpected
recovery within a very short time. (Such dramatic improvement
9780399536212_IHateYou_TX_p1-272.indd 232 20/09/10 11:06 AM
232 APPENDIX B
is inconsistent with the usual course of schizophrenia.) Still other
patients exhibited symptoms suggestive of depression, but their
radical swings in mood did not t the usual prole of depressive
disorders.
Psychological testing also conrmed the presence of a new,
unique classication. Certain patients performed normally on
structured psychological tests (such as IQ tests), but on unstruc-
tured, projective tests requiring narrative personalized responses
(such as the Rorschach inkblot test), their responses were much
more akin to those of psychotic patients, who displayed thinking
and fantasizing on a more regressed, more childlike level.
During this postwar period, psychoanalysts fastened onto dif-
ferent aspects of the syndrome, seeking to develop a succinct delin-
eation. In many ways the situation was like the old tale of the blind
men who stood around an elephant and touched its various anatom-
ical parts, trying to identify them. Each man described a different
animal, of course, depending on which part he touched. Similarly,
researchers were able to touch and identify different aspects of the
borderline syndrome but could not quite see the whole organism.
Many researchers (Zilboorg, Hoch and Polatin, Bychowski, and
others)
3,4,5
and DSM-II (1968)
6
rallied around the schizophrenia-
like aspects of the disorder, using such terms as “ambulatory schizo-
phrenia,” “pre-schizophrenia,” “pseudoneurotic schizophrenia,”
and “latent schizophrenia” to describe the illness. Others concen-
trated on these patients’ lack of a consistent, core sense of identity.
In 1942, Helene Deutsch described a group of patients who over-
came an intrinsic sense of emptiness by a chameleon-like altering of
their internal and external emotional experiences to t the people
and situations they were involved with at the moment. She termed
this tendency of adopting the qualities of others as a means of gain-
ing or retaining their love the “as-if personality.”
7
In 1953, Robert Knight revitalized the term borderline in his
9780399536212_IHateYou_TX_p1-272.indd 233 20/09/10 11:06 AM
APPENDIX B 233
consideration of “borderline states.”
8
He recognized that, even
though certain patients presented markedly different symptoms
and were categorized with different diagnoses, they were express-
ing a common pathology.
After Knight’s work was published, the term borderline became
more popular, and the possibility of using Stern’s general border-
line concept as a diagnosis became more acceptable. In 1968, Roy
Grinker and his colleagues dened four subtypes of the borderline
patient: (1) a severely aficted group who bordered on the psy-
chotic; (2) a “core borderline” cluster with turbulent interpersonal
relationships, intense feeling states, and loneliness; (3) an “as-if”
group easily inuenced by others and lacking in stable identity;
and (4) a mildly impaired set with poor self-con dence and bor-
dering on the neurotic end of the spectrum.
9
Yet, even with all this extensive pioneering research, the diag-
nosis of borderline personality, among working clinicians, was still
drenched in ambiguity. It was considered a “wastebasket diagno-
sis” by many, a place to “dump” those patients who were not well
understood, who resisted therapy, or who simply did not get bet-
ter; the situation remained that way well into the 1970s.
As borderline personality became more rigorously de ned and
distinguishable from other syndromes, attempts were made to
change the ambiguous name. At one point, “unstable personal-
ity” was briey considered during the development of DSM-III.
However, borderline character pathology is relatively xed and
invariable (at least for a considerable period) despite its chaos—it
is predictably stable in its instability. No other names have been
prominently proposed as a replacement.
In the 1960s and 1970s, two major schools of thought evolved
to delineate a consistent set of criteria for dening the borderline
syndrome. Like some other disciplines in the natural and social
sciences, psychiatry was split ideologically into two primary
9780399536212_IHateYou_TX_p1-272.indd 234 20/09/10 11:06 AM
234 APPENDIX B
camps—one more concept oriented, the other more in uenced by
descriptive, observable behavior that could be more easily retested
and studied under laboratory conditions.
The empirical school, led by John G. Gunderson of Harvard
and favored by many researchers, developed a structured, more
behavioral denition, one based on observable criteria and thus
more accessible to research and study. This denition is the most
widely accepted and in 1980 was adopted by DSM-III and per-
petuated in DSM-IV (see chapter 2).
The other more concept-oriented school, led by Otto Kernberg
of Cornell and favored by many psychoanalysts, proposes a more
psychostructural approach that describes the syndrome based on
intrapsychic functioning and defense mechanisms rather than overt
behaviors.
Kernberg’s “Borderline Personality
Organization” (BPO)
In 1967, Otto Kernberg introduced his concept of Borderline Per-
sonality Organization (BPO), a broader concept than the current
DSM-IV’s Borderline Personality Disorder. Kernberg’s conceptual-
ization places BPO midway between neurotic and psychotic person-
ality organization.
10,11
A patient with BPO, as dened by Kernberg,
is less impaired than a psychotic, whose perceptions of reality are
severely contorted, making normal functioning impossible. On the
other hand, the borderline is more disabled than a person with neu-
rotic personality organization, who experiences intolerable anxiety
as a result of emotional conicts. The neurotic’s perception of iden-
tity and system of defense mechanisms are usually more adaptive
than those of the borderline.
BPO encompasses other Axis II, or characterological disorders,
9780399536212_IHateYou_TX_p1-272.indd 235 20/09/10 11:06 AM
APPENDIX B 235
such as paranoid, schizoid, antisocial, histrionic, and narcissistic
personality disorders. In addition, it includes obsessive-compulsive
and chronic anxiety disorders, hypochondriasis, phobias, sexual
perversions, and dissociative reactions (such as dissociative iden-
tity disorder—also known as multiple personality disorder). In
Kernberg’s system, patients currently diagnosed with BPD would
constitute only about 10 to 25 percent of patients classi ed BPO.
A patient diagnosed with BPD is conceived as occupying a lower
functioning, higher severity level within the overall BPO diagnosis.
Though Kernberg’s system was not ofcially adopted by the
APA, his work has had (and continues to have) signi cant in u-
ence as a theoretical model for both clinicians and researchers.
In general, Kernberg’s schema emphasizes the inferred internal
mechanisms discussed below.
Variable Sense of Reality
Like neurotics, borderlines retain contact with reality most of the
time; however, under stress the borderline can regress to a brief
psychotic state. Marjorie, a twenty-nine-year-old married woman,
sought therapy for increasing depression and marital dishar-
mony. An intelligent, attractive woman, Marjorie related calmly
throughout her initial eight sessions. She eagerly assented to a joint
interview with her husband, but during the session she turned
uncharacteristically loud and belligerent. Dropping her facade of
self-control, she began to berate her husband for alleged in deli-
ties. She accused her therapist of taking her husband’s side (“You
men always stick together!”) and accused both of engaging in a
conspiracy against her. The sudden transformation from a relaxed,
mildly depressed woman to a raging, paranoid one is quite char-
acteristic of the kind of rapidly shifting borders of reality observed
in the borderline.
9780399536212_IHateYou_TX_p1-272.indd 236 20/09/10 11:06 AM
236 APPENDIX B
Nonspecic Weaknesses in Functioning
Borderlines have great difculty tolerating frustration and coping
with anxiety. In Kernberg’s framework, impulsive behavior is an
attempt to diffuse this tension. Borderlines also have defective sub-
limation tools; that is, they are unable to channel frustrations and
discomforts in socially adaptive ways. Though borderlines may
exhibit extreme empathy, warmth, and guilt, these exhibitions are
often rote, more manipulative gestures for display purposes only,
rather than true expressions of feeling. Indeed, the borderline may
act as if he has totally forgotten a dramatic effusion that occurred
only moments before, much like a child who suddenly emerges
from a temper tantrum all smiles and laughter.
Primitive Thinking
Borderlines are capable of performing well in a structured work or
professional environment, but below the surface linger grave self-
doubts, suspicions, and fears. The internal thought processes of
borderlines may be surprisingly unsophisticated and primal, cam-
ouaged by a stable facade of learned and rehearsed platitudes.
Any circumstance that pierces the protective structure shielding
the borderline may unleash a ood of chaotic passions concealed
within. The example of Marjorie (above) illustrates this point.
Projective psychological tests also reveal the borderline’s primi-
tive thought processes. These tests—such as the Rorschach and
Thematic Apperception Test (TAT)—elicit associations to ambigu-
ous stimuli, such as inkblots or pictures, around which the patient
creates a story. Borderline responses typically resemble those of
schizophrenics and other psychotic patients. Unlike the coherent,
organized responses usually observed among neurotic patients,
those from borderlines often describe bizarre, primitive images—the
9780399536212_IHateYou_TX_p1-272.indd 237 20/09/10 11:06 AM
APPENDIX B 237
borderline might see vicious animals cannibalizing one another,
where the neurotic sees a butter y.
Primitive Defense Mechanisms
The coping mechanism of splitting (see chapter 2) preserves the bor-
derline’s perception of a world of extremes—a view in which peo-
ple and objects are either good or bad, friendly or hostile, loved or
hated—in order to escape the anxiety of ambiguity and uncertainty.
In Kernberg’s conceptualization, splitting often leads to “magi-
cal thinking”: superstitions, phobias, obsessions, and compulsions
are used as talismans to ward off unconscious fears. Splitting also
results in derivative defense mechanisms:
• Primitive idealization—insistently placing a person or object
in the “all-good” category so as to avoid the anxiety accom-
panying the recognition of faults in that person.
• Devaluation—an unrelenting negative view of a person or
object; the opposite of idealization. Using this mechanism,
the borderline avoids the guilt of his rage—the “all-bad” per-
son fully deserves it.
• Omnipotence—a feeling of unlimited power in which one feels
incapable of failure or sometimes even of death. (Omnipo-
tence is also a common feature in the narcissistic personality.)
• Projection—disavowing features unacceptable to the self and
attributing them to others.
• Projective identication—a more complex form of projec-
tion in which the projector continues an ongoing manipula-
tive involvement with another person, who is the object of
the projection. The other person “wears” these unacceptable
9780399536212_IHateYou_TX_p1-272.indd 238 20/09/10 11:06 AM
238 APPENDIX B
characteristics for the projector, who works to ensure their
continued expression.
For example, Mark, a young, married man who is diagnosed
as borderline, nds his own sadistic and angry impulses unaccept-
able and projects them onto his wife, Sally. Sally is then perceived
by Mark (in his black-and-white fashion) to be a “totally angry
woman.” All of her actions are interpreted as sadistic. He uncon-
sciously “pushes her buttons” to extract angry responses, thus
con rming his projections. In this way, Mark fears yet simultane-
ously controls his perception of Sally.
