Borderline Personality Organisation

September 2000

 

Steve Cottrell & Peter Jones

 

Introduction

Definitions

Structural Model

Developmental Issues

Counter-transference reactions

Some Therapeutic Considerations

Developmental Roadmap of Ego State Formation

 

Introduction

 

This paper summarises some of the background to the diagnostic criteria of Borderline Personality Organisation (BPO) and posits a second-order structure of the archaeopsyche (C2), integrating some of the work of Carlo Moiso (of the Italian, or Psychodynamic Transactional Analysis School) and the formulations of psychodynamic luminaries such as Kernberg, Winnicott and Masterson. We wrote this paper some time ago, hence many of the references are now quite dated. However, we hope it’s still useful and have posted it here in response to an upsurge in interest in working with clients with this diagnosis. Some of the language, particularly with reference to ego states is specific to Transactional Analysis, so needs to be read in that context.

 

The concept of Borderline Personality Organisation (BPO) arose in the 1950’s to account for clients who could neither be classified as neurotic nor as psychotic. Though Knight (1953) introduced the term within this context, it was Stern (1938) who first coined the term, categorizing clients who had previously been described as ‘as-if personalities’, ‘latent schizophrenics’, ‘pseudopsychopathic schizophrenics’, ‘pseudoneurotic schizophrenics’, ‘sub-clinical schizophrenics’ and ‘occult schizophrenics’.

 

The difficulty in labelling this clinical entity is echoed by the controversy and disagreement inherent in it’s definition. Different theoretical orientations propose different diagnostic criteria. Thus one encounters behavioural, symptomatic, psychodynamic formulations and psychological test findings forming the basis of diagnostic categorisation of the Borderline Personality Organisation. Our focus here will be upon symptomatic features and psychodynamic formulations of the phenomena.

 

Some Definitions of BPO

 

(a) Descriptive Formulations

 

As noted above, the concept of BPO arose to account for a group of clients who appeared to belong neither to the pre-existing categories of neurosis nor psychosis, yet exhibited features usually associated with both.

 

Adler (1973) conceptualises borderline as referring to those clients who possess:

 

“Certain fixed personality characteristics and who maintain an adequate capacity to rest reality except under severe stress when they become transiently psychotic ‘and’ when functioning optimally they exhibit many neurotic level strengths”.

 

Gunderson (1975) identified six features indicative of borderline personality organisation. Intense affect, either depression or hostility, a history of impulsive behaviour, a certain social adaptiveness, brief psychotic experiences, ‘loose thinking’ in unstructured situations and relationships that vacillate between superficiality and intense dependence.

 

It was largely the work of Gunderson and his associates that resulted in the American Psychiatric Association’s diagnostic criteria in DSM III-R (1987).

 

The DSM IIIR (1987) criteria for BPO are that the individuals long-term functioning should be characterised by at least five of the following:

 

 

 

 

 

 

 

 

Kernberg (1984, 1989, 1993) points out the limitations of such a descriptive, symptomatic approach. Firstly it fails to distinguish the common features of severe and of less severe personality disorders and secondly there can be considerable overlap between BPO and other severe personality disorders, for example narcissistic and anti-social

personality disorders.

 

(b) Psychodynamic formulations

 

Kernberg’s formulation (1984, 1989) is psychodynamic and structural. He proposes three main features of BPO:

 

 

Identity diffusion

 

Akhtar (1984) notes the following features of identity diffusion

 

 

Kernberg posits these features to result from pathological object relations. Which in this instance refer to the internal object world. This theory concerns itself with the internalisation of external relations and suggests that the difficulties experienced by individuals with BPO result from a failure to integrate intrapsychic representations of self and others.

 

Greene (1982) notes that:

 

“(The) internal social schemata of borderline of borderline patients consist of only partial aspects of self and objects in emotionally crude relation to each other”.

 

Furthermore, these aspects of self and other are defensively separated  into “all good” and “all bad” representations. The individual presents with a chaotic, fragmented two-dimensional view of self and others. Emotional subtlety, sophisticated role-relatedness and psychological depth are all missing from the representational world of the borderline individual.

 

Primitive Defensive operations

 

 

Splitting

 

Primitive, defensive operations are centred around the mechanism of splitting, which is the division of self and external objects into ‘all good’ and ‘all bad’ resulting in sudden and complete reversals of all feelings and conceptualisations about oneself or another. A child is usually confused when a parent conveys mutually inconsistent messages, for example by saying “I love you” whilst being emotionally misaligned through incongruent vocal or non-verbal behaviour. The child finds it difficult to attribute the meaning of both messages to the same person.

