Why “Borderlines” Don’t Bother Me

I have been a psychiatrist for over 30 years now and have probably treated thousands of patients. Over the years I have come across a diagnosis that I neither find useful, nor frightens me. I am speaking of course of the dreaded “Borderline”. No other diagnosis in psychiatry is so connected with negative emotions. For some odd reason I never quite feared it. Perhaps I never really understood it, but more likely I did not find it so “otherwordly”. In 1938, the term was used to describe patients on the borderline of psychotic symptoms but by the 70’s Kernberg defined it as a middle ground between “psychosis and neurosis”. With DSM-III came the diagnostic criteria that we have now come to use and in DSM-5 the criteria included

1. Pervasive pattern of instability in interpersonal relationships, self image and emotions
2. Frantic efforts to avoid real or imagined abandonment
3. Impulsivity that is self-damaging
4. Recurrent suicidal behavior
5. Chronic feelings of emptiness
6. Inappropriate, intense anger
7. Transient stress related alterations in reality

The criteria do not make it “scary” but rather the fact that these individuals are seen as very high risk. Of course no one wants to be responsible to provide treatment to “high risk” patients, but technically, that is actually our job. Dealing with a person that has certain feelings of emptiness, thinks about dying, becomes angry at the drop of the hat and is impulsive does not sound like a picnic, but how is it worse than treating the individual with Schizophrenia, Bipolar Disorder, Severe Major Depression or Panic Disorder. All these individuals are “high risk’. Many lack insight into their illness and are often non-compliant. Many do not get better despite the work of the psychiatrist. Many people who are labeled Borderline actually do get better, with the recent estimate being 80% (Gunderson). So a person who has the ability to engage in therapy, have a connection with their emotional state, finds these symptoms as ego dystonic and tends to get better is the “problem” patient we all avoid?

My own experience comes from the school of ego psychology and addiction. Early on in my psychiatric training I began to work with a mentor who changed my view of addiction in general and opened my eyes to the field of ego psychology. He began teaching us that the addict is not a mysterious creature, but rather an individual who suffers from an illness and the sequelae of this illness affects personality structure. He would quote Norm Zinberg and would look at the issue of “ego atrophy”as the core issue in the manifestation of the disease of addiction. It is the behavior that stems from this atrophy that creates the negative perception of the therapist.. Remove the chemical and the individual can improve and function normally. Understanding the pathology of patients via the window of ego psychology it was more important to understand the level of maturity of the defenses (as noted by Vaillant), and work towards a corrective experience. In other words, go back to where the arrest occurred and then help the patient move forward.

I happily entered into my second year of training and was introduced to Kernberg and first started looking at “Borderlines” in a different way. I began to think of myself as the limit setter, and if limits are broken I needed to respond. Roughly translated, acting out in any form could lead to termination, and I could feel good about myself since it was all the patients fault. I now know that this simplistic view of Kernberg was destructive, but to be fair, I found reading Kernberg difficult. I would then listen to the “oral history” of what he meant from my senior residents and junior faculty who continued speaking to issues of splitting and manipulation. I was eventually assigned my first “borderline” patient. She was a young woman who would cut the bottom of her feet to feel “something”. I would see her 2 times a week, and she would say nothing. Every Friday night at 9pm I would be paged by the hospital and eventually I would speak to her. She would tell me she is on a bridge in Albany and was planning to jump. In my best limit setting voice I would explain to her that I hoped she did not do it, and would see her on Tuesday. She would hang up and I would spend the rest of the weekend terrified. On Monday I would go for supervision and he would tell me that I set limits which was good. This torture lasted for 6 months until I was assigned to a new supervisor who told me that she obviously was terrified of the weekend and the loneliness that it would create and that I should see her on Fridays in the late afternoon. The phone calls stopped.

I became less comfortable with Kernberg due to the extent of confrontation and interpretation that needed to be done in order to make any progress. I worried that this technique might make things worse and found it difficult to see the patient as having poor ego function and being able to tolerate psychodynamic interpretation. I would drive the patient off the bridge if I pushed too hard. Perhaps if I was better trained and more confident I would find Kernberg easier to follow, but I was not. In addition, I do not do well with conflict and confrontation. A technique that centers on this would not work well for me. (I know the purists reading this would tell me to get into treatment. I did, three times and I still do not like conflict). I also found it counter-intuitive. If an individual showed an arrest at a certain stage of ego development, would not nurturing to a more mature stage be better? I know it would take longer, and may not work quite as well, but it would at least move the patient into a better place while showing concern.