Pathological Concept of Self
“Identity diffusion” describes Kernberg’s conception of the bor-
derline’s lack of a stable, core sense of identity. The borderline’s
identity is the consistency of Jell-O: it can be molded into any con-
guration that contains it, but slips through the hands when you
try to pick it up. This lack of substance leads directly to the iden-
tity disturbances outlined in criterion 3 of DSM-IV’s description
of BPD (see chapter 2).
Pathological Concept of Others
As “identity diffusion” describes the borderline’s lack of a stable
concept of self, “object inconstancy” describes the lack of a stable
concept of others. Just as his own self-esteem depends on current
circumstances, the borderline bases his attitude toward another
person on the most recent encounter, rather than on a more sta-
ble and enduring perception grounded in a consistent, connected
series of experiences.
Often, the borderline is unable to hold on to the memory of
9780399536212_IHateYou_TX_p1-272.indd 239 20/09/10 11:06 AM
APPENDIX B 239
a person or object when he, she, or it is not present. Like a child
who becomes attached to a transitional object that represents a
soothing mother gure (such as Linus’s attachment to his blan-
ket in the Peanuts cartoons), the borderline uses objects, such as
pictures and clothing, to simulate the presence of another person.
For example, when a borderline is separated from home for even a
brief period, he typically takes many personal objects as soothing
reminders of familiar surroundings. Teddy bears and other stuffed
animals accompany him to bed, and snapshots of family are care-
fully placed around the room. If he is left home while his wife is
away, he often stares longingly at her picture and her closet, and
smells her pillow, seeking the comfort of familiarity.
For many borderlines, “out of sight, out of mind” is an excru-
ciatingly real truism. Panic sets in when the borderline is separated
from a loved one because the separation feels permanent. Because
memory cannot be adequately utilized to retain an image, the bor-
derline forgets what the object of his concern looks like, sounds
like, feels like. To escape the panicky sensation of abandonment
and loneliness, the borderline tries to cling desperately—calling,
writing, using any means to maintain contact.
9780399536212_IHateYou_TX_p1-272.indd 240 20/09/10 11:06 AM
9780399536212_IHateYou_TX_p1-272.indd 241 20/09/10 11:06 AM
RESOURCES
Printed Materials
OVERVIEWS
“Borderline Personality Disorder.” Journal of the California Alliance for the
Mentally Ill, Vol. 8, No. 1, 1997. Comments from experts, families, and
persons with BPD.
Sometimes I Act Crazy: Living with Borderline Personality Disorder, by
J. J. Kreisman and H. Straus. Hoboken, NJ: John Wiley & Sons, 2004.
Detailed review of BPD symptoms, many from the patient’s perspective,
and recommendations for coping; directed toward families.
New Hope for People with Borderline Personality Disorder, by N. R. Bock-
ian, V. Porr, and N. E. Villagran. Roseville, CA: Prima Publishing, 2002.
A readable book for the layperson emphasizing better prognosis.
Understanding and Treating Borderline Personality Disorder: A Guide for
Professionals and Families, by J. G. Gunderson and P. D. Hoffman.
Washington, DC: American Psychiatric Publishing, 2005. A readable
review for clinicians and families.
9780399536212_IHateYou_TX_p1-272.indd 242 20/09/10 11:06 AM
242 RESOURCES
Borderline Personality Disorder: A Clinical Guide (2nd ed.), by J. G. Gunder-
son. Washington, DC: American Psychiatric Publishing, 2008. Directed
primarily for practitioners; includes a comprehensive list of resources.
Borderline Personality Disorder Demystied: An Essential Guide for
Understanding and Living with BPD, by R. O. Friedel. New York: Mar-
lowe & Company, 2004. A readable guide for families.
FAMILY AND PERSONAL ACCOUNTS
Siren’s Dance: My Marriage to a Borderline: A Case Study, by A. Walker.
Emmaus, PA: Rodale, 2003. A spouse’s experience.
Lost in the Mirror: An Inside Look at Borderline Personality Disorder (2nd
ed.), by R. Moskovitz. Dallas, TX: Taylor Publications, 2001. Intimate
descriptions of borderline pain.
Get Me Out of Here: My Recovery from Borderline Personality Disorder,
by R. Reiland. Center City, MN: Hazeldon Publishing, 2004. A personal
account.
Stop Walking on Eggshells: Taking Your Life Back When Someone You Care
About Has Borderline Personality Disorder, by R. Kreger and P. T. Mason.
Oakland, CA: New Harbinger Publications, 1998. An instructive manual.
The Essential Family Guide to Borderline Personality Disorder, by R. Kre-
ger. Center City, MN: Hazelden, 2008. Follow-up to Stop Walking on
Eggshells with suggestions for the family.
Borderline Personality Disorder in Adolescents: A Complete Guide to
Understanding and Coping When Your Adolescent Has BPD, by B. A.
Aguirre. Beverly, MA: Fair Winds Press, 2007. Dealing with the adoles-
cent borderline.
Surviving a Borderline Parent: How to Heal Your Childhood Wounds and
Build Trust, Boundaries, and Self-Esteem, by K. Roth and F. B. Fried-
man. Oakland, CA: New Harbinger Publications, 2003. For the children
of borderline parents.
Websites
BPD CENTRAL
www.bpdcentral.com
One of the oldest and most comprehensive sites with many suggested books
and articles.
9780399536212_IHateYou_TX_p1-272.indd 243 20/09/10 11:06 AM
RESOURCES 243
BPD TODAY
www.borderlinepersonalitytoday.com
Lists many articles and books on BPD.
BPD RESOURCE CENTER
www.bpdresources.net
Recommends books and articles, author interviews, and general information
for individuals and families.
NEW YORK PRESBYTERIAN HOSPITAL INFORMATION
www.bpdresourcecenter.org
Westchester Division of Cornell and Columbia University Hospitals main-
tains an active treatment unit headed by Otto Kernberg, MD, and a gen-
eral informational website.
NATIONAL INSTITUTE OF MENTAL HEALTH SUMMARY
www.nimh.nih.gov/health/publications/borderline-personality-disorder-
fact-sheet/index.shtml
General information.
MAYO CLINIC INFORMATION
mayoclinic.com/health/borderline-personality-disorder/DS00442
General information and answers to questions.
BORDERLINE PERSONALITY DISORDER DEMYSTIFIED
www.bpddemysti ed.com
This is a site animated by Robert O. Friedel, MD, a leading psychiatrist and
author of Borderline Personality Disorder Demysti ed.
PERSONALITY DISORDERS AWARENESS NETWORK PDAN
www.pdan.org
PDAN works to increase public awareness about the impact of BPD on chil-
dren, relationships, and society.
FACING THE FACTS
www.bpdfamily.com
One of the largest sites providing information and support for families.
9780399536212_IHateYou_TX_p1-272.indd 244 20/09/10 11:06 AM
244 RESOURCES
BPD RECOVERY
www.bpdrecovery.com
A site for individuals recovering and looking for help with BPD.
WELCOME TO OZ
http://groups.yahoo.com/group/welcometooz
Bulletin board for family members and loved ones of persons with BPD.
WELCOME TO OZPROFESSIONALS
http://groups.yahoo.com/group/wtoprofessionals
Bulletin board and email communication for practitioners working with BPD.
BORDERLINE PERSONALITY DISORDER SANCTUARY
www.mhsanctuary.com/borderline
Provides education, books, support, and a state-by-state listing of physicians
and therapists.
NATIONAL EDUCATION ALLIANCE FOR BORDERLINE
PERSONALITY DISORDER NEABPD
www.borderlinepersonalitydisorder.com
Support and education for patients, relatives, and professionals.
TREATMENT AND RESEARCH ADVANCEMENTS ASSOCIATION FOR
PERSONALITY DISORDER TARAAPD
www.tara4bpd.org
National nonprot organization advocates for individuals with BPD and
their families, sponsors workshops and seminars, operates a national
resource and referral center, and articulates BPD issues to congressional
legislators.
Treatment Centers
THE GUNDERSON RESIDENCE OF MCLEAN HOSPITAL FOR WOMEN ONLY
115 Mill Street
Belmont, MA 02178
617-855-2000
www.gundersonresidence.org
9780399536212_IHateYou_TX_p1-272.indd 245 20/09/10 11:06 AM
RESOURCES 245
NEW YORK PRESBYTERIAN HOSPITAL, WESTCHESTER DIVISION
21 Bloomingdale Road
White Plains, NY 10605
914-949-8384
AUSTEN RIGGS CENTER
25 Main Street
Stockbridge, MA 01262
800-51-RIGGS
SILVER HILL HOSPITAL
208 Valley Road
New Canaan, CT
866-542-4455
www.SilverHillHospital.org
SLS RESIDENTIAL CENTER
2505 Carmel Avenue
Brewster, NY 10509
888-8-CARE-4U
9780399536212_IHateYou_TX_p1-272.indd 246 20/09/10 11:06 AM
9780399536212_IHateYou_TX_p1-272.indd 247 20/09/10 11:06 AM
NOTES
PREFACE
1. John Cloud, “Minds on the Edge,” Time (January 19, 2009): 42–46.
2. John G. Gunderson, “Borderline Personality Disorder: Ontogeny of a
Diagnosis,” American Journal of Psychiatry 166 (2009): 530–539.
1. THE WORLD OF THE BORDERLINE
1. Bridget F. Grant, S. Patricia Chou, Rise B. Goldstein, et al., “Prevalence
Correlates, Disability, and Comorbidity of DSM-IV Borderline Person-
ality Disorder: Results from the Wave 2 National Epidemiologic Survey
on Alcohol and Related Conditions, Journal of Clinical Psychiatry 69
(2008): 533–544.
2. John G. Gunderson, Borderline Personality Disorder (Washington, DC:
American Psychiatric Publishing, 1984).
3. Klaus Lieb, Mary C. Zanarini, Christian Schmahl, et al., “Borderline
Personality Disorder,” Lancet 364 (2004): 453–461.
4. Mark Zimmerman, Louis Rothschild, and Iwona Chelminski, “The
Prevalence of DSM-IV Personality Disorders in Psychiatric Outpa-
tients,” American Journal of Psychiatry 162 (2005): 1911–1918.
9780399536212_IHateYou_TX_p1-272.indd 248 20/09/10 11:06 AM
248 NOTES
5. Donna S. Bender, Andrew E. Skodol, Maria E. Pagano, et al., “Prospec-
tive Assessment of Treatment Use by Patients with Personality Disor-
ders,” Psychiatric Services 57 (2006): 254–257.
6. Marvin Swartz, Dan Blazer, Linda George, et al., “Estimating the
Prevalence of Borderline Personality Disorder in the Community,” Jour-
nal of Personality Disorders 4 (1990): 257–272.
