Timothy Rogers, MA, LMFT
Licensed Marriage & Family Therapist mfc101500
- Let me be the last therapist you see -
Mentalization Based Therapy (MBT ) and Transference-Focused Psychotherapy ( TFP) are evidence-based psychodynamic psychotherapies that are clearly effective in the treatment of BPD. The research effort has been great, overcoming important methodological and logistical obstacles. Dissemination of these therapies is bringing psychoanalysis back to the mental health community and strengthening its links with empirical research and universities.
Borderline Personality Disorder (BPD) is considered a disorder of attachment and mentalizing capacity--a difficulty in thinking about others as having an inner world with feelings and conceptions different from one's own--and targeted four main areas: identification and appropriate expression of affect, development of stable internal representations, formation of a coherent sense of self, and capacity to form secure relationships.
A mother who fails to develop a confident sense of Self tends to foster the continuance of the symbiotic union (merger, boundarylessness or undifferentiatedness) with her child and thus encourages him to remain dependent in order to maintain her own emotional equilibrium.
She seemed to be overwhelmingly threatened by her child’s emerging individuality, which sounded as a warning that he was destined to leave her, eventually forever. Not being able to handle, what she perceived as abandonment, she was unable to support the child’s efforts to separate from her and express his own Self through play and exploration of the world.
The child develops a False Self as a way to avoid the severe feelings of devastation and loss when faced with the possibility of losing his mother (aka a way to survive). Additionally, he is rewarded by mother’s affection and comfort of HER self when demonstrating dependence on her.
The message sent to the vulnerable child from an unavailable or emotionally intrusive or withholding mother object is: “If I am me and attempt to express that me, she will leave me and I won’t exist.” - the child stays stuck in the earliest underdeveloped process of separation, of existing without mother as part of his identity.
This process is stopped, and his sense of Self (agency) is lost (seemingly). The child with a false self cannot look for a magic rescuer but must struggle through the childhood years constantly having to contend with the mother’s repeatedly expressed negative attitudes towards the emergence of his real self.
As the child gets older, the discrepancy between his chronological age and the level of his psychological functioning widens. He develops a sense of "no self" which becomes progressively more entrenched over time as the individual encounters and struggles with the challenges of Each. Life. Phase.
The abandonment depression is first experienced at an age when the young child cannot reflect on it or articulate what is happening. The child simply feels that the flow of life is cruelly disrupted and that he teeters on the verge of annihilation should the vital support of what, at the time, appear to him to be their causes.
In therapy the clinical picture presented by the patient is quite detailed and explicit, and in spite of the variations of age, sex, career, and stage of life, the picture is also rather predictable, for this trauma dilemma springs from a common dynamic patterned on early family circumstances and interactions sometimes combined with physical health problems.
The abandonment dynamic is always precipitated by an event such as separation or loss, or a situation requiring self-assertion and autonomy, which ruptures the line of defenses erected to prevent depression, leaving the person vulnerable to a full onslaught of the abandonment depression.
In moments such as these, the person is brought to grips with how inadequately his false self prevents the painful feelings of depression. He feels deflated. The false and deflated self keeps his life empty, vulnerable, and driven by the constant fear the his defenses will be breached. AND THEY ARE.
Any separation stress analogous to the original traumatic separation experienced as a young child can trigger the abandonment dynamic.
The predictable events in the natural life cycle that represent further growth opportunities for the healthy child can precipitate a breakdown in the child with a deflated false self. The major passages and stages of life threaten his defenses and bring on the abandonment depression when he realizes he has insufficient strengths or resources to rely on.
The (natural) dependency expected and accepted in the preschool years and beyond helps to conceal the child’s clinging defenses and the fact that the real self is not growing. At the time the parents are able to deny the failure to grow. These defenses may begin to fail when the child enters nursery school, kindergarten, or goes off to camp; however, unless the child is exposed to a severe separation stress during these years, he manages to struggle through with his problems unnoticed.
As the school years progress and the child grows older, he encounters more complex emotional and social tasks that tap his inadequate capacities to function autonomously, thereby revealing their deficiencies. Each advancing year poses its own unique challenges to which the child fails to respond in ways that promote growth and maturity. Eventually he leaves the local school and enters high school where his defensive patterns are even less able to prevent the abandonment depression.
