Saturday, January 23, 2010

Notes on Borderline Personality

Here are the notes I sent to a colleague who asked me for some help in understanding another colleague who has borderline characteristics. I wasn’t trying to be definitive, or to address the issues and controversies surrounding this diagnosis, just to give some practical advice. Perhaps others may find it useful.

While the borderline personality style can present in different ways, one of the most frequently encountered is the person who has genuine skills in both productive work and relationships, but whose attachment dynamics have been severely compromised at a young age, such that she (or, of course, he) cannot really attach in a trusting and trustworthy way on a long term basis aside from being on either side of a very clear dependency relationship; up or down.  The individual's unconscious (and it is unconscious) formula for attachment survival is to divide others so that her alliance with key supporters is attained by their alliance with her in rejecting another or others; this is the "splitting,” “triangulating” dynamic.  A borderline patient on an inpatient unit famously splits the unit by allying some staff with her against other staff, and sometimes it takes lots of work to unravel the knot the borderline person has created.

Such people can't really be wholehearted members of teams, because they can't trust colleagues; but they can be members of productive teams in which specified tasks are done by various people in order to come together into a result.  However, their relational pattern as team members will still be to split, even at the expense of the success of the team, so that both their work and their tendency to split will have to be managed by the team leader.  

There are different hypotheses about how borderline personality disorders come about.  Barbara Oakley attributes it mainly to genetics, in "Evil Genes."  Psychoanalytically oriented theorists look to early childhood experiences, in which the patient was alternately seduced (in one way or another) and rejected by a powerful parent, usually with the other parent being too weak to make a difference.  As in most things psychological, probably it’s a combination of nature and nurture.

There are lots of nuances of this, of course. As a therapist, I often see patients with family histories in which a parent allied a child with himself or herself at the expense of other family members, who are rejected. Sometimes my patient is the child who was seduced, sometimes the one who was rejected. Sometimes the seduction-rejection behavior cycles, such that the parent seduced (not necessarily sexually, but emotionally) the child and treated her as very special, then rejected her and treated her as a bad person or a non-person, then cycled that treatment again and again.  

The result is that the borderline tends to have a "good object/bad object" attitude toward others in his life, alternately feeling beloved and betrayed.  So, those who have been "good objects" and thought they had a trustworthy and dependable interlocutor suddenly find themselves excoriated and vilified, and wonder what hit them.  Of course, the cycle can turn the other way as well, so that the person who was opposed and undermined can suddenly become the special and perfect and desired one.  The seduction/betrayal dynamic repeats, and people who relate with people with borderline personality styles have that “walking on eggshells” feeling, of always being about to do something wrong, without knowing it.

Working with such a person means that the working relationship has to be managed, because trust is not really available, especially if you are the person who threatens the borderline and whom he is trying to ally with others against.  Over the run of time, as the borderline becomes more secure, he may alter his focus in terms of whom he tries to split off from whom.  

The key to managing a working relationship with a borderline is in two parts:  1. Keep your productive agenda going, and 2. Deflect splitting by refocusing attacking energy onto productive work; not by taking it personally and rising to the bait.  The splitting behavior is unconsciously strategic, a substitute for healthy attachment, which the borderline person never really had. Therapy for people with borderline personality tendencies aims at establishing secure attachment. Dialectical Behavior Therapy (DBT) is a new therapy that has been developed for helping borderline patients feel a secure sense of attachment within their therapeutic relationship.  

Borderlines typically feel a great deal of apprehension and anxiety, much of which is repressed and projected out onto others.  They are masters at appearing calm while provoking and upsetting others by attacking them, then pointing to those whom they have provoked and saying, "What's wrong with them?"  For this reason, maintaining a low-key emotional tone can be important in dealing with a borderline-type person.   

Few people are severe borderlines all the time; they couldn't function in society if they were.  Lots of people have borderline tendencies, and some people have them more strongly than others.  Such tendencies can be exacerbated by stress that can be brought about by big life changes, even apparently positive ones like starting a new job, entering a new relationship or a more intimate level of relationship, etc.  

Because the person with a borderline personality disorder may seem to be quite normal much of the time, and can be quite charming (remember, the borderline person was often seduced emotionally as a child), the observer may be fooled into thinking that the borderline pattern is over.  The truth is that, without personality change so deep that it affects the foundation of the person's being, the borderline pattern is still there, beneath the surface, just waiting for the right conditions to activate it. It takes insight and wisdom for a borderline personality pattern to change.