7. James J. Hudziak, Todd J. Boffeli, Jerold J. Kreisman, et al., “Clinical
Study of the Relation of Borderline Peronality Disorder to Briquet’s Syn-
drome (Hysteria), Somatization Disorder, Antisocial Personality Disor-
der, and Substance Abuse Disorders,” American Journal of Psychiatry
153 (1996): 1598–1606.
8. Mary C. Zanarini, Frances R. Frankenburg, John Hennen, et al., “Axis
I Comorbidity in Patients with Borderline Personality Disorder: 6-Year
Follow-Up and Prediction of Time to Remission,” American Journal of
Psychiatry 161 (2004): 2108–2114.
9. Craig Johnson, David Tobin, and Amy Enright, “Prevalence and Clini-
cal Characteristics of Borderline Patients in an Eating-Disordered Popu-
lation,” Journal of Clinical Psychiatry 50 (1989): 9–15.
10. Joel Paris and Hallie Zweig-Frank, “A 27-Year Follow-Up of Patients
with Borderline Personality Disorder,” Comprehensive Psychiatry 42
(2001): 482–484.
11. Alexander McGirr, Joel Paris, Alain Lesage, et al., “Risk Factors for
Suicide Completion in Borderline Personality Disorder: A Case-Control
Study of Cluster B Comorbidity and Impulsive Aggression,” Journal of
Clinical Psychiatry 68 (2007): 721–729.
12. Thomas Widiger and Paul T. Costa Jr., “Personality and Personality
Disorders,” Journal of Abnormal Psychology 103 (1994): 78–91.
13. John M. Oldham, “Guideline Watch: Practice Guideline for the Treat-
ment of Patients with Borderline Personality Disorder,” Focus 3 (2005):
396–400.
14. Robert L. Spitzer, Michael B. First, Jonathan Shedler, et al., “Clinical
Utility of Five Dimensional Systems for Personality Diagnosis,” Journal
of Nervous and Mental Disease 196 (2008): 356–374.
15. American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders, 4th ed., Text Revision (Washington, DC: American
Psychiatric Association, 2000): 706–710.
9780399536212_IHateYou_TX_p1-272.indd 249 20/09/10 11:06 AM
NOTES 249
16. Lisa Laporte and Herta Guttman, “Traumatic Childhood Experiences
as Risk Factors for Borderline and Other Personality Disorders,” Journal
of Personality Disorders 10 (1996): 247–259.
17. Mary C. Zanarini, Lynne Yong, Frances R. Frankenburg, et al., “Sever-
ity of Reported Childhood Sexual Abuse and Its Relationship to Sever-
ity of Borderline Psychopathology and Psychosocial Impairment Among
Borderline Inpatients,” Journal of Nervous and Mental Disease 190
(2002): 381–387.
18. Carolyn Z. Conklin and Drew Westen, “Borderline Personality Disorder in
Clinical Practice,” American Journal of Psychiatry 162 (2005): 867–875.
19. Thomas H. McGlashan, “The Chestnut Lodge Follow-Up Study III,
Long-Term Outcome of Borderline Personalities,” Archives of General
Psychiatry 43 (1986): 20–30.
20. Louis Sass, “The Borderline Personality,” New York Times Magazine
(August 22, 1982): 102.
21. Mary C. Zanarini, Frances R. Frankenburg, John Hennen, et al., “Pre-
diction of the 10-Year Course of Borderline Personality Disorder,”
American Journal of Psychiatry 163 (2006): 827–832.
22. Mary C. Zanarini, Frances R. Frankenburg, D. Bradford Reich, et al.,
“Time to Attainment of Recovery from Borderline Personality Disor-
der and Stability of Recovery: A 10-Year Prospective Follow-Up Study,”
American Journal of Psychiatry 168 (2010): 663–667.
23. J. Christopher Perry, Elisabeth Banon, and Floriana Ianni, “Effective-
ness of Psychotherapy for Personality Disorders,” American Journal of
Psychiatry 156 (1999): 1312–1321.
2. CHAOS AND EMPTINESS
1. Stefano Pallanti, “Personality Disorders: Myths and Neuroscience,”
CNS Spectrums 2 (1997): 53–63.
2. Jerold J. Kreisman and Hal Straus, Sometimes I Act Crazy: Living with
Borderline Personality Disorder (Hoboken, NJ: John Wiley & Sons,
2004): 13.
3. Jess G. Fiedorowicz and Donald W. Black, “Borderline, Bipolar, or
Both?” Current Psychiatry 9 (2010): 21–32.
4. Henrik Anckarsater, Ola Stahlberg, Tomas Larson, et al., “The Impact
of ADHD and Autism Spectrum Disorders on Temperament, Character,
9780399536212_IHateYou_TX_p1-272.indd 250 20/09/10 11:06 AM
250 NOTES
and Personality Development,” American Journal of Psychiatry 163
(2006): 1239–1244.
5. Carlin J. Miller, Janine D. Flory, Scott R. Miller, et al., “Childhood
Attention-Decit/Hyperactivity Disorder and the Emergence of Person-
ality Disorders in Adolescence: A Prospective Follow-Up Study,” Journal
of Clinical Psychiatry 69 (2008): 1477–1484.
6. Alexandra Philipsen, Mathias F. Limberger, Klaus Lieb, et al., “Atten-
tion-Decit Hyperactivity Disorder as a Potentially Aggravating Factor
in Borderline Personality Disorder,” British Journal of Psychiatry 192
(2008): 118–123.
7. Andrea Fossati, Liliana Novella, Deborah Donati, et al., “History of
Childhood Attention Decit/Hyperactivity Disorder Symptoms and
Borderline Personality Disorder: A Controlled Study,” Comprehensive
Psychiatry 43 (2002): 369–377.
8. Pavel Golubchik, Jonathan Sever, Gil Zalsman, et al., “Methylpheni-
date in the Treatment of Female Adolescents with Co-occurrence of
Attention Decit/Hyperactivity Disorder and Borderline Personality
Disorder: A Preliminary Open-Label Trial,” International Clinical Psy-
chopharmacology 23 (2008): 228–231.
9. Randy A. Sansone and Lori A Sansone, “Borderline Personality and the
Pain Paradox,” Psychiatry 4 (2007): 40–46.
10. James J. Hudziak, Todd J. Boffeli, Jerold J. Kreisman, et al., “Clinical
Study of the Relation of Borderline Peronality Disorder to Briquet’s Syn-
drome (Hysteria), Somatization Disorder, Antisocial Personality Disor-
der, and Substance Abuse Disorders,” American Journal of Psychiatry
153 (1996): 1598–1606.
11. Vedat Sar, Gamze Akyuz, Nesim Kugu, et al., “Axis I Dissociative
Disorder Comorbidity in Borderline Personality Disorder and Reports
of Childhood Trauma,” Journal of Clinical Psychiatry 67 (2006):
1583–1590.
12. Richard P. Horevitz and Bennett G. Braun, “Are Multiple Personalities
Borderline?” Psychiatric Clinics of North America 7 (1984): 69–87.
13. Julia A. Golier, Rachel Yehuda, Linda M. Bierer, et al., “The Relation-
ship of Borderline Personality Disorder to Posttraumatic Stress Disorder
and Traumatic Events,” American Journal of Psychiatry 160 (2003):
2018–2024.
9780399536212_IHateYou_TX_p1-272.indd 251 20/09/10 11:06 AM
NOTES 251
14. Andrew E. Skodol, John G. Gunderson, Thomas H. McGlashan, et al.,
“Functional Impairment in Patients with Schizotypal, Borderline,
Avoidant, or Obsessive-Compulsive Personality Disorder,” American
Journal of Psychiatry 159 (2002): 276–283.
15. T. J. Trull, D. J. Sher, C. Minks-Brown, et al., “Borderline Personal-
ity Disorder and Substance Use Disorders: A Review and Integration,”
Clinical Psychological Review 20 (2000): 235–253.
16. Mary C. Zanarini, Frances R. Frankenburg, John Hennen, et al., “Axis
I Comorbidity in Patients with Borderline Personality Disorder: 6-Year
Follow-Up and Prediction of Time to Remission,” American Journal of
Psychiatry 161 (2004): 2108–2114.
17. Drew Westen and Jennifer Harnden-Fischer, “Personality Pro les in
Eating Disorders: Rethinking the Distinction Between Axis I and Axis
II,” American Journal of Psychiatry 158 (2001): 547–562.
18. Regina C. Casper et al., “Bulimia: Its Incidence and Clinical Importance
in Patients with Anorexia Nervosa,” Archives of General Psychiatry 37
(1980): 1030–1035.
19. Beth S. Brodsky, Kevin M. Malone, Steven P. Ellis, et al., “Characteris-
tics of Borderline Personality Disorder Associated with Suicidal Behav-
ior,” American Journal of Psychiatry 154 (1997): 1715–1719.
20. Paul H. Soloff, Kevin G. Lynch, Thomas M. Kelly, et al., “Character-
istics of Suicide Attempts of Patients with Major Depressive Episode
and Borderline Personality Disorder: A Comparative Study,” American
Journal of Psychiatry 157 (2000): 601–608.
21. Alexander McGirr, Joel Paris, Alain Lesage, et al., “Risk Factors for
Suicide Completion in Borderline Personality Disorder: A Case-Control
Study of Cluster B Comorbidity and Impulsive Aggression,” Journal of
Clinical Psychiatry 68 (2007): 721–729.
22. American Psychiatric Association, DSM-IV-TR (2000): 706–710.
23. Christian G. Schmahl, Bernet M. Elzinga, Eric Vermetten, et al., “Neural
Correlates of Memories of Abandonment in Women with and Without Bor-
derline Personality Disorder,” Biological Psychiatry 54 (2003): 142–151.
24. Norman Rosten, Marilyn: An Untold Story (New York: New American
Library, 1967): 112.
25. Norman Mailer, Marilyn: A Biography (New York: Grosset & Dunlap,
1973): 86.
9780399536212_IHateYou_TX_p1-272.indd 252 20/09/10 11:06 AM
252 NOTES
26. Ibid., 108.
27. George S. Zubenko et al., “Sexual Practices Among Patients with Bor-
derline Personality Disorder,” American Journal of Psychiatry 144
(1987): 748–752.
28. Barbara Stanley, Marc J. Gameroff, Venezia Michalsen, et al., “Are Sui-
cide Attempters Who Self-Mutilate a Unique Population?” American
Journal of Psychiatry 158 (2001): 427–432.
29. Randy A. Sansone, George A. Gaither, and Douglas A. Songer, “Self-
Harm Behaviors Across the Life Cycle: A Pilot Study of Inpatients with
Borderline Personality,” Comprehensive Psychiatry 43 (2002): 215–218.