It is not surprising that so many symptoms of the impaired real self are seen in adolescence when dependency is expected to recede and more rigorous social requirements for independence must be met. High school engages the child’s time and energy more intensely than grammar school, often taking the child farther from home where he will meet a wider range of boys and girls from varied backgrounds.
It is increasingly common for teenagers to hold part-time or even full-time jobs while going to school, which plays even more stress on their ability to function independently, manage time, relate to adults, and fulfill obligations in creative, autonomous ways. Making friends, dating, and experimenting with sex also place demands on the adolescent’s sense of self, testing his or her values.
During the adolescence these years can be devastating as the real world closes in on the youngster finds increasingly fewer places to hide. In order to defend against the abandonment depression, he may act out with forms of self-destructive behavior. The typical acting-out defenses include use of drugs and alcohol to drown or soothe the depression, sexual promiscuity, running away from home, truancy, abusive or provocative acts of disrespect to authority figures, stealing, reckless driving, or violent acts against persons or property that may provoke direct confrontation with the law.
These symptomatic behaviors demonstrate the danger of depression and the tension associated with it. In terms of school work, a standard defense for avoiding self-assertion and self-expression is a passing but mediocre school record, which may label the student as an underachiever. Graduation from high school, of course, can breach the adolescent defenses completely as the teenager realizes that he will be thrown into the adult world of college or career. Often intimations of abandonment depression begin in the senior year, the symptoms intensifying as the commencement date approaches.
Diagnostic criteria for 301.83 Borderline Personality Disorder
DSM IV Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) frantic efforts to avoid real or imagined abandonment.
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
(3) identity disturbance: markedly and persistently unstable self-image or sense of self
(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
(7) chronic feelings of emptiness
(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
(9) transient, stress-related paranoid ideation or severe dissociative symptoms
from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association
John Bowlby’s studies of children aged 13-32 months who were separated from their mothers (a complementary study to Mahler’s work) filled in additional pieces of the puzzle of what goes wrong, preventing the emergence of a unique and whole self. Bowlby studied the mourning process that children who were hospitalized for a physical illness went through when they were not able to have their mothers around them as they were used to at home. He discovered that mourning could take two courses:
-One type of mourning enabled the individual to relate to and find satisfaction in new objects. This is considered to be a healthy way to mourn.
- A second kind of mourning that pathologically prevents a person from developing new relationships and outlets. This kind of mourning proceeds through three phases:
The first is the protest and wish for reunion phase that may last a few hours or several weeks, during which the child appears acutely distressed at having lost its mother and seeks to recapture her by whatever limited means he possesses. He entertains strong expectations and wishes that she will return. He tends to reject others, such as nurses and doctors, who offer to do things for him, although some children will cling desperately to a particular nurse.
In the second phase hopelessness sets in. The child sinks into despair and may even stop moving. He tends to cry monotonously or intermittently, and becomes withdrawn and more inactive, making no demands on the environment as the mourning state deepens.
-In the third phase the child begins to show more interest in his or her surroundings, and this is usually welcomed as a sign of recovery.
I came to recognize that when my patients go through a separation experience that they have been defending themselves against all their lives, they seem to react just like Bowlby’s infants in the second stage of despair.
The separation brings on a catastrophic set of feelings, which I have called an abandonment depression.
To defend against this mental state, they retreat into the defensive patterns encouraged by the false self, which they have learned over the years will ward off this abandonment depression. In adults without a sense of their real self, the abandonment depression symbolizes a replaying an infantile drama:
The child returned for support and encouragement, but the mother was unavailable or unable to provide it. The acknowledgment and approval, so crucial to developing the capacities of expression, assertiveness, and commitment, were simply not there.
Years later as adults, those patients hear the same message from those they have selected in order to repeat the pattern. It is not okay to be the unique separate self you really are—or could become.
Masterson, James F.. Search For The Real Self: Unmasking The Personality Disorders Of Our Age (p. 59). Free Press.
First in the womb and later outside of it, there is in all of us a natural, healthy and necessary process of physically separating from mother (umbilical cord cut at birth), cerebrally separated (child’s mind development realizing they are not still the same person as mother-> from birth up to age 3), and the emotional separation (developing and exploring and expressing an autonomous sense of self). However, if during the last two phases of development of the child’s sense of agency (Self), there is a lacking of Self from the mother, the child experiences the trauma of abandonment depression.
You, Your Self & Why