I began reading extensively and the list focused on the positive corrective effect of the therapeutic relationship. I read Leston Havens “A Safe Place”, I read anything I could by Gunderson, I read the Kohut Seminars, I read Balint’s the Basic Fault. I became interested in the issues of attachment, object relations and how the ongoing give and take between child and parent gives rise to the ego function that we see. I stopped using the word “Borderline” or “Narcissist”. I found them to be derogatory and often saw the patient responding more to the negative connotation than to the quality of the therapy. I began seeing my patients in terms of ego development, and saw these patients as suffering from Pre-oedipal arrest in development. I also began to believe that they could get better. I began to look at lowering their distress with medication and became somewhat comfortable with my own personal theoretical opinion. I utilized a kinder and gentler treatment. Since I was not teaching psychodynamic theory or treatment, I was able to muddle along and not have to articulate my rationale. When my patient was admitted and the nursing staff would explain every part of the behavior using the word “borderline” I would nod, and continue my work. I did not debate. In fact, if the patient annoyed me, I would then agree. (this was before my second psychotherapy).

At some point I re-entered academic psychiatry and I needed to be able to explain my feelings and theories to trainees. The books came out again. I began attending lectures at William Allison White Institute and eventually the CJ Jung Institute. I completed training in Meaning Centered Psychotherapy and obtained certification in Jungian Psychotherapy. Most importantly I began teaching more and had to put a theory behind my clinical activity. I also needed to guide trainees through the treacherous land of countertransference. I needed to teach how they often used the diagnosis of Borderline Personality as a weapon. I began learning more about DBT and Linehan. I began looking at Kernberg’s new approach of Transference Focused Therapy. Most importantly, I went back into therapy (#2).

And I continued to treat patients who continued to teach me. I began looking at the diagnosis as a barrier erected to separate the patient and the therapist. The barrier was particularly effective in preventing us getting too close to the “Borderline”. I began seeing that we feared certain patients, and those patients we called Borderline. We feared what would happen secondary to their manipulation. We worried that they would die and we would be to blame. We worried that their lack of progress would make us look bad in the eyes of our peers. Those of us that practiced psychodynamically based psychotherapy also feared that our lack of success would give ammunition to the behaviorists and pharmacologists to be used against us.

Not only did I search for theoretical support for the treatment approach I was choosing, I also went back into therapy( #3, my first Jungian). Part of the work has allowed me to write this little piece. Most importantly, I developed an understanding of why I approached my work in a different way than some of the other clinicians in my department.

I strongly feel that “Borderline” diagnosis should not be used. I like to explain to my patients that they suffer from a disorder and this disorder has two major components. The one has to do with their mood and how it is difficult to modulate. The second is with the ability to tolerate closeness and aloneness. I feel that if we wish to call their disorder something I prefer to use dysregulated mood disorder. In some cases I would add Complex Post Traumatic Disorder. I tell them they will be called “Borderline” in many other places. I also educate them that this diagnosis has little meaning as to the prognosis. We see Borderline as “bad” but actually the vast majority of individuals get better.

I then turn to relationships, both present and past. I explain that it is common for some of these dynamics to become a part of the treatment. I explain that we need to look at it but not act on it. I also borrow from Linehan, and make myself more available. I allow patients to reach out between sessions if needed during a crisis. I feel that the idea that they need to be mindful is essential, and borrow from Linehan and her quest for spiritual answers which as a Jungian I support. I borrow from Buddishm and teach that life is suffering and it is our response that can be controlled. And I focus on the relationship. I am present. I am empathic. I am tolerant. I provide positive affirmation where appropriate. I look at growth and I applaud it. I see setbacks as a way to refocus and grow.

As I write I see my approach as “Relational”, “Interpersonal”, “Self Psychology”, “Spiritual”, “Transferential”, “ Existential”. Perhaps I can call it the “RISSTE” techique , or maybe just the “Ioannou Method”. In the end, what I would like to think of it as is a Humanistic technique, that brings together the aspects that define our humanity and allows us to grow.