I Hate You--Don't Leave Me: Understanding the Borderline Personality

by Jerold J. Kreisman

When the child is unable to bond appropriately with a parent, he has difficulty understanding 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 parent’s pathology, which may consist of physical or emotional abuse or abandonment, or inappropriate smothering of independence, or from both.

TFP theorizes that identity diffusion and splitting are early, primary elements in normal development. However, in BPD, normal, developing integration of opposite feelings and perceptions is disrupted by frustrating caregiving. The borderline is stuck at an immature level of functioning.

Thus, the primary point to be gleaned from these studies is not which treatment works best, but that psychotherapeutic treatment does work! Unfortunately, psychotherapy has been figuratively 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 diabetes, instruction on caring for a healing wound, or psychotherapy) 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 companies pay less than one-tenth of the reimbursement rate directed for many minor outpatient surgical procedures.

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 system. In the usual acute stress situation, this system activates the “fight-flight” 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, ongoing stress dismantles the regenerative circuit and the stress alarms continue unabated, inflicting negative impact on the body, including shrinkage in characteristic areas of the brain. This pattern has been observed in several disorders, including BPD, PTSD, major depression, and certain anxiety disorders.

The FDA considers a generic drug “equivalent” to a branded medicine if blood levels in healthy volunteers are within 20 percent variation, a significant difference in some patients.

Everywhere she looked she saw women who were prettier, smarter, better. She wished her hair was prettier, her eyes a different color, her skin clearer. When she looked in a mirror, she did not see the reflection 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.

“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 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.

Psychological change requires resisting unproductive automatic reflexes and consciously and willfully choosing other alternatives—choices that are different, even opposite, from the automatic reflex.

If a journey of a thousand miles begins with a single step, the borderline’s journey through the healing process begins with a single limp. Change is a monumental struggle for the borderline, much more difficult 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.

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 find that relying on themselves is like walking for the first time.