 

This mechanism is supported by denial, the individual is aware they have experienced opposite and contradictory views of themselves and others but this awareness has no emotional relevance to the individual and does not influence their current state of mind.

 

Projective Identification

 

Projective identification or psychotic identification is a complex process whereby the subject projects an intolerable intra-psychic experience onto an object, maintains empathy (in the sense of emotional awareness) with what he projects, tries to control the object in a continuing effort to defend against the intolerable experience and out of awareness in actual interaction with object, causes the object to experience what has been projected onto him. Paradoxically it may lead to a sharing of affective states, what Casement (1985) calls ‘communication by impact’ and provides the therapist with insight of the clients object world.

 

Closely related to, and in addition to splitting are the mechanisms of idealisation, devaluation and omnipotence.

 

Reality testing

 

Reality testing can be defined as the capacity to differentiate self from non-self, and intra-psychic from external origins of perceptions and stimuli, and to evaluate one’s own affect, behaviour and thought content in terms of ordinary social norms.

 

Kernberg (1984) based upon the three criteria identified above, proposes the continuum of psychopathology reproduced in table 1.

 

                                                                   Postulated Structural Model of C2 in BPO

Split internal world – failure to integrate positive and negative aspects of self and others
 
 

 

 

 

All-bad experiences
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


In the psychotherapeutic relationship, self and object representations may be activated in the transference. The processes of projection and identification will be operating – thus a devalued depreciated self representation will be projected onto the therapist whilst the client identifies with a harsh critical object representation, hence the notion of ‘identification with the aggressor’. The affective link may be anger or fear. Typical self-object representations activated in the transference as shown below (table 2). (Kernberg et al 1989)

 

Self

Object

 

Destructive bad infant

Punitive sadistic parent

Controlled enraged child

Controlling parent

Unwanted child

Uncaring, self involved parent

Defective worthless child

Contemptuous parent

Abused victim

Sadistic attacker

Sexually assaulted prey

Rapist

Deprived child

Selfish parent

Out of control angry child

Impotent parent

Naughty sexually exciting child

Castrating parent

Dependent gratified child

Doting admiring parent

 

 

 

                                                               Table 2.

 

Nigg et al (1991) reports a correlation between adults diagnosed with BPO and childhood sexual abuse.

 

Developmental Issues

 

Psychodynamic formulations posit that early family relationships and experiences contribute to the development of borderline conditions. Adler (1978) suggested that the sense of aloneness felt by these individuals may be accounted for by their parent’s misattunement and emotional unavailability to them when they were children. Masterson and Rinsley (1975) described pathological enmeshment in childhood with overprotective parenting interfering with autonomous development. On the basis of the developmental theories of Mahler (1975), Masterson and Rinsley (1975) suggested that selective parental availability during the separation-individuation phase of development predisposes an adult to borderline psychopathology in later life. In this view the child’s symbiotic needs are accepted, whilst his autonomous strivings are rejected. Consequently, one may conceptualise the borderline client’s childhood as combining elements of overprotection and of neglect. This is consonant with Melges’ (1978) conceptualisation of BPO as an attachment disorder – with oscillations between  feelings of abandonment and engulfment; an inability to achieve ‘felt security’ from inter-personal relations as a direct consequence of their fragmented chaotic internal world.

 

Subsequent studies by Herman et al (1989), Zweig-Frank (1991) and Nigg et al (1991) point to a continuum of early family environments – from aloofness to physical abuse – as possible developmental antecedents of BPO.

 

Common counter-transference reactions

 

Countertransference may be regarded as the totality of therapist responses to the client. Transference and counter-transference phenomena concern the re-activation of the ‘there-and then’ in the ‘here-and-now’. Racker (1968) differentiates concordant and complementary counter-transference reactions. Clarkson (1989) succinctly defines both types. In concordant counter-transference the therapist experiences the client’s avoided emotional experience or resonates empathically with the clients own experience.

 

Complementary counter-transference is when the therapist complements the clients real or fantasised projection as Parent or Child of the clients parent by responding with feeling probably experienced by the original parent.