30. Paul H. Soloff, Kevin G. Lynch, and Thomas M. Kelly, “Childhood
Abuse as a Risk Factor for Suicidal Behavior in Borderline Personality
Disorder,” Journal of Personality Disorders 16 (2002): 201–214.
31. Nikolaus Kleindienst, Martin Bohus, Petra Ludascher, et al., “Motives
for Nonsuicidal Self-Injury Among Women with Borderline Personality
Disorder,” Journal of Nervous and Mental Disease 196 (2008): 230–236.
32. Thomas H. McGlashan, Carlos M. Grilo, Charles A. Sanislow, et al.,
“Two-Year Prevalence and Stability of Individual DSM-IV Criteria for
Schizotypal, Borderline, Avoidant, and Obsessive-Compulsive Personal-
ity Disorders: Toward a Hybrid Model of Axis II Disorders,” American
Journal of Psychiatry 162 (2005): 883–889.
3. ROOTS OF THE BORDERLINE SYNDROME
1. Randy A. Sansone and Lori A. Sansone, “The Families of Borderline
Patients: The Psychological Environment Revisited,” Psychiatry 6
(2009): 19–24.
2. Jerold J. Kreisman and Hal Straus, Sometimes I Act Crazy: Living with
Borderline Personality Disorder (Hoboken, NJ: John Wiley & Sons,
2004): 13–15.
3. Eric Lis, Brian Greeneld, Melissa Henry, et al., “Neuroimaging and
Genetics of Borderline Personality Disorder: A Review,” Journal of Psy-
chiatry and Neuroscience 32 (2007): 162–173.
4. Paul A. Andrulonis, Bernard C. Glueck, Charles F. Stroebel, et al.,
“Organic Brain Dysfunction and the Borderline Syndrome,” Psychiatric
Clinics of North America 4 (1980): 47–66.
5. Margaret Mahler, Fred Pine, and Anni Bergman, The Psychological
Birth of the Human Infant (New York: Basic Books, 1975).
9780399536212_IHateYou_TX_p1-272.indd 253 20/09/10 11:06 AM
NOTES 253
6. A Letter from T. E. Lawrence to Charlotte Shaw (August 18, 1927), as
quoted by John E. Mack, A Prince of Our Disorder: The Life of T. E.
Lawrence (Boston: Little, Brown, 1976): 31.
7. Sally B. Smith, Diana in Search of Herself (New York: Random House,
1999): 38.
8. Norman Mailer, Marilyn: A Biography (New York: Grosset & Dunlop,
1973): 86.
9. The Mail on Sunday (June 1, 1986), as quoted in Sally B. Smith (1999): 10.
10. Andrew Morton, Diana: Her True Story—In Her Own Words (New
York: Simon & Schuster, 1997): 33–34.
11. John G. Gunderson, John Kerr, and Diane Woods Englund, “The Fami-
lies of Borderlines: A Comparative Study,” Archives of General Psychia-
try 37 (1980): 27–33.
12. Hallie Frank and Joel Paris, “Recollections of Family Experience
in Borderline Patients,” Archives of General Psychiatry 38 (1981):
1031–1034.
13. Ronald B. Feldman and Herta A. Gunman, “Families of Borderline
Patients: Literal-Minded Parents, Borderline Parents, and Parental Pro-
tectiveness,” American Journal of Psychiatry 141 (1984): 1392–1396.
4. THE BORDERLINE SOCIETY
1. Christopher Lasch, The Culture of Narcissism (New York: W.W. Nor-
ton, 1978): 34.
2. Louis Sass, “The Borderline Personality,” New York Times Magazine
(August 12, 1982): 13.
3. Peter L. Giovachinni, Psychoanalysis of Character Disorders (New
York: Jason Aronson, 1975).
4. Christopher Lasch (1978): 5.
5. David S. Greenwald, No Reason to Talk About It (New York: W.W.
Norton, 1987).
6. Paul A. Andrulonis, personal communication, 1987.
7. Patrick E. Jamieson and Dan Romer, “Unrealistic Fatalism in U.S. Youth
Ages 14 to 22: Prevalence and Characteristics,” Journal of Adolescent
Health 42 (2008): 154–160.
8. “Number, Time, and Duration of Marriages and Divorces,” Washing-
ton, DC: U.S. Census Bureau, 2005: 7–10.
9. Christopher Lasch (1978): 30.
9780399536212_IHateYou_TX_p1-272.indd 254 20/09/10 11:06 AM
254 NOTES
10. George S. Zubenko et al., “Sexual Practices Among Patients with Bor-
derline Personality Disorder,” American Journal of Psychiatry 144
(1987): 748–752.
11. Otto Kernberg, “Borderline Personality Organization,” Journal of the
American Psychoanalytic Association 15 (1967): 641–685.
12. Jason Fields, “Children’s Living Arrangements and Characteristics:
March 2002,” Current Population Reports, P20-547, U.S. Census
Bureau, 2003.
13. “The State of Unions 2005,” Report of the National Marriage Project,
Rutgers University (2005): 17–21.
14. Jason Fields, U.S. Census Bureau (2003).
15. Edward F. Zigler, “A Solution to the Nation’s Child Care Crisis,” paper
presented at the National Health Policy Forum, Washington, DC (1987): 1.
16. U.S. Department of Health and Human Services Administration for
Children and Families, Child Maltreatment 2003: Summary of Key
Findings: 4–34.
17. U.S. Department of Health and Human Services Administration for
Children, Youth, and Families, Child Maltreatment 2007 (Washington,
DC: U.S. Government Printing Ofce, 2009): 24.
18. Judith L. Herman, Father-Daughter Incest (Cambridge, MA: Harvard
University Press, 1981).
19. National Clearinghouse on Child Abuse and Neglect Information, Long-
Term Consequences of Child Abuse and Neglect, Washington, DC, 2005.
20. Susan Jacoby, “Emotional Child Abuse: The Invisible Plague,” Glamour
(October 1984); Edna J. Hunter, quoted in USA Today (August 1985): 11.
21. W. Hugh Missildine, Your Inner Child of the Past (New York: Simon &
Schuster, 1963).
22. Judith Wallerstein and J. B. Kelly, “The Effect of Parental Divorce:
Experiences of the Preschool Child,” Journal of the American Academy
of Child Psychiatry 14 (1975): 600–616.
23. Ibid.
24. M. Hetherington, “Children and Divorce,” in Parent-Child Interaction:
Theory, Research, and Prospect, ed. R. Henderson, Psychiatric Opinion
11 (1982): 6–15.
25. David A. Brent et al., “Post-Traumatic Stress Disorders in Peers of
Adolescent Suicide Victims: Predisposing Factors and Phenomenology,”
9780399536212_IHateYou_TX_p1-272.indd 255 20/09/10 11:06 AM
NOTES 255
Journal of the American Academy of Child and Adolescent Psychiatry
34 (1995): 209–215.
26. Chaim F. Shatan, “Through the Membrane of Reality: Impacted Grief
and Perceptual Dissonance in Vietnam Combat Veterans,” Psychiatric
Opinion 11 (1982): 6–15.
27. Chaim F. Shatan, “The Tattered Ego of Survivors,” Psychiatric Annals
12 (1982): 1031–1038.
28. “Concern Mounts Over Rising Troop Suicides,” CNN.com, Febru-
ary 3, 2008, www.cnn.com/2008/US/02/01/military.suicides (accessed
August 18, 2009).
29. Chaim F. Shatan, “War Babies,” American Journal of Orthopsychiatry
45 (1975): 289.
30. “Faith in Flux: Changes in Religious Afliation in the U.S.,” Pew Forum
on Religion and Public Life, April 27, 2009, http://pewforum.org/Faith
-in-Flux.aspx (accessed July 7, 2010).
31. Amanda Lenhart and Mary Madden, “Social Networking Websites and
Teens,” Pew Internet and American Life Project, January 7, 2007, www
.pewinternet.org/Reports/2007/Social-Networking-Websites-and-Teens
.aspx (accessed September 2, 2009).
32. Robin Hamman, “Blogging4business: Social Networking and Brands,”
Cybersoc.com, April 4, 2007, www.cybersoc.com/2007/04/blogging4
busine.html (accessed September 14, 2009): Paper delivered April 4,
2007, summarizing Microsoft ndings.
33. Jean M. Twenge and W. Keith Campbell, The Narcissism Epidemic:
Living in the Age of Entitlement (New York: Free Press, 2009): 1–4.
6. COPING WITH THE BORDERLINE
1. Andrew M. Chanen, Martina Jovev, Henry J. Jackson, “Adaptive Func-
tioning and Psychiatric Symptoms in Adolescents with Borderline Per-
sonality Disorder,” Journal of Clinical Psychiatry 68 (2007): 297–306.
2. David A. Brent et al., “Risk Factors for Adolescent Suicide,” Archives of
General Psychiatry 45 (1988): 581–588.
3. Alexander McGirr, Joel Paris, Alain Lesage, et al., “Risk Factors for
Suicide Completion in Borderline Personality Disorder: A Case-Control
Study of Cluster B Comorbidity and Impulsive Aggression,” Journal of
Clinical Psychiatry 68 (2007): 721–729.
9780399536212_IHateYou_TX_p1-272.indd 256 20/09/10 11:06 AM
256 NOTES
7. SEEKING THERAPY
1. American Psychiatric Association, “Practice Guideline for the Treat-
ment of Patients with Borderline Personality Disorder,” American Jour-
nal of Psychiatry 158 (2001, October Supplement): 4.
2. Otto Kernberg, Borderline Conditions and Pathological Narcissism
(New York: Jason Aronson, 1975).
3. James F. Masterson, Psychotherapy of the Borderline Adult (New York:
Brunner/Mazel, 1976).
4. Norman D. Macaskill, “Therapeutic Factors in Group Therapy with
Borderline Patients,” International Journal of Group Psychotherapy 32
(1982): 61–73.
5. Wendy Froberg and Brent D. Slife, “Overcoming Obstacles to the Imple-
mentation of Yalom’s Model of Inpatient Group Psychotherapy,” Inter-
national Journal of Group Psychotherapy 37 (1987): 371–388.
6. Leonard Horwitz, “Indications for Group Therapy with Borderline
and Narcissistic Patients,” Bulletin of the Menninger Clinic 1 (1987):
248–260.
7. Judith K. Kreisman and Jerold J. Kreisman, “Marital and Family Treat-
ment of Borderline Personality Disorder,” in Family Treatment of Per-
sonality Disorders: Advances in Clinical Practice, ed. Malcolm M.
MacFarlane (New York: Haworth Press, 2004): 117–148.
8. Thomas A. Widiger and Allen J. Frances, “Epidemiology and Diagno-
sis, and Comorbidity of Borderline Personality Disorder,” in American
Psychiatric Press Review of Psychiatry, ed. Allen Tasman, Robert E.
Hales, and Allen J. Frances, vol. 8 (Washington, DC: American Psychi-
atric Publishing, 1989): 8–24.
8. SPECIFIC PSYCHOTHERAPEUTIC APPROACHES
1. Anna Bartak, Djora I. Soeteman, Roes Verheul, et al., “Strengthening
the Status of Psychotherapy for Personality Disorders: An Integrated
Perspective on Effects and Costs,” Canadian Journal of Psychiatry 52
(2007): 803–809.
2. John G. Gunderson, Borderline Personality Disorder: A Clinical Guide,
2nd ed. (Washington, DC: American Psychiatric Publishing, 2008):
242–243.
3. Cameo F. Borntrager, Bruce F. Chorpita, Charmaine Higa-McMillan,
et al., “Provider Attitudes Toward Evidence-Based Practices: Are the
9780399536212_IHateYou_TX_p1-272.indd 257 20/09/10 11:06 AM
NOTES 257
Concerns with the Evidence or with the Manuals?” Psychiatric Services
60 (2009): 677–681.
4. Aaron T. Beck, Arthur Freeman, and Denise D. Davis, Cognitive Ther-
apy of Personality Disorders, 2nd ed. (New York: Guilford, 2006).
5. Marsha M. Linehan, Cognitive-Behavioral Treatment of Borderline
Personality Disorder (New York: Guilford, 2003).
6. Nancee Blum, Bruce Pfohl, Don St. John, et al., “STEPPS: A Cognitive-
Behavioral Systems-Based Group Treatment for Outpatients with Bor-
derline Personality Disorder—A Preliminary Report,” Comprehensive
Psychiatry 43 (2002): 301–310.
7. Jeffrey E. Young, Janet S. Klosko, Marjorie E. Weishaar, Schema Ther-
apy: A Practitioner’s Guide (New York: Guilford, 2003).
8. Peter Fonagy, “Thinking About Thinking: Some Clinical and Theoreti-
cal Considerations in the Treatment of a Borderline Patient,” Interna-
tional Journal of Psychoanalysis 72, pt. 4 (1991): 639–656.
9. Anthony Bateman and Peter Fonagy, Mentalization-Based Treatment
for Borderline Personality Disorder: A Practical Guide (Oxford, UK:
Oxford University Press, 2006).
10. Anthony Bateman and Peter Fonagy, “8-Year Follow-Up of Patients
Treated for Borderline Personality Disorder: Mentalization-Based Treat-
ment Versus Treatment as Usual,” American Journal of Psychiatry 165
(2008): 631–638.
11. Otto F. Kernberg, Michael A. Selzer, Harold W. Koeningsberg, et al.,
Psychodynamic Psychotherapy of Borderline Patients (New York: Basic
Books, 1989).
12. Frank E. Yeomans, John F. Clarkin, and Otto F. Kernberg, A Primer for
Transference-Focused Psychotherapy for the Borderline Patient (Lan-
ham, MD: Jason Aronson, 2002).
13. Robert J. Gregory and Anna L. Remen, “A Manual-Based Psychody-
namic Therapy for Treatment-Resistant Borderline Personality Disor-
der,” Psychotherapy: Theory, Research, Practice, Training 45 (2008):
15–27.
14. Eric M. Plakun, “Making the Alliance and Taking the Transference
in Work with Suicidal Borderline Patients,” Journal of Psychotherapy
Practice and Research 10 (2001): 269–276.
15. Allan Abbass, Albert Sheldon, John Gyra, et al., “Intensive Short-
Term Dynamic Psychotherapy for DSM-IV Personality Disorders: A
9780399536212_IHateYou_TX_p1-272.indd 258 20/09/10 11:06 AM
258 NOTES
Randomized Controlled Trial,” Journal of Nervous and Mental Disease
196 (2008): 211–216.
16. Antonio Menchaca, Orietta Perez, and Astrid Peralta, “Intermittent-
Continuous Eclectic Therapy: A Group Approach for Borderline Person-
ality Disorder,” Journal of Psychiatric Practice 13 (2007): 281–284.
17. John F. Clarkin, Kenneth N. Levy, Mark F. Lenzenweger, et al., “Evalu-
ating Three Treatments for Borderline Personality Disorder: A Multi-
wave Study,” American Journal of Psychiatry 164 (2007): 922–928.
18. Josephine Giesen-Bloo, Richard van Dyck, Philip Spinhoven, et al.,
“Outpatient Psychotherapy for Borderline Personality Disorder: Ran-
domized Trial of Schema-Focused Therapy vs. Transference-Focused
Psychotherapy,” Archives of General Psychiatry 63 (2006): 649–658.
19. Antoinette D. I. van Asselt and Carmen D. Dirksen, “Outpatient Psy-
chotherapy for Borderline Personality Disorder: Cost-Effectiveness of
Schema-Focused Therapy vs. Transference-Focused Psychotherapy,”
British Journal of Psychiatry 192 (2008): 450–457.
9. MEDICATIONS: THE SCIENCE AND THE PROMISE
1. Ted Reichborn-Kjennerud, “Genetics of Personality Disorders,” Psychi-
atric Clinics of North America 31 (2008): 421–440.
2. Randy A. Sansone and Lori A. Sansone, “The Families of Borderline
Patients: The Psychological Environment Revisited,” Psychiatry 6
(2009): 19–24.
3. Bernadette Grosjean and Guochuan E. Tsai, “NMDA Neurotransmis-
sion as a Critical Mediator of Borderline Personality Disorder,” Journal of
Psychiatry and Neuroscience 32 (2007): 103–115.
4. A ntonia S . New, Ma rianne Goodm an , Joseph Triebwasser, et al., “Recent
Advances in the Biological Study of Personality Disorders,” Psychiatric
Clinics of North America 31 (2008): 441–461.
5. Bonnie Jean Steinberg, Robert L. Trestman, and Larry J. Siever, “The
Cholinergic and Noradrenergic Neurotransmitter Systems and Affective
Instability in Borderline Personality Disorder,” in Biological and Neu-
robehavioral Studies of Borderline Personality Disorder (Washington,
DC: American Psychiatric Publishing, 2005): 41–62.
6. Mary C. Zanarini, Catherine R. Kimble, and Amy A. Williams, “Neuro-
logical Dysfunction in Borderline Patients and Axis II Control Subjects,”
9780399536212_IHateYou_TX_p1-272.indd 259 20/09/10 11:06 AM
NOTES 259
Biological and Neurobehavioral Studies of Borderline Personality Disor-
der (Washington, DC: American Psychiatric Publishing, 2005): 159–175.
7. Jose Manuel de la Funete, Julio Bobes, Coro Vizuete, et al., “Neurologic
Soft Signs in Borderline Personality Disorder,” Journal of Clinical Psy-
chiatry 67 (2006): 541–546.
8. Eric Lis, Brian Greeneld, Melissa Henry, et al., “Neuroimaging and
Genetics of Borderline Personality Disorder: A Review,” Journal of Psy-
chiatry and Neuroscience 32 (2007): 162–173.
9. American Psychiatric Association, “Practice Guideline for the Treat-
ment of Patients with Borderline Personality Disorder,” American Jour-
nal of Psychiatry 158 (2001, October Supplement).
10. Mary C. Zanarini and Frances R. Frankenburg, “Omega-3 Fatty Acid
Treatment of Women with Borderline Personality Disorder: A Double-
Blind Placebo-Controlled Pilot Study,” American Journal of Psychiatry
160 (2003): 167–169.
11. Christopher Pittenger, John H. Krystal, and Vladimir Coric, “Initial
Evidence of the Benecial Effects of Glutamate-Modulating Agents in
the Treatment of Self-Injurious Behavior Associated with Borderline
Personality Disorder” (Letter to the Editor), Journal of Clinical Psy-
chiatry 66 (2005): 1492–1493.
12. American Psychiatric Association: Diagnostic and Statistical Manual
of Mental Disorders, Revised, 3rd ed. (DSM-III-R) (Washington, DC:
American Psychiatric Association, 1987): 16.
13. Michael H. Stone, The Fate of Borderline Patients: Successful Outcome
and Psychiatric Practice (New York: Guilford, 1990).
14. Mary C. Zanarini, Frances R. Frankenburg, John Hennen, et al., “The
McLean Study of Adult Development (MSAD): Overview and Implica-
tions of the First Six Years of Prospective Follow-Up,” Journal of Per-
sonality Disorders 19 (2005): 505–523.
15. Andrew E. Skodol, John G. Gunderson, M. Tracie Shea, et al., “The
Collaborative Longitudinal Personality Disorders Study: Overview and
Implications,” Journal of Personality Disorders 19 (2005): 487–504.
10. UNDERSTANDING AND HEALING
1. Andrew Morton, Diana: Her New Life (Philadelphia: Trans-Atlantic
Publications, 1995): 155.
9780399536212_IHateYou_TX_p1-272.indd 260 20/09/10 11:06 AM
260 NOTES
APPENDIX B. EVOLUTION OF THE BORDERLINE SYNDROME
1. Michael H. Stone, “The Borderline Syndrome: Evolution of the Term,
Genetic Aspects and Prognosis,” American Journal of Psychotherapy 31
(1977): 345–365.
2. Adolph Stern, “Psychoanalytic Investigation of and Therapy in the Bor-
der Line Group of Neuroses,” The Psychoanalytic Quarterly 7 (1938):
467–489.
3. Gregory Zilboorg, “Ambulatory Schizophrenia,” Psychiatry 4 (1941):
149–155.
4. Paul Hoch and Philip Polatin, “Pseudoneurotic Forms of Schizophre-
nia,” Psychiatric Quarterly 23 (1949): 248–276.
5. Gustav Bychowski, “The Problem of Latent Psychosis,” Journal of the
American Psychoanalytic Association 4 (1953): 484–503.
6. Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. (DSM-
II) (Washington, DC: American Psychiatric Association, 1968).
7. Helene Deutsch, “Some Forms of Emotional Disturbance and the Rela-
tionship to Schizophrenia,” The Psychoanalytic Quarterly 11 (1942):
301–321.
8. Robert P. Knight, “Borderline States,” Bulletin of the Menninger Clinic
17 (1953): 1–12.
9. Roy R. Grinker, Beatrice Werble, and Robert C. Drye, The Borderline
Syndrome (New York: Basic Books, 1968).
10. Otto Kernberg, “Borderline Personality Organization,” Journal of the
American Psychoanalytic Association 15 (1967): 641–685.
11. Otto Kernberg, Borderline Conditions and Pathological Narcissism
(New York: Jason Aronson, 1975).