 

Possible therapist reactions are already shown in table 3, either by empathic resonance of the client’s current feeling state (concordant) or following the client’s projection of a self or object representation (complementary)

 

In general under complementary counter-transference, the therapist becomes identified with an internal imago that the client at that point cannot tolerate and thus dissociates and projects – the therapist coming to feel the client cannot tolerate in himself.

 

Some therapeutic considerations

 

In working with clients with borderline psychopathology the therapist must be able to tolerate intense, rapidly shifting affect within the relationship.

 

Winnicott’s (1965) notion of the ‘holding environment and Bion’s (1967) of containment are applicable here. The therapist in essence acts as a ‘container’ for the client’s emotional experiences, organising and helping modulate them, and feeding them back to the client in a more tolerable form.

 

Masterson (1976) focuses on what he calls ‘abandonment depression’ as a feature of borderline psychopathology. This represents a grieving process – for the loss of the symbiotic relationship and the loss of years of autonomous functioning that were never available to the individual with BPO.

 

Kernberg (1984, 1989) focuses on transference analysis within a supportive setting, i.e. working in the ‘here and now’ along the transference – counter-transference paradigm. His primary focus via clarification, confrontation and interpretation is the integration the split internal object as it becomes manifest transactionally in the psychotherapeutic relationship.

 

Woods and Woods (1982) have described borderline individuals as being ‘grounded in their affect’, meaning they use the vocabulary of thought while primarily experiencing the world through their affective responses. The intense nature of their emotional experiences leads to cognitive confusion. Alden & Osti (1989) notes a triad of cognitive distortions in individuals with BPO. They note that each clients diversity in their presentation can be accounted for by differences in figure and ground  between the three distortions. For example, the depressed and compliant client will present initially with distortion (1), reinforced through distortions (2) and (3). The hostile client presents with distortion (2) figural, supported by distortion (1) and (3). The more rigid client believes most strongly distortion (3) supported in turn by the other two. The defence of projective identification is represented in cognitive terms by distortions (1) and (2) while splitting is described best by distortion (3).

 

                                                                  Triad of cognitive distortions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

And…
 
 

 

 


They stress the importance of decontamination work in establishing adequate A2 functioning in these individuals. Item 3, ‘Everything is all (good) or nothing (bad) is of central importance since Osti regards this as a transactional manifestation of the splitting mechanism. Until sufficient A2 functioning is available, techniques that reinforce splitting, e.g. creative projective techniques, polarity and two-chair work should be avoided.

 

Moiso (1985) notes the importance of ‘establishing a transference relationship’ and offers that: ‘the transference projection is the necessary condition for the establishment of such a relationship’. Tolerance of the intense affects, from raging hatred to doting admiration are a necessary pre-condition for effective work with P1 transference projections. Moiso (1985) stresses that the therapist must have permission to experience counter-transference reactions and to utilise them in therapeutic work (see Winnicott, 1949, Hate in the countertransference). In effect the therapist confronts the clients own omnipotent fantasies concerning his destructive feelings by surviving them.

 

Differentiation of personality organisation (Kernberg 1984)

 

 

 

Neurotic

Borderline

Psychotic

 

Identity

Integration

Sharply delimited self and object representations. Integrated identity.

Identity diffusion. Contradictory aspects of self and others are poorly integrated and kept apart.

 

 

Self and object representations are poorly delimited.

 

 

Defensive

Operations

Repression and higher level defences: reaction formation, isolation, undoing, intellectualisation.

Defences protect against intrapsychic conflict. Interpretation improves functioning.

 

 

Splitting and lower level defences. Projective identification, idealisation, omnipotence, denial & devaluation

Defences protect against disintegration and self-object merger. Interpretation can lead to regression.

Reality

Testing

Intact

Largely intact

Lost

 

 

 

                        

                            Table 1.