9780399536212_IHateYou_TX_p1-272.indd 261 20/09/10 11:06 AM
INDEX
Page numbers in italics represent charts.
Abandoned Child mode, 182, 183
Abandonment, 15
after divorce, 96
recreating, 118
separation as, 134
Abilify, 198
ABT. See Alliance- Based Therapy
Abuse, 3
childhood, 13, 54, 58, 75, 92–93,
113, 135–36, 164–65, 166, 169,
184, 208
domestic violence, 51, 76, 87, 113
emotional, 93–94, 135–36
in marriage, 87–88
self- esteem after, 93, 94
self- mutilation after, 94, 135
sexual, 54, 58, 92, 113, 135, 164,
166, 168, 169, 208
unpredictability of, 135
Acceptance
of anger, 111–12
as conditional, 122
of consequences, 127
self- , 110, 111–12, 146
by therapist, 175
Acetylcholine, 194
ADHD, 27, 29–30
Adolescent Risk Communication
Institute, 85
Adolescents, 69–70, 85, 136–37
Affair, 113–14, 121, 204, 206
Affective disorders, 27, 29
Age, 17–18, 140–41
Aging, 140–41
Albee, Edward, 101, 169
Alcoholics Anonymous, 109
Alcoholism, 73, 125
of fathers, 167
in relationships, 221
Allen, Woody, 142
Alliance- Based Therapy (ABT), 187
Ambivalence, 14, 106–7
America
culture of, 77–79
politics of, 82
religion of, 82
American Psychiatric Association, 6, 148
Amphetamines, 57
Anger, 3
acceptance of, 111–12
art therapy for, 169–70
as avoidance, 114
compensating for, 130
as control, 143–44
disproportionate, 51, 128
feedback with, 120–21
in job, 16
at manipulation, 132, 133
with psychotherapy, 51–52, 147,
164–65, 207
9780399536212_IHateYou_TX_p1-272.indd 262 20/09/10 11:06 AM
262 INDEX
Anger (cont.)
during recreation, 139
response to, 129
SET- UP system with, 120–21
unpredictability of, 119–20, 128
Annenberg Public Policy Center, 85
Anorexia nervosa, 33–34, 211
Antibiotics, 195–96
Antidepressant medication, 2, 125,
196–97, 212
Antisocial personality, 32–33
Anxiety, 4, 64–65, 69
Anxiolytics, 199
Art therapy, 168–70
Asendin, 197
As-if personality, 232
Associated Personality Disorders, 27, 32–33
Ativan, 199
Atypical antipsychotics, 198
Austen Riggs Center, 187
Autistic phase, 64
Automatic re exes, 211–12
Autonomy, 63, 64
in object constancy phase, 67
Aventyl, 197
Axis I, in DSM, 202
Axis II, in DSM, 26, 202
Beck, Aaron, 179
Behavior modi cation therapy, 148
Bibliotherapy, 169
Binge eating, 4
Bipolar disorder, 23, 27, 29
Blame, 135, 221
Borderline Personality Disorder (BPD)
by age group, 17–18, 140–41
Awareness Month, xiii
in brain, 62, 193–95
celebrities with, 19–20
coping with, 127–28
creativity with, 138
as cultural, 79–82
curing, 20, 202–3
de ned, 6, 8–11, 36–53, 80
degrees of, 9–10, 21
developmental theories of, 63
in DSM- III, 6, 8–9
environmental factors in, 60
evolution of, 229–39
extremes of, 136
genetics of, 60, 61, 193–94
geographically, 18
hospitalization rate of, 170
identifying, 124–26, 137, 155–56
“nature vs. nurture,” 60, 72–73, 193
for older people, 140–41
other disorders with, 6, 8, 23, 26–33,
27, 125, 126
personality in, 25–26
recreation with, 139–40
research on, 20
social factors with, 77–84
symptoms of, 9, 10–11, 17, 125
time for, 85–86
underrecognition of, 5–6, 17, 19, 80,
126, 136–37
in women, 16–17, 36, 78, 87, 89, 90
in workplace, 137–38
Borderline Personality Organization
(BPO), 234–35
Boredom, 50
Boundary setting, 218
BPD. See Borderline Personality Disorder
Brain, BPD and, 62, 193–95
Brain trauma, 62
Bulimia, 33–34, 125
Campbell, W. Keith, 100
Caregiving. See Families
Carroll, Lewis, 204
Cat’s Cradle (Vonnegut), 99
CBT. See Cognitive- Behavioral Therapy
Celebrities, 19–20
Celexa, 197
Centaur, The (Updike), 37
Change
control with, 210–12
effects of, on others, 220–21
towards independence, 218–19
initiating, 215–16
job, 138
leaving the past for, 216–17
perfectionism and, 217–18
practicing, 214–15
in relationships, 219–22
self- assessment for, 212–14, 213
Character, 25
Childhood
abuse in, 13, 54, 58, 75, 92–93, 113,
135–36, 164–65, 166, 169, 184, 208
ADHD in, 29–30
adolescence, 69–70, 85, 136–37
9780399536212_IHateYou_TX_p1-272.indd 263 20/09/10 11:06 AM
INDEX 263
caregiving in, 88, 89–90, 91
con icts of, 55, 68–69
criticism in, 74, 75, 205
identity in, 98, 133
inconsistency in, 133, 134, 135
intimacy in, 66, 95, 97
leaving behind, 216–17
in MBT perspective, 184
moving in, 75, 81, 98
neglect in, 72, 74–75, 93–94, 168
object relations stages of, 63–68
parent- child attachment, 62, 63, 66,
97–98, 133–34, 184
pessimism in, 85
self- esteem in, 67
separation in, 2, 42, 63, 65, 66, 67,
134–35
splitting and, 64–65, 68–69
suicide in, 85
trauma in, 70–72, 135
Church, 98
Clinging, 218–19
Clozaril, 198
Cluster suicides, 44
Cognitive- Behavioral Therapy (CBT),
151, 179
Cognitive- perceptual distortions, 200
Communication. See also SET- UP
system, for communication
contradictions in, 106–7
perseverance in, 122
rejection of, 120
Community, sense of, 98, 99
Competitiveness, 163
Compliments, 136, 139
Compulsive behaviors, 34–35
Computerized tomography (CT), 195
Con ict, 120
childhood, 55, 68–69
choosing one’s battles in, 134
in marriage, 133, 134
in relationships, 124
Confrontation, 109, 120
in group therapy, 162
in psychotherapy, 160
Consequences, 104
acceptance of, 127
in “Tough Love” groups, 109
Consistency, 121
inconsistency, 7, 133, 134, 135
in psychotherapy, 146
Constancy, 117–22, 130, 139, 219. See
also Object constancy
Continuity, historical, 84–85
Contradictions, 106–10, 179–80
Control
anger as, 143–44
change and, 210–12
with eating disorders, 211
with emptiness, 116
in job, 16
parental, 55, 57, 59–60, 63
of relationships, 204–5, 206
rituals for, 131
of self, 117
by therapist, 152, 154, 207
Coping mechanisms, 153. See also
individual coping mechanisms
Countertransference, 151, 153–54, 156
Creativity, 138
Criticism, 2–3
in childhood, 74, 75, 205
reaction to, 16, 32
self- esteem with, 77
CT. See Computerized tomography
Cults, 35, 43–44
Culture
BPD as response to, 79–82
fragmentation of, 80–84
materialism in, 83
modern, 77–79
relationships and, 86–87, 88
sexuality in, 86, 88
Victorian, 77
Culture of Narcissism, The (Lasch),
78–79, 100
Custody, in divorce, 94–96
Cutting. See Self-mutilation
Cymbalta, 197
Dance therapy, 169
Dating websites, 86
DBT. See Dialectical Behavioral Therapy
DDP. See Dynamic Deconstructive
Psychotherapy
Degradation, 93
Degrees of borderline, 9–10, 21
Depakote, 198
Dependency, 133
in group therapy, 164
SET- UP system with, 128
on therapist, 161, 162
9780399536212_IHateYou_TX_p1-272.indd 264 20/09/10 11:06 AM
264 INDEX
Depression, 22–23, 27. See also
Antidepressant medication
case study, 110
compensating for, 130
emptiness and, 50
suicide and, 143
Detached Protector mode, 183
Deutsch, Helene, 232
Devaluation, 237
Developmental theories, 63
Diagnosis. See also Diagnostic and
Statistical Manual of Mental
Disorders
dimensional approach to, 9–10
of personality disorders, 84–85
Diagnostic and Statistical Manual of
Mental Disorders (DSM)
classi cations, 223–27
DSM- III, 6, 8–9, 202
DSM- IV- TR, xvi, 10–11, 26, 32
state disorders in, 26
trait disorders in, 26, 32
Dialectical Behavioral Therapy (DBT),
179–81, 186–87, 189
Diana (princess of Wales), 68, 71, 220
Diary card, in DBT, 181
DID. See Dissociative identity disorder
Differentiation, 219–20
Differentiation phase, 65
Dilantin, 198
Discrimination, 114, 115
Dissociative disorders, 27, 31
Dissociative identity disorder (DID), 27,
31, 209
Divorce, 76, 86, 91
consistency after, 134
custody after, 94–96
Domestic violence, 51, 76, 87, 113
Domination, as child abuse, 93
Drugs. See Pharmacotherapy; Substance
Abuse; individual names
Dynamic Deconstructive Psychotherapy
(DDP), 187
EAPs. See Employee Assistance Programs
Eating disorders
anorexia nervosa, 33–34, 211
binge eating, 4
bulimia, 33–34, 125
control of, 211
as secondary symptom, 8, 23, 125
Eccentricity, 137–38
Effexor, 197
Ego, 99–100
Elavil, 197
Elderly, BPD in, 17–18
Emotional blackmail, 128
Emotional hemophilia, 11–12
Emotions
avoidance of, 146
emotional abuse, 93–94, 135–36
guilt over, 110–12
negative, 110–11, 112
over- reactivity of, 180
Empathy, 32, 38, 163
Empathy segment, of SET- UP system,
102–3, 104–5, 105
with anger, 120
in case studies, 108, 111, 115, 116, 117
with contradictions, 108, 109, 110
with dependency, 128
with emptiness, 116, 117
with impulsivity, 131
with negativity, 111
with object constancy, 119
with victimhood, 115
Employee Assistance Programs (EAPs), 138
Emptiness
control and, 116
depression and, 50
SET- UP system and, 116, 117
Endorphins, 49, 62
Engulfment, 38
Enmeshment, 106
Environment, 60
Equilibrium, 221–22
Existential angst, 50
Expectations
in relationships, 105
of roles, 89
Exploratory psychotherapy, 160–61,
167–68
Facebook, 99
Families, 2, 4, 86
abuse by, 13, 54, 58, 75, 87–88,
135–36, 164–65, 168, 169, 208
caregiving in, 88, 89–90, 91
control, 55, 57, 59–60, 63
demands of, 126
dependence on, 123–24
dual- income, 81, 89, 90, 91, 97, 98
9780399536212_IHateYou_TX_p1-272.indd 265 20/09/10 11:06 AM
INDEX 265
extended, 91, 98–99
“faux family,” 99–100
heritability in, 54–60, 70, 193
idealization of, 166
reconciliation of, 166
self- destructiveness in, 109
single- parent, 91, 94
social roles in, 88–89
structure of, 91
therapist alliance with, 167
Family therapy, 165–68
Family tree, 167
Fanapt, 198
Fatal Attraction, 121
Fatalism, 85
Fathers
absent, 56, 57, 63, 71, 94, 96–97, 113,
205, 206
abuse by, 54, 58, 75, 135–36, 164–65, 168
after divorce, 94–96
alcoholism of, 167
roles of, 88–89
war veteran, 96–97
Fault, 83
“Faux family,” 99–100
“Fight or ight” response, 194
Fonagy, Peter, 184
Free association, 148
Freud, Sigmund, 19, 77, 79–80, 229–30
Frustration, 110, 111
Future, fear of, 84–86
Gabatril, 198
Gambling, 34
Gaugin, Paul, 51
Gender. See also Women
de ned, 10
identity, 78
roles, 88–90
Generic drugs, 201
Genetic reconstruction, 160
Geographical mobility, 98–99. See also
Relocations
Geodon, 198
Gestalt, 183
Giovachinni, Peter L., 84
Glutamate, 199
Greene, Graham, 216–17
Gregory, Robert J., 187
Grinker, Roy, 233
Group loyalties, 82
Group therapy, 162–65
STEPPS, 181–82
Guilt
over emotions, 110–12
over mother, 132–33
punishment and, 135
Gunderson, John G., 177–78, 234
Haldol, 198
Hallucinations, 23
Handicap, 127
Helplessness, 127, 128, 132
Hewitt, James, 68
Hierarchy, of treatment, 180
Hispanics, 18
Histrionic personality, 33
Hitler, Adolf, 19–20
Holocaust survivors, 97
Homeostasis, 221
Hospitalization, case study, 143–46
acute, 171–72
BPD rate of, 170
contract with, 172
discharge from, 57, 144–45, 170, 172
goals of, 172, 173–74
long- term, 172–74
partial, 172, 174–75
Househusbands, 89
HPA. See Hypothalamic- pituitary- adrenal
axis
Hypnosis, 148
Hypochondria, 30–31
Hypothalamic- pituitary- adrenal (HPA)
axis, 194
ICE. See Intermittent- Continuous Eclectic
Therapy
Idealization
of families, 166
of mother, 97
primitive, 237
of relationship, 118, 207, 220
splitting with, 13–14
Identity, 3
adolescent, 69–70
in childhood, 98, 133
constancy of, 219
diffusion, 238
from external sources, 43
gender, 78
instability of, 40–42
9780399536212_IHateYou_TX_p1-272.indd 266 20/09/10 11:06 AM
266 INDEX
Identity (cont.)
loss of, 13
in modern culture, 77–78
personality fragments, 208–9
through psychotherapy, 153
roles for, 12, 39, 42
self- esteem and, 40–41, 207–8
separate, 218–19
sexual, 90
splitting and, 14
Identity diffusion, 185, 186
Illness, 16, 30–31, 126
Impulsive Character (Reich), 231
Impulsivity, 44
emergence of, 130–31
from loneliness, 45
pharmacotherapy for, 200
self- esteem and, 132
SET- UP system for, 131
unpredictability of, 131–32
Indecisiveness, 218
Independence, 116, 128
change towards, 218–19
in relationships, 220
Individualism, 83
Inner contentment, 117
Insight, 116
Insurance, 172, 178, 190
Intensive Short- Term Dynamic
Psychotherapy (ISTDP), 187–88
Intermittent- Continuous Eclectic Therapy
(ICE), 188
Intimacy
in childhood, 66, 95, 97
in relationships, 15, 23–24, 37–38, 40
Invalidation, 180
Invega, 198
Iraq War vets, 96
ISTDP. See Intensive Short- Term Dynamic
Psychotherapy
Jealousy, 38
Jerry Maguire, 40
Job
BPD in workplace, 137–39
frequent changes of, 138
moving for, 81, 90
structure of, 16
Jonestown Massacre, 43
Journal of Adolescent Health, 85
Justice, 83
Kernberg, Otto, 185, 234–39
Klein, Melanie, 231
Kleptomania, 34
Klonopin, 199
Knight, Robert, 232–33
Lamictal, 198
Lasch, Christopher, 78–79, 86, 100
Lawrence, T. E., 66
Legal system, 83
Lennon, John, 92
Lexapro, 197
Librium, 199
Life expectancy, 85
Limits, 121–22
Limping, 215–16
Linehan, Marsha M., 179
Loneliness
avoidance of, 15, 36–37
impulsivity from, 45
Loxitane, 198
Luvox, 197
Magical thinking, 35
Mahler, Margaret, 64
Mailer, Norman, 41, 71
Male menopause, 43
Manipulation, 37, 38
anger at, 132, 133
of psychotherapy, 143, 144–46, 147
through self- mutilation, 48
through suicide threats, 128
MAOIs. See Monoamine oxidase inhibitors
Marilyn (Mailer), 41
Marilyn: An Untold Story (Rosten), 37
Marriage
abuse in, 87–88
con icts in, 133, 134
divorce, 76, 86, 91, 94, 95–96, 134
Masochism, 34–35
Materialism, 83
MBT. See Mentalization- Based Therapy
Meaning, quest for, 116
“Me Decade, The” (Wolfe), 100
Medical school, 77
Medication. See Pharmacotherapy
Memento, 44
Memories, 85–86
Mentalization, 184, 220
Mentalization- Based Therapy (MBT),
184, 187
9780399536212_IHateYou_TX_p1-272.indd 267 20/09/10 11:06 AM
INDEX 267
Microsoft, 99–100
Midlife crisis, 43
Miller, Arthur, 123
Mindfulness, 180
Missildine, Hugh, 93–94
Misunderstandings, 122
Mocking, in workplace, 139
Monoamine oxidase inhibitors (MAOIs), 197
Monroe, Marilyn, 37, 41, 71
Mood shifts, 11–12, 49
with affective disorders, 29
to anger, 119–20
as BPD symptom, 125
living with, 129–30
pharmacotherapy for, 200
Mood stabilizer medication, 198
Mother
critical, 205
guilt over, 132–33
intimacy with, 66, 97
neglect by, 72, 74–75, 168
overinvolved, 133–34
sexual abuse by, 208
working, 89, 90, 91
Movement therapy, 169
Moving, 75, 81, 90, 98, 124
Multiple personality disorder, 27, 31, 209
Music therapy, 169
MySpace, 99
N- acetylcysteine, 199
Narcissism, 32
of parents, 97–98
of social networking, 100
Narcissism Epidemic, The (Campbell), 100
Nardil, 197
National Institute of Mental Health
(NIMH), xiii
Native Americans, 18
“Nature vs. nurture,” 60, 72–73, 193
Navane, 198
Negativity. See Emotions
Neuroendocrinology, 194
Neuroleptics, 198–99
Neurontin, 198
Neuroses, 19, 77
Neurotransmitters, 61, 194
New York Times, 80
NIMH. See National Institute of Mental
Health
NMDA dysregulation, 194
Norpramin, 197
Nuclear holocaust, threat of, 85
Numbness, 47–48, 117
Object constancy, 38, 64–65, 67–69
in adolescence, 69–70
in relationships, 118
SET- UP for, 119
with therapist, 152
Object relations, 63–68
Obsessive behavior, 161
“Off- label” use, 196, 200–201
Omega- 3 fatty acid preparation, 199
Omnipotence, 237
O’Neill, Eugene, 1
Opiate antagonists, 199
Opioid system, 194
Outpatient treatment. See Hospitalization
Overprotectiveness, 127
Pain, 30
Pamelor, 197
Panic attacks, 125–26
Paradox, 7, 30, 82, 179–80
Paranoia, 52
Parasite, borderline as, 218–19, 220
Parent- child attachment, 62, 63, 66,
97–98, 133–34, 184
Parnate, 197
Passivity, 110–11
Pathology, 21
Paxil, 197
Peer groups, 43, 44, 162–65
Perfectionism, 110, 112, 217–18
Personality, 212–14, 213
disorders, 25–28, 27, 84–85
fragments, 208–9
histrionic, 33
multiple personality disorder, 27,
31, 209
of therapist, 177–78
traits, 15, 24
PET scanning, 36, 195
Pexeva, 197
Pharmacotherapy, 24, 148. See also
Self- medication
alternative, 199
antidepressant medication, 2, 125,
196–97, 212
anxiolytics, 199
customization of, 195–96
9780399536212_IHateYou_TX_p1-272.indd 268 20/09/10 11:06 AM
268 INDEX
Pharmacotherapy (cont.)