 

 

Borderline Personality Organisation (After Hoyt)

 

 

Description

 

 

Doors

Easily upset

 

Open – Behaviour

Unrealistic

 

Target – Thinking

Overwhelmed

 

Trap – Feelings

Impulsive

 

Escape Hatch – Suicide

Hostile dependency

 

 

Cycle of merging

 

Drivers – Try Hard, Please Me/Others

Losing self

 

Rackets – Anger, Emptiness, Conflict, Hatred

Chaotic sense of self and others

 

Games – Blemish, GYWP, WDY-YB, NIGYSOB

 

 

 

Injunctions

 

 

Therapeutic Issues

Don’t Be

 

Stay in A2

Don’t Be Sane

 

Avoid Power-Plays

Don’t Think

 

Tolerate Affect

Don’t Grow Up

 

Stroke A2 Thinking

Don’t Make It

 

Teach self-Soothing

Don’t Trust

 

Provide Structure

Don’t Be Close

 

 

 

 

                                                              

Interpersonal Relationships

 

 

Common Reactions to Therapist

Tumultuous, Chaotic

 

Demanding, Entitlement, Helpless

Impulsive, Clinging

 

Enraged, Rejecting, Scornful

Intolerance of Solitude

 

“See, I knew you were just like the others…”

Frequent rage and loathing

 

Seductive, Flattering, Provocative

Destructive acting-out

 

 

Cycle of Merging and Rejection

 

 

Loses Self in Relationship

 

 

 

 

Common Therapist Reactions to Client

 

 

 

Frightened, Overly active, Antagonistic

 

 

Rejecting, Guilty, Withdrawn, Confused

 

 

Unusually Intense Emotionality, Feeling Manipulated, Resentful

 

 

 

 

 

                                                                           Table 3

 

Developmental Roadmap of Ego State Formation

 

 

[(a) Normal, (b) Pathologic, (c) Characteristic object relations. Broken vectors indicate developmental arrests. From Haykin, 1980]

 

 

 

References

 

Adler, G. (1973) Hospital Treatment of Borderline Patients. Am. J. Psychiatry 130:1.

 

Akhtar, S. (1984) The Syndrome of Identity Diffusion. Am. J Psychiatry 141:11.

 

Alden, M. & Osti, J. (1989) Cognitive Distortions in Borderline Personality Disorders. Transactional Analysis Journal 19:1.

 

American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders.

 

Bion, W.R. (1967) Second Thoughts: Collected Papers. Basic Books.

 

Casement, P. (1985) On Learning from the Patient. Routledge.

 

Clarkson, P. (1989) Transactional analysis: An integrated Approach. Routledge.

 

Greene, L. (1981) The patient-staff community meeting as therapeutic agent for borderline personality disorder. In Wolberg and Aronson (Eds.) Group and Family Therapy (1982) Brunner/Mazell.

 

Gunderson, J. & Singer, M. (1975) Defining Borderline Patients. Am. J. Psychiatry 132:1.

 

Haykin, M.D. (1980) Type Casting. Transactional Analysis Journal 10:4.

 

Hoyt, M.F. (1989) Psychodiagnosis of Personality Disorders. Transactional Analysis Journal  19:2.

 

Kernberg, O.F. (1984) Severe Personality Disorders. Yale.

 

Kernberg, O.F. (1993) Aggression in Personality Disorders and Perversions. Yale.

 

Kernberg, O.F.; Selzer, M.A.; Applebaum, A.H.; Carr, A.C. & Koenigsburg, U.W. (1989) Psychodynamic Psychotherapy of Borderline Patients.

 

Mahler, M., Pine, F. & Bergman, A. (1975) The Psychological Birth of the Human Infant. Hutchinson.

 

Masterson, J.F. & Rinsley, D.B. (1975) The Borderline Syndrome: The role of the mother in the genesis and psychic structure of the borderline personality. Int. J. Psychoanalysis, 56:163.

 

Masterson, J.F. (1976) Psychotherapy of the Borderline Adult: A Developmental Approach.

 

Melges, F.T. & Swartz, M.S. (1989) Oscillations of Attachment in Borderline Personality Disorder. Am. J. Psychiatry 146:9.

 

Moiso, C. (1985) Ego States and Transference. Transactional Analysis Journal 15:3.

 

Nigg, J.T. et al (1991) Object Representations in the Early Memories of Sexually Abused Borderline Patients. Am. J. Psychiatry.

 

Racker, H. (1968) Transference and Countertransference. I.U.P.

 

Winnicott, D.W. (1965) Maturational Processes and the Facilitating Environment. Karnac.

 

Woods, K. & Woods, M. (1982) Treatment of Borderline Conditions. Transactional Analysis Journal 12.

 

Zweig-Frank, H. & Paris, J. (1991) Parents Emotional Neglect and Over-Protection According to the Recollections of Patients With Borderline Personality Disorder. Am. J. Psychiatry. 148:5.

 

 

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