dilemma of, 192
generic drugs, 201
mood stabilizer medication, 198
neuroleptics, 198–99
“off- label,” 196, 200–201
opiate antagonists, 199
psychotherapy vs., 176
by symptom, 200
Phobias, 126
Physical appearance, 4
Plastic surgery, 100
Plato, 74
Play, borderlines at, 139–40
Polarity, 82–83
Politics, 82–83
Post- Traumatic Stress Disorder (PTSD), 31
Poverty, 18
Power, 16
Power and the Glory, The (Greene),
216–17
“Practice Guideline for the Treatment of
Patients with Borderline Personality
Disorder,” 148
Practicing phase, 65
Precision, 83
Predicting borderline behavior, 131–32
Prejudice, 77
Pristiq, 197
Projection
of ambivalence, 106–7
with staff members, 171
Projective identi cation, 237
Promiscuity, 34–35
Protection, 146
Provocative behavior, 112
Prozac, 197
Psychic distance, 15
Psychoanalysis, 148, 149
Psychodynamic psychotherapy, 148, 151,
183–86
Psychoeducation, 181
Psychological mindedness, 184
Psychosis, 52–53. See also Hallucinations
Psychotherapy, 20, 24. See also Therapist
acceptance in, 175
anger with, 51–52, 147, 164–65, 207
approaches, 148, 151, 157, 160–75,
176–77, 178, 186–88, 190–91
art, 168–70
assessment of, 157–58
avoidance of, 158
bibliotherapy, 169
breaks in, 150, 158
case study, 142–47
cognitive- behavioral, 151, 179–82
comparing, 186–89
consistency in, 146
countertransference in, 151, 153–54,
156
devaluation of, 190
exploratory, 160–61, 167–68
frequency of, 143, 150, 151, 157, 160,
161, 178, 180, 183, 184, 186
goals of, 148–49, 157, 178
group, 162–65, 181–82
honesty in, 159
length of, 147, 149–51
manipulation of, 143, 144–46, 147
maximizing, 159–60
pharmacotherapy vs., 176
psychodynamic, 148, 151, 183–86
relationships during, 152
research on, 178, 184–85, 189
results of, 150
second opinion, 158
standardization of, 177
supportive, 161–62
termination of, 153
therapeutic alliance in, 148–49, 151,
154–55, 157–60, 167
transference in, 151–53
PTSD. See Post- Traumatic Stress Disorder
Punishment, 48
guilt and, 135
in relationships, 34–35
Racism, 114, 115
Rage. See Anger
Rapprochement phase, 65–66, 81–82
Reality TV, 100
Reassurance, 118, 119
Recreation, 139–40
Redemption, 48
Regression, 173, 174–75
Reich, Wilhelm, 231
Rejection
of communication, 120
conditional, 122
need for, 120–21
9780399536212_IHateYou_TX_p1-272.indd 269 20/09/10 11:06 AM
INDEX 269
perception of, 107
of sexuality, 110–11
Relationships. See also Marriage
after ending of, 121
change in, 219–22
con ict in, 124
control of, 204–5, 206
culture and, 86–87, 88
equilibrium in, 221–22
expectations in, 105
in group therapy, 164
idealization of, 118, 207, 220
independence in, 220
instability in, 13, 37–40
intimacy in, 15, 23–24, 37–38, 40
with married partners, 113–14, 121,
204, 206
overlapping, 88
patient- therapist, 148–49, 151, 154–55,
157–60, 167
during psychotherapy, 152
roles in, 221
sabotage of, 3, 58, 136
self- acceptance and, 112
self- esteem in, 87
self- punishment in, 34–35
Relaxation, 140
Religion, 83, 205
American, 82
churches and relocation, 98
Relocations, 75, 81, 90, 98, 124
Re- parenting, 182, 183
Repression, 77
Research, 20, 178, 184–85, 189, 193
Responsibility, 107, 109, 127, 146, 217
Revia, 199
Rilutek, 199
Risperdal, 197
Rituals, 68, 131
Rivalry, 163
Rorschach tests, 232, 236
Rosten, Norman, 37
Safety, 120, 129
Saphris, 198
Sass, Louis, 80–81
Schema, 181, 182–83
Schema- Focused Therapy (SFT), 182–83,
187, 189
Schema modes, 182–83
Schizophrenia, 23, 27, 28
School phobia, 69
Seduction, 38
Self- acceptance, 110, 111–12, 146
Self- assessment, 212–14, 213
Self- destructiveness. See also Cutting;
Eating disorders; Substance abuse;
Suicide
in families, 109
helplessness with, 132
through self- mutilation, 45–49
sexuality and, 145
Self- esteem, 32, 39
after abuse, 93, 94
childhood, 67
with criticism, 77
identity and, 40–41, 207–8
impulsivity and, 132
in relationships, 87
Self- medication, 61
Self- mutilation, 23
after abuse, 94, 135
self- destructiveness through, 45–49
as self- medication, 61
Sensitivity, 16
Separation
as abandonment, 134
anxiety, 64–65, 69
in childhood, 2, 42, 63, 65, 66, 67,
134–35
Separation- individuation phase, 64,
69–70, 81
Serenity Prayer, 220
Seroquel, 198
Serotonin- norepinephrine reuptake
inhibitors (SNRIs), 197
Serotonin reuptake inhibitors (SRIs),
196, 201
SET- UP system, for communication. See
also individual segments of SET- UP
case studies of, 106–21
de ned, 102–4, 103
uses of, 122
Sexuality, 43. See also Promiscuity;
Relationships
control with, 205
in culture, 86, 88
development of, 54
identity with, 90
online, 86
9780399536212_IHateYou_TX_p1-272.indd 270 20/09/10 11:06 AM
270 INDEX
Sexuality (cont.)
rejection of, 110–11
self- destruction and, 145
sexual abuse, 54, 58, 92, 113, 135, 164,
166, 168, 169, 208
sexual orientation, 90
with therapist, 154
Sexually transmitted infections, 137
SFT. See Schema- Focused Therapy
Shingling, 88
Sinequan, 197
Skills training, 182
SNRIs. See Serotonin- norepinephrine
reuptake inhibitors
Social media, 79, 99–100
Social networking, 99–100
Social rapprochement, 81–82
Social smiling, 65
Socioeconomics, 18
Solitude, 36–37, 79
Somatization Disorder, 27, 30–31
Sometimes I Act Crazy: Living with
Borderline Personality Disorder
(Kreisman and Straus), 61
Soviet Union, 82
Splitting
in childhood, 64–65, 68–69
constancy and, 117–18
with idealization, 13–14
in TFP, 185
Split treatment, 202
SRIs. See Serotonin reuptake inhibitors
Staff members, 171
STAIRWAYS, 182
Standardization, of treatment, 177
State disorders, 26
Stelazine, 198
STEPPS. See Systems Training for
Emotional Predictability and
Problem- Solving
Stern, Adolph, 231
Stranger anxiety, 65
Straus, H., 61
Structure, 78, 138–39, 145, 146
of families, 91
in hospitalization, 173
job, 16
Substance abuse, 27–28, 137. See also
Alcoholism
as avoidance, 13, 33, 45
as self- medication, 61
Success, 112
Suicide, 8
in adolescents, 137
after divorce, 95
as avoidance, 12
in childhood, 85
“cluster suicides,” 44
as cry for help, 45–46, 106–7, 108,
124, 128, 137
depression and, 143
rates of, 35, 202–3
response to, 108, 128
as strategy, 85
Supportive psychotherapy, 161–62
Support segment, of SET- UP system, 102,
104, 104
with anger, 120
in case studies, 107–8, 111, 114–15,
116, 117
with contradictions, 107–8, 109, 110
with dependency, 128
with emptiness, 116, 117
with impulsivity, 131
with negativity, 111
with object constancy, 119
with victimhood, 114–15
Suppression, 161
Surmontil, 197
Sydenham, Thomas, 22
Symbiosis, 218–19, 220
Symbiotic phase, 64
Systems Training for Emotional
Predictability and Problem- Solving
(STEPPS), 181–82
Tattoos, 46–47
TCAs. See Tricyclic antidepressants
Teasing, 139
Tegretol, 198
Telephone coaching, 181
Temperament, 25
TFP. See Transference- Focused
Psychotherapy
Thematic Apperception Test (TAT), 236
Therapeutic alliance, 148–49, 151,
154–55, 157–60, 167
Therapist
acceptance by, 175
choice of, 156–57, 178
control by, 152, 154, 207
countertransference of, 151, 153–54, 156
9780399536212_IHateYou_TX_p1-272.indd 271 20/09/10 11:06 AM
INDEX 271
dependency on, 161, 162
family alliance by, 167
fears of, 149
object constancy with, 152
patient relationship with, 148–49,
151, 154–55, 157–60, 167
personality of, 177–78
role of, 155–56
second opinion, 158
sexuality with, 154
in SFT, 183
trust in, 149, 152, 219
Therapy. See Psychotherapy
Thinking
distorted, 179
magical, 35
Thorazine, 198
Through the Looking Glass (Carroll), 204
Tillich, Paul, 36
Time, 85–86, 141
Time magazine, xii
Tofranil, 197
Tolstoy, Leo, 50, 54, 176
Topamax, 198
Touching, 127
“Tough Love,” 109
Trait disorders, 26, 32
Trance state, 148
Transference, 151–53. See also
Countertransference
in exploratory psychotherapy, 161
in supportive psychotherapy, 162
Transference- Focused Psychotherapy
(TFP), 185–86, 187, 189
Transitional objects, 67–68, 239
Trauma. See also Abuse
brain, 62
in childhood, 70–72, 135
among war veterans, 96–97
Tribes, 99
Tricyclic antidepressants (TCAs), 197
Trilafon, 198
Trileptal, 198
Trust, 117, 118
in therapist, 149, 152, 219
Truth segment, of SET- UP system, 103–4,
105, 106, 127
with anger, 120–21
in case studies, 109–10, 111, 115, 116, 117
consistency in, 121
with contradictions, 108, 109–10
with dependency, 128
with emptiness, 116, 117
with impulsivity, 131
with negativity, 111
with object constancy, 119
with victimhood, 115
Twelve- step programs, 220
Twenge, Jean M., 100
Twin studies, 193
Twitter, 100
Unavailability, 93
Understanding, 122
Unpredictability
of abuse, 135
of anger, 119–20, 128
of impulsivity, 131–32
over time, 141
Updike, John, 37
Valium, 199
Van Gogh, Vincent, 51
Verbalization, 169, 170
Victimization, 15, 47, 87, 107, 112–15
Violence, 129, 132
domestic violence, 51, 76, 87, 113
Vivactil, 197
Voltaire, 192
Vonnegut, Kurt, 42, 99
War veterans, 96–97
Weight, 56–57
Who’s Afraid of Virginia Woolf?
(Albee), 169
Wolfe, Tom, 100
Women
BPD in, 16–17, 36, 78, 87, 89, 90
eating disorders for, 33
omega- 3 fatty acid for, 199
roles of, 88–89, 90
working, 89, 90, 91
World War II vets, 96
Worthlessness, 87
Xanax, 199
Young, Jeffrey, 182
Zoloft, 197
Zonegran, 198
Zyprexa, 198
9780399536212_IHateYou_TX_p1-272.indd 272 20/09/10 11:06 AM
ABOUT THE AUTHORS
Jerold J. Kreisman, MD, graduated from Cornell University Medical
College in New York City. He is a Distinguished Life Fellow of the American
Psychiatric Association and Associate Clinical Professor in the Department
of Psychiatry, St. Louis University. In addition to coauthoring Sometimes I
Act Crazy: Living with Borderline Personality (2004), Dr. Kreisman has
written articles and book chapters on a variety of subjects. I Hate You—
Don’t Leave Me (1989) is considered a classic in the popular and academic
literature on BPD. Dr. Kreisman maintains a private practice in St. Louis,
Missouri.
Hal Straus is the author or coauthor of seven books on psychology,
sports, and health topics. He has published numerous articles in national
magazines, including Ladies’ Home Journal, Men’s Health, American
Health, Redbook, and McCall’s. He is the director of publications at a
medical specialty society and lives in the San Francisco Bay